Thursday, March 3, 2011

Final Week: Janiuay Community Exposure (February 26 - March 2)

The morning of February 26th arrived in full sunshine, and we headed into the weekend with an orientation to our upcoming community experience set to take place in the rural district of Janiuay. Following a brief orientation and drive to reach the bamboo staff house where we would be housed for the upcoming week we headed out for our first introduction to the Barungi, Maytag-Ubo. Arriving at the community involved trekking across a river and through the following rice patties. We participated in an ocular survey (windshield survey) of the community including a further hike to view the communities main water source. That night 5 of us had the chance to be involved in the deliveries of two separate baby boys. Participating in deliveries within the community involves acting in one of the following roles: Handler ( this role involves delivering the baby, cutting the cord, and delivering the placenta), Baby care (this role includes taking the baby after birth and performing vital sign checks, cleaning, measuring, weighing and administering vital immunizations such as Vitamin K, Erythromycin, and in the Philippines Hepatitis B). The final role, the Assist exists only when there are 3 attendants (or students) available and involves stimulating Oxytocin release through massage, monitoring the mother’s vital signs, and administrating Methrogen (Oxytocin, which helps the uterus contract). These deliveries took place into the earlier morning of Sunday morning, and an exhausted group of students fell thankfully into our floor mats for a few hours of sleep.

On Sunday morning, a few of the students attended mass with the Filipino delegates. We were surprised to see that the large church was filled to capacity with worshippers, many of whom were spilling out the front doors. We later learned that there are actually 4 services held in all, each just as packed as the one we attended. This demonstrates the huge role that religion and spirituality plays in many Filipino’s lives. After mass we returned to the community to conduct epidemiological surveys, interviewing the local families to uncover trends in health related concerns. Due to monsoon type rains we unfortunately had to postpone the scheduled community assembly.

Monday was a busy day, beginning with IMCI (integrated management of childhood illness) at the Rural health Unit. We held the previously cancelled community assembly in the afternoon and had two speakers come to deliver health and leadership information to the community. Miss Santacera, a faculty member of St. Paul’s University spoke to the community on the existing community-college partnership as well as on leadership development. The second speaker was from the Department of Agriculture and discussed the pros and cons of growing mushrooms as an additional livelihood to the current broomstick making. The community was told to consider it’s options and the meeting ended in true Filipino style with a shared meal.

Tuesday morning we joined our Filipino colleagues in reporting (doing presentations) on common diseases found in the community, some of these included TB (tuberculosis), Intestinal parasites, Gastroenteritis, Rabies, and Pneumonia. Following this informative activity 6 of us went on a tour of Janiuy’s original church which was built during the Spaniard’s occupation in 1875. We also toured the cemetery and were shocked to learn that many of the plots are public plots, meaning that the family must re-rent them every 5 years to ensure a place for their loved ones to rest. The afternoon marked our final visit to the community. Once again we were privy to unseasonable downpours, and the participants’ numbers were fewer then expected. In true Filipino style we did not let the pouring rain, or humid heat deter us from having a good time. We finished our community experience by dancing with the kids, viewing a Filipino version of the turtle and the hair story, and sharing of food. A few of our members experienced the difficulty of remaining upright while trudging through the rice fields on the way home. An exchange of traditions took place in the evening when the Filipino students had their 1st taste of Smores, and the Canadian students had their first taste of Balut (a fertilized egg with a duck embryo in it). On our final day at St. Paul’s we attended a divine feast with the Sister’s of St. Pauls and ended the experience with many tears and heart felt good-byes with our Filipino delegates. This exchange of memories and good-byes, summed up an eventful, damp and truly enriching week of experiences we will surely never forget.

We have learned so much these past few months and would like to mention just a few of our observations about Filipino culture and our many learning experiences. We have built long-lasting and unforgettable relationships with so many of our Filipino colleagues and friends. Their hospitable nature, warm, caring personalities have touched us in more ways then we can express. There was never a moment when they would not go out of their way to accommodate our many needs, and always with a glowing smile in place. Their infectious laughter and humorous wit could cheer us up in our moments of illness, or simply home-sickness. This optimistic outlook in life filters into many aspects of their patient relationships and care. We have learned so much from these individuals such as how to appreciate the smaller things in life, how to relax and be more spontaneous operating on Filipino time rather then it has to happen right now. They live with the attitude of "work hard, play hard" always game for an adventure or new experience. We have picked up on how to be more resourceful and innovative in practice, observing these traits in many of the students, faculty and staff we have worked beside. We have noticed a strong family and spiritual dimension to their care, a focus on holistic care. They focus on healing not only body, but mind and spirit as well. We have learned how to live in close quarters, sacrificing our beloved privacy and personal space for constant companionship. We have noticed the benefits of using fewer gloves, turning the lack of resources into a positive, through the use of therapeutic touch. These are just a few of the many many things we have learned and appreciated these past few months.

As this will be our last blog before we head into the world as competent and caring future nurses, we would like to take the time to thank everyone who made this unbelievable experience possible. We would like to send out a huge thank you to all of the UERM and St. Paul’s faculty, staff and students who demonstrated great patience for our blunders and showed unrestrained hospitality throughout our stay. We would also like to thank the University of Saskatchewan College of Nursing and of course our very own facilitator and guide Susan Fowler-Kerry, whom without, none of this would have been possible.

Of course we cannot forget Dean Carmelita C. Divinagracia and Sister Carolina Agravante, both outstanding role models and gracious hosts. Thank you to everyone we have had the chance to interact with over these past two months, we cannot even begin to name all of the many many wonderful people who have touched and changed us. We will take this experience and all those we have met with us, using the many lessons taught to us as we finish this passage and continue on our journeys to become culturally competent and critically thinking nurses.

Farewell until we meet again.

Yours truly,

Valerie Butt, Amy Paiva, Carol Scrievner, Melanie Fontaine, Cristina Santoro, Leia Evans, Lisa Francis and Tamara Benjamin

Friday, February 25, 2011

Week 7 - Last week of our acute care practicum!

It’s hard to believe that this was the last week of our acute care practicum; the time has just flown by!! All 8 of us got to the opportunity to be placed in an Intensive care unit (ICU) this week; it was a great way to end things off.

Medical Intensive Care Unit (MICU)

We (Melanie, Tamara, Valerie and Cristina) had our rotation in the Medical Intensive Care Unit at St. Paul Hospital this past week.  The unit has a twelve bed capacity which is staffed with one head nurse, six registered nurses, and one nursing aid. The main types of cases seen in the MICU are cerebral vascular accidents, and acute respiratory illnesses (i.e. pneumonia, asthma exacerbation). Our first impression of the unit was that the physical appearance and set up were modern and very comparable to what we are used to seeing in Canada. For example, the unit had a central nursing station, spacious private rooms equipped with cardiac monitors and wall suction. As the week went on we came to realize that although the unit appeared to be similar to those back home, essential medical supplies were lacking. Although technology is available on MICU, the quality of care depends on the financial status of the patients.  As an example, in the hospital at home gloves are available in abundance here, however, patients supply the gloves and if unavailable you improvise.  Also this week we learned about the financial burdens many families face when their loved one is hospitalized, a typical cost per day would be 15,000- 20,000 php which exchanges to approximately 400- $600.00 dollars Canadian. 
One of the experiences we observed while on the unit was a patient receiving emergency medical interventions.  This patient was suffering from acute respiratory distress which was related to thick, dry secretions compromising his airway. For all of us this was our first experience observing a medical emergency where a patient was in need of intubation. This experience gave us a clear picture of what it is like working with an unstable patient given that their health status can deteriorate within minutes. Thankfully the patient was successfully intubated and stabilized due to the timely response of the MICU team.
We spent the week working with mechanical ventilators, suctioning, monitoring central venous pressure( monitors hydration status), nasogastric and PEG tube feeds, the Glasgow coma scale (assesses neuro status through best verbal response, eye opening, and motor response), decubitus ulcer (bed sore) dressing changes, and monitoring vital signs. Our final week in hospital allowed for us to refine our skills as these patients required close monitoring and in-depth assessment.  

Neonatal Intensive Care Unit (NICU)

This week Carol and Lisa were in the Neonatal Intensive Care Unit (NICU).   During this time we both had the opportunity to care for infants in all the different areas of the NICU, which meant caring for newborns with various levels of acuity.  The most common cases we observed on the unit were jaundice and premature newborns.  A more rare and severe case was a baby that had an esophageal atresia, which occurs when the esophagus ends in a pouch rather than connecting normally to the stomach, as well as a tracheal-esophageal fistula, which is an abnormal connection between the trachea and the esophagus.  This same baby also had an imperforated anus, a congenital (present from birth) defect in which the opening to the anus is missing or blocked.  Another infant had a large hemangioma, which is a benign self-involuting tumour (swelling or growth) of endothelial cells, the cells that line blood vessels.
Our roles and responsibilities on the unit included monitoring vital signs, providing regular feedings both orally and via oral-gastric tubes, testing blood glucose levels, preparing and administering IV medications, monitoring output, reconstituting medications, providing mouth care, inserting oral-gastric tubes, providing colostomy care, and administering erythromycin gel into the eyes and Vitamin K injections to newborns. 
This week we both had the opportunity to observe a circumcision, which was the first time for both of us. The procedure was difficult to watch as the baby appeared to be in excruciating pain. We were both surprised to learn that no anesthetic was provided.  It was a challenge for us to observe the remainder of the procedure knowing that the infant had received nothing for pain.
Another challenge we identified this week was when we were assigned service/charity patients that could not afford to pay for the medical care prescribed for them.  If families were unable to pay for treatments, then the patients would not get them.  An example that occurred quite frequently was medications not being available and the patient would end up missing that scheduled dose.   Another example we observed this week was one service patient with a colostomy who could not afford the proper colostomy pouch, thus the stoma was covered only with gauze and tape.  The use of gauze demonstrated to us how here in the Philippines they really utilize and manage their resources according to the situation.  However, we knew that over time the gauze would not be ideal because there is large potential for skin breakdown.  Witnessing the service patients miss out on medical treatments due to their own lack of funds made us feel fortunate to have socialized medicine back in Canada where each person has access to all treatments while in the hospital.
Overall, we had an amazing learning experience on the unit. The staff were all very welcoming to our presence and enriched our experience by answering any of the questions we had.  Although there were moments when it was difficult to witness newborns with ill health, it was rewarding to know that we could be the person that comforted them when they cried.  Our time on the unit started and ended just as quickly, however we both leave feeling more confident in our abilities to care for newborns.

