Today was pretty busy and I got to
perform a lot of direct patient care procedures
3 IM Injections
1 Intradermal Injection
Wound Care
Tube Feeding
IV Removal
and the usual syringe loading,
vital signs, medication passing, and paperwork
The first two IM injections were for a
patient who was involved in a mine collapse in Mantalongon. I
injected two rounds of tetanus toxoid on the left and right deltoid
muscles. Prior to those two injections I also performed an
intradermal skin test injection to confirm a negative allergic
reaction to the vaccine. My initial (albeit amateur) prognosis was a
severe concussion because the patient seemed to be confused and had
difficulty maintaining balance. However, after reading his chart, the
doctor had diagnosed him with a ruptured eardrum and mild concussion.
I wasn't there during the doctors initial prognosis or during the
doctors diagnosing, but I'll haphazard a guess that his confusion
might have been caused by his loss of hearing and his inability to
balance due to the concussion further exacerbated by the torn
eardrum. I'll also guess that tetanus toxoid was prescribed due to
the likelihood of an ear infection. Tetanus here is almost as common
as Dengue Fever, but since they can prevent tetanus with tetanus
toxoid, I have yet to see a patient with tetanus symptoms.
The third IM injection was given to a
pediatric patient – my first IM injection on a child. This one I
was nervous about because the nurse told me I had to estimate how far to inject the needle. I'm not sure if there are different needle
lengths for children compared to adults, but supplies here are short
so the needle length used on this pedia patient was the same length I
used on the full grow adult. With adult IM injections it's fairly
easy because, most of the time, you can insert the needle fully
without worrying about hitting a bone. However, this particular pedia
patient was not only small, but fairly skinny, so I had to ensure the
needle was inserted deep enough for the medicine to take, but not so
deep as to hit the bone. But, like I had written in a previous post,
confidence goes a long way in ensuring you can perform medical tasks
correctly, and the nurses here are all very good at boosting my
confidence. The pedia patient was the definition of calm and didn't
cry or flinch during the injection. I was so pumped up that I had
performed an IM injection on a pediatric patient correctly that, like
an idiot, I totally forgot to tell the patient that they had done
well. I'll have to remember that next time.
I was also able to perform another IV
removal as well as tube feeding.
The nurse today also documented most of
my direct patient care procedures with my video camera, but I won't
post those until I can edit out faces and such. I will, however, post
a few still frames here so you can check out a little bit of what I'm
doing.
It is worth noting that every single
person who appeared in the video or is captured on film is aware and
has given consent that I am documenting them for educational
purposes. I am extremely grateful for the people who have allowed me
to do this and will do my utmost to respect their privacy and
maintain their dignity.
It is also worth reminding you that, while it is standard operating procedure to wear gloves when doing any sort of direct patient care, supplies here are always low and/or nonexistent, so gloves are reserved for when risk of infection is great.
I went back to work at the hospital
today. I've been moved from the ER/OPD to the Nurses Station/Ward and
will be in this position for about a week before going back to the ER
on night duty. It's my first day in this portion of the hospital and
already I got to perform two direct patient care procedures I'd never
done before.
The first was in intramuscular
injection. Surprisingly enough, the IM injection is much easier than
performing a skin test. With a skin test, you have to be fairly
precise. You can't come in at too steep an angle and you don't want
to push the needle too far. Also, once the needle is in place, you
have to have steady hands or you might push the needle out from under
the skin. With the IM injection, all you really have to do is find a
nice meaty spot on the arm and inject. The hard part is pulling back
on the plunger to ensure now back-flow of blood (as I explained in
one of my earlier entries, back-flow of blood into the syringe means
you've hit a vein and you should immediately pull the needle out).
I'm going to apply some rudimentary physics education here: the
plunger resists a pulling motion because the diameter of the needle
is so small and the amount of “stuff” (muscle tissue, body fluid,
etc.) in the persons arm acts as a barrier between the hole and the
plunger creating a small vacuum. Long story short, it was hard
pulling back on the plunger before introducing the medication. The
nursing staff was very encouraging and just told me to be confident
and, with time, I'll develop a method that's easier, quicker, and
more painless.
The second procedure I got to do was
NGT feeding. They have a patient here who is in a persistent
vegetative state and requires an NGT to eat.
First ensure the tube is directly
in the stomach. Simply take a stethoscope, place it on the stomach,
and use a plunger to push a tiny bit of air into the feeding tube
(they lack a proper plunger here so what they use instead is
something like a big medicine dropper). What you're listening for is
a gurgling sound, which indicates the air has made its way into the
stomach.
Next is the pre-flush. Kink the
tube and pour in 5cc's of sterile water. Un-kink and let it drain
freely.
After that, pour in the liquid
food. This part is tricky because the food is rather viscous. Use
giant medicine dropper to help push the fluid through the tube.
However, push directly on the top of the medicine dropper and not on
the sides or the top of the dropper will keep popping off.
Once the fluid is consumed, flush
with an additional 10cc's of sterile water.
Aside from those two things, I also got deliver medicine via intravenous therapy (IVT). Pretty straight forward: sterilize the
port then inject the medication. My needle work is getting a little
bit better, too. It's easier for me to premix solutions and fill the
syringe without getting too much air in.
Working at the nurses station also
allowed me to see the safeguards in place to ensure correct patient
medication. Everything is confirmed. Before shift, orally give a
report that the follow shift must write down by hand. Check the
kardex. Check the doctors order. Check that the medication matches
the doctors order. Check the patients wristband. Ask the patient
their name. Tell them the medication and what it's for. Give the
medication. There are probably way more safeguards than I mentioned,
but those were the ones I could pick up on because they move fairly
quickly because they're used to it and because a lot of the
medication is time sensitive; perhaps a combination of both, really.
