Day 83 Dalaguete, Cebu DPC# Delivery Room, Intramuscular Injection, Intradermal Injection

I came back to Dalaguete today and worked in the ER. I did a couple skin tests and received a few patients for OPD checkups.

I also got to help with another delivery today. It was fairly quick and the nursing staff let me help prepare the infant right after delivery. After the baby had skin to skin contact with the mother and had started suckling (which is policy for the hospital here), the nursing staff cleaned off the baby and let me help with the measurements. We measured the circumference of the head, overall height, chest size, and weight. Afterwards, the nursing staff let me inject the infant with vitamin K. It's the first time I've ever injected a newborn and, in many ways, it was much easier than injecting adults. Firstly, the nurses loaded a syringe that we usually use for skin tests because the needle is much smaller and the infant doesn't need a huge dose.

There's a trick for loading such a small syringe (we used tuberculin syringes, which are 1cc). When drawing in whatever medication you're gonna use, the syringe has a tendency to fill with a bit of air (I've noticed this is especially true with TB syringes). That might not cause so much of a problem with 5cc syringes because you can always plunge out the excess air after loading some of the medication. With a 1cc chamber though, the amount of air is significant enough to throw off the measurement. Basically, in order to get an accurate measurement, you have to fill what you can and measure off starting from the bottom of the syringe. So let's say you want .3cc's of some medication. Instead of stopping and measuring from the .3cc line, you pull the plunger back and measure form somewhere near the middle or the back. So .3cc's might be loaded between  .6cc's and .3cc's (instead of 0-.3). Once you have that measured, you plunge out the excess air and you know that the .3cc's you have left are medication. The actual injection was simple because the needle was small enough that I could insert it all the way without hitting the bone (the injection site was the thigh).

Anyway, a pretty interesting day -- it'a always nice when I get to help with deliveries.

Day 68 Dalaguete, Cebu #DPC Intradermal skin injeciton

I worked the night shift (2300-0700) today and it was a night of firsts for me. 

The first patient to come in for the night was a young adult male who was brought in by friends after he deliberately ingested liquid fertilizer. The intent, though unconfirmed because the patient was unresponsive, was attempted suicide. Allegedly he had been having personal problems and, prior to ingesting the fertilizer, had drunk a significant amount of Tuba (a type of "wine" made from the sap of certain palm trees). I did a little research and found the ingredients in the fertilizer that might have been the same type that the patient ingested:

Sodium Ortho-nitrophenolate=0.468%

Sodium para-nitrophenolate=0.893%

Sodium Mono-nitroguaricolate=0.298%

Sodium Ortho-nitrophenolate=0.468%

Sodium para-nitrophenolate=0.893%

Sodium Mono-nitroguaricolate=0.298%

The doctor called for a referral to the city and had him hooked to an IV (plain NSS) and ordered an injection via IVTT of ranitidine. This is the first person I've ever met whose attempted suicide. Even more, he's the first person I've met who is actively undergoing a suicide attempt. The thing that strikes me the most about this encounter is that I didn't have any sort of emotional response until after the patient had been referred to the city -- that is, I didn't think about it as a suicide attempt until after he had been stabilized and referred. It's impossible not to feel some sort of emotion when working with people. That's something I've come to understand working as a CNA. However, one of the things that has weighed heavily on my heart is wondering if I'll be able to cope with emotionally distressing situations. Working as a CNA helped understand part of that -- I have come to view the residents at the nursing home I work with as friends, and therefore we work as a team. But that kind of familiarity comes with time. This suicide attempt was the first time I had been measured against an immediate stressful emotional situation.

I remember about 2-3 years ago I had the opportunity to shadow a doctor at a gastroenterology clinic. I had just finished watching a doctor perform and upper endoscopy on a man and they found that he had incurable esophageal cancer. The doctor was showing me some of the images he had captured of the esophagus and told me had the patient come in just 4-6 months earlier, they might have been able to treat it. However, it was too late and the doctor said the patient had maybe 6 months left to live. The doctor said it without sounding sad, and I remember how I thought it was so dispassionate to just state the facts so plainly.

But now, I've come to realize that you have to maintain a level of emotional distance in order to keep your mind clear. Weighing down your mind with too much emotion can translate into poor decision making which can cause poor performance as a doctor/physician assistant/nurse. It's not that you need to lack passion, you just have to know how to keep it from clouding your judgement.  

Another first for me that happened on this shift was exposure to a contagious patient. Obviously I've been around contagious residents back in Oregon (especially around the winter time with colds and whatnot), but tonight a patient came in and the doctors initial prognosis was TB. Of course, all of us were wearing masks, but it suddenly dawned on me that exposure to all sorts of pathogens will be inevitable when I work as a PA. The good thing is, even though I suddenly realized this, it didn't prevent me from continuing my work. Anyway, since it was after 5 and the lab technician was already gone, the doctor had the patient admitted and put in isolation until further tests could be done to confirm the prognosis.

I also performed an intradermal skin injection on another patient to test for an allergic reaction.

Day 67 Dalaguete, Cebu #DPC Intradermal skin injection

Today I worked both the AM and PM shift (700-2300).

I spent the AM shift on the ward and it was the same routine as usual: help prep/pass medication and take vital signs.

During the PM shift I switched over to the ER and performed an intradermal skin injection to test for an allergic reaction. Later during the evening an adolescent came in with severe stomach pain. The doctor on duty gave a prognosis of appendicitis in less than five minutes. He asked the patient if he had pain or blood during urination, when the last bowel movement was, and if they had measured a fever (yes for the fever which was confirmed after doing vitals upon entry to the ER). The doctor then began to press down on his stomach in four different areas each time getting closer and closer to the appendix. As soon as he touched the appendix the patient displayed extreme pain and the doctor called for a referral to the city. While waiting for the ambulance, the patient was hooked to an IV, given ranitidine via IVTT, and paracetamol PO.