Surgical Intensive Care Unit (SICU)
Amy and Leia were the students placed in the SICU this week. We started off our week with an orientation to the unit and the nursing functions that we were allowed to do and not allowed to do. This unit is a six bed capacity with acute critical patients, ranging from pediatric to geriatric patients. This week the unit census included; head injury (motor vehicle accident and craniotomy), spinal cord compression and appendectomy. Both of us got to do nasogastric tube feeds and administration of medications, suctioning of oral secretions of an endotrachial tube and tracheostomy. One thing that we both got to practice on an hourly basis for the four days was the neurological vital signs. This allowed us to assess the patients level of consciousness and ultimately if they were progressing negatively or positively with their current medical condition.
On our last day the both of us got to observe a code blue (which is a cardiac arrest) on our unit. The professionals involved were very calm and collected throughout the whole process. We imagined this process to be a lot more urgent and faster. We were thinking that this could be because it is an intensive care unit and that the experience they possess with codes has influenced how they react and practice in a high stress situation.
Overall, it was great week in SICU because of our clinical instructor, staff and the learning opportunities that were offered to us. From this exposure we both have experienced a steep learning curve. We were able to have discussions throughout the week where we both realized there is a universality of nursing care that we shared with our counterparts.


We had the opportunity to watch a velada (play) put on by some of the students at St. Paul’s University and produced by Sr. Carolina Agravante. The Velada this year marked an historic event in the life and mission of the Sisters of St. Paul of Chartres in the Philippines. It is the Sister’s 100th year of presence here in Iloilo City. The production captured the Sister’s charisma and influence in the building up of St Paul’s University through song and dance set to the music of the new generation of pop and rock.

Valerie was asked to give a lecture to a class of 4th year nursing students on her experience with type I Diabetes and the use of an insulin pump to manage her glucose levels. Valerie gave the students the opportunity to see and learn about something that they have never had first-hand experience with before. She was able to provide a view of health care from the patient’s perspective and help us all to understand the central role of the patient in the provision of health care services. Her presentation was very informative and stimulated the audience to get involved and ask questions. Great job Val!!

Tuesday, February 22, 2011

Acute Practicum: St. Paul's Hospital (February 14-20th)

February 14th-20th, 2011

Another week has flown by as we continue our journey at St.Paul's Hospital Iloilo. It was a full week of Surgical Intensive Care Unit (SICU) exposure for Melanie, Cristina & Valerie and Operating Room/Delivery Room (OR/DR) exposure for Carol, Lisa, Tamara, Leia &Amy. This week also happened to be marked by some special anniversaries!


We began on Monday, February 14th with orientation where we were introduced to our instructor. We headed straight to the unit and became familiar with the environment and patient conditions. The SICU has a 6 bed capacity and upon arrival it was at full capactiy. The nursing care is provided by two staff nurses, one charge nurse, and one nurse aide. We initiated our learning by discussing each patients case as though we were in nursing rounds. From our discussions we determined nursing diagnoses as it pertained to each client. Utilizing nursing diagnoses is heavily integrated within St.Paul's nursing curriculum. We are familiar with nursing diagnoses and we felt that our discussions allowed us to fully grasp the basics of the nursing process. This helped in identifying and prioritizing nursing interventions as it relates to each client. We were 3 students to 1 instructor. This allowed for an enviornment condusive to collaboartive and reciprocative learning which stimulated questions regarding clinical manifestations.From these discussions we were inspired to research more and more!

Many patients in SICU are admitted due to trauma and need emergency operations. The main patient cases which present include severe head injuries. Utilizing Skyscape via our iPod touches provided by the College of Nursing we were able to access evidenced based research regarding brain injury patients. We learned that the etiology demonstrates that the most common admissions