What's really impressive is the report for the next shift. The head
nurse on duty says the patients name, age, medication received (or
refused), how fluid much is left in an IV bottle before needing
changing, the drips per minutes for said IV bottle, how many total
bottles have been consumed since admission, the time the bottle was
hooked, the time any medication was given, the time any future
medication must be given, and any procedure done to the patient. The
head nurse says all of this in about 3 – 4 minutes while the
relieving nursing staff writes it all down by hand. The attention to
detail and the listening skills required are incredible. Maybe I'll
get footage of it next time.
That's me on the back of the
motorcycle. The first part of the video makes Dalaguete look rainy
and overcast all the time, but I guarantee you that's not the case.
It was super warm this morning and the clouds made it feel twice as
humid as it normally is.
It's not on the video but I got to do
my first needle work today! I performed a couple skin tests. The hard
part isn't really the injecting part since the allergen in question
is only injected intradermally. Prepping is, what I feel, separates
pros from amateurs. Compared to the nurses here, I'm obviously much
slower, and I'm clumsy when loading the syringe. It feels awkward
holding the vial in one hand and using the other hand to steady the
syringe while pulling back on the plunger. Both times I let a ton of
air in and had to keep reintroducing the needle to the vial to fill the chamber completely. I'm sure it's something that
gets easier with repetition, so hopefully I'll get better at it.
Ricky's son (Ricky is my second cousin
and whose house I'm staying at – that was his daughter, Pearl, in
the video) came in today to get his stitches removed and they let me
do it. It's not hard at all. Just snip the stitches and pull up at
the ends where the knots are. I think the nurses here are amused at
how excited I get when I get to do something hands on.
An older gentleman was admitted after
he fell flat on his face right into the dirt. I'm not really sure how
it happened but Ricky showed me how to x-ray the skull (Ricky is the
RadTech at the hospital), which you can see in the video. Luckily the
attending physician at the time said there was no bone damage, but he
prescribed a tetanus shot and a few other antibiotics.
An adolescent female was also admitted
due to a motor vehicle accident. The accident knocked out her four
front teeth and she had some pretty painful looking scrapes, but
other than that she was ok. She was also given a tetanus shot as well
as a couple other shots – one intravenously and one intramuscular.
The nurses asked if I wanted to perform the IM shot, and I said yes
but that I'd never done it before, so they decided to let me watch
this time. I asked how they avoid hitting the bone and they told me
it's not that hard. The tricky part is making sure you don't hit a
nerve or rupture a large collection of blood vessels. The technique
is to inject first, then pull back on the plunger a bit. If blood
starts seeping in, then you immediately pull the needle out, if not
you're good and can start introducing the medication.
After work, around 1800, Ricky took me
to the local slaughter house. This next gigantic bulk of writing is
going to be a personal spiel and have nothing medical related at all,
but I still feel it's extremely important to talk about. It will get
a bit graphic, so prepare yourself for that if you have a weak
stomach and want to keep reading. Prior to my visit here I started
practicing a pescatarian diet. I kept at it for about a year and a
half and told myself that when I got to the Philippines I wouldn't
force my eating habits on Ricky's family.
I have no problem with people
consuming animals. I think it's a very natural thing, and healthy for
the human body since there are some nutrients our body needs found
primarily in animals. I know the argument can be made that
supplements can be taken in order to offset any negative side-effects
of a vegetarian or vegan diet. However, I would challenge proponents
of that philosophy to think about the impact manufacturing said
supplements would have on the environment. It requires energy to
produce concentrated forms of any chemical, and sadly, clean
renewable energy isn't the main source of electricity yet. Anyway,
that's a topic for another time. What I'm trying to say is, I don't
think there's anything wrong with consuming animals, but I do feel
there is a very large disconnect between people (especially among
Americans) and the food on their plate. I was always raised to take
only as much food as I could eat, and to reduce waste as much as
possible. My decision to abstain from meat, aside from fish, is
because I feel it's necessary to experiencing killing the animal you
choose to consume (that's why I still eat fish). Taking an animals
life in order to continue yours reinforces the idea that you have
to take care of the things that take care of you.
When Ricky took me to the slaughter
house I didn't realize they were going to be slaughtering pigs right
then. For anyone that has already butchered animals before this next
part might sound silly, but I have to mentally, nay, spiritually,
prepare myself for the act of killing an animal. This is a rural
area, so they still slaughter animals by traditional means: a knife,
a length of rope, cold water, and hot water. They also take care to
use as much of the animal as possible, so the most efficient way of
killing the animal is slicing it in the jugular and letting it bleed
out. I knew prior to coming here that the butchering wasn't going to
be modernized, but what I wasn't prepared for was the noise. Pigs
know they are going to be killed, and they squeal extremely loud. The
pig only survives a few minutes after the jugular is cut, but they
continue to squeal and struggle up until their last moments. That for
me is the hardest part. Hearing the animal suffer saddens me greatly,
but all I have to do is look at how malnourished most of the people
are here and that outweighs any sort of protest I might have against
the butchering of these animals.
I'll be going back on Sunday to help
slaughter a pig. I'm extremely nervous about it simply because I know
it will be hard mentally and emotionally, but it's something I feel I
need to do in order to help me fully understand the importance of
waste reduction. I also feel it's the best way for me to pay my
respect towards a creature whose existence I am using in order to
continue mine.
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