Day 49 Dalaguete, Cebu #DPC Intradermal skin injection, nebulizer, ECG assist, IVTT

Today was a fairly busy night in the ER.

The first patient was an infant that came in with a 39.9 degrees Celsius fever (103.8 degrees Fahrenheit). The doctor order paracetamol PO and kept the infant in the ER for a few hours for observation. The medication reduced the infants fever so the doctor told them to come back tomorrow. Normally, the doctor would order a UA and have them wait for the results, but since it was after hours, the lab technician was already gone and wouldn't be back until tomorrow morning.   

The second patient to come in was an older gentlemen suffering from breathing problems. I administered three rounds of sulfate salbutamol via nebulizer at fifteen minute intervals after completion of each dose. The nurse hooked him to an IV and I injected hydrocortison and cefuroxime via IVTT. Prior to injecting the cefuroxime, I performed an intradermal injection skin test to confirm a negative allergic response to the antibiotic. After the injections, I helped hook him to to an ECG and prepared the printed readouts for the doctor to interpret.

I also prepped the delivery room but it turned out to be a false alarm and the patient didn't deliver that night.

Day 48 Dalaguete, Cebu #DPC Intradermal skin injection

A slow night in the ER tonight. A patient came in around 2:00AM. I performed an intradermal skin injection and the patient was admitted. Other than that, no one else came during my shift. 

Since I don't have much to say about working the floor tonight, I want to talk a little bit about the importance of rice here. I know that, if you're American, you might have heard that rice is the Asian equivalent of the potato. The only problem with that comparison is it doesn't even come close to describe how important rice is. To give you an example of how important rice is here, all you have to do is look at the language.

The word for food/eat in Bisaya is: kaon.
The word for rice in Bisaya is: kaNon.

The only difference between the word food and rice is a single consonant. In colloquial speech, the word for rice can be used to mean food -- instead of using kaon, kanon can be be used.

The word sudan roughly translates to: partner with rice. It describes the food you're going to eat with rice. At first, this word doesn't seem to describe how important rice is. It's only after you think about it that it dawns on you. The word sudan implies that rice is already going to be eaten. The fact that there's a word here that, by definition, means food secondary to rice illustrates how engrained rice is in the culture.

Rice is eaten with every meal. Sometimes rice is the meal. As long as someone has rice, they at least have something to eat. It's on every table weather you're poor or rich. It's eaten with every meal. It's on every menu (even the McDonalds here has rice on the menu). It's on every plate.

From a health perspective, this aspect of the culture is important because the genesis of a majority of health problems can be traced to rice. White rice, to be exact. All the empty carbohydrates from white rice lead to weight problems and diabetes.

The simple solution: stop eating rice.
The reality: rice is part of the culture.

Asking a Filipino to stop eating rice is the same as asking them to stop drinking water. It's the same as asking them to deny a part of their culture.


This type of dilemma is when the scientific aspect of medicine must come secondary to the human aspect. Scientifically, reducing the intake of empty carbohydrates is healthy. From a humanities standpoint, asking someone to deny their culture is inhumane. At what point is living worth more than their quality of life?

Day 46 Dalaguete, Cebu #DPC Nebulizer, Intradermal Injection

I worked he night shift today at the ER. At 3:00AM a patient came in with difficulty breathing. O2 was administered immediately by the nurse at 5mL/min. The nurse went to fetch the doctor and delegated the initial vitals to me. The vitals upon entry were as follows:

HR 120
RR 40
T 36.6 Celsius

Before I could take the BP the doctor arrived and told me to wait until he had an initial prognosis. From what I could make out in Bisaya, the patient has known food allergies and has had respiratory problems before, but she didn't recall eating anything that might have set off an allergic reaction. The doctor order Salbutamol via nebulization; three doses given at fifteen minute intervals after the completion of each dose. He then asked me to take the BP during the first Salbutamol dose. I measured her BP at 110/70; by this time her RR had decreased significantly and she was taking deep controlled breathes. The nurse hooked her up to an IV and Cortisol was injected via IVTT to help reduce the bodies stress by acting as an upregulator in an anti-inflammatory pathway. Since the cause of the constricted breathing was unknown, the doctor also order an injection of Cefuroxime (also via IVTT) to combat an early possible bacterial infection. The nurse asked me to perform an intradermal skin test injection before introducing the full dose of Cefuroxime.

Day 36 Dalaguete, Philippines #DPC Intradermal Injection

Another routine day. However, I was able to interview and understand an OPD patient using only Bisaya! There were a lot of OPD patents waiting to be interviewed so the nurse on duty just let me interview on my own and had me refer to her if I had questions. I gave another intradermal skin test injection before a patient was admitted.

Day 35 Dalaguete, Philippines #DPC Intradermal Injection

Very quite and very routine in the ER/OPD today for PM shift. More OPD patients for flu like symptoms and fevers. One patient was admitted and I administered an intradermal skin test injection. I stayed at the hospital again for night shift, but only two patients showed up suffering from flu-like symptoms. Neither of them were admitted. Neither had experienced fevers so the doctor told them to be monitored overnight and to come back if they became feverish or started vomiting.

Day 28 Dalaguete Philippines #DPC IM Injection, Intradermal Injection, Wound Care, IV Removal

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.

IV Removal

IM injection of tetanus toxoid.

NGT tube feeding.

Wound cleaning with providone-iodine (PVPI)