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 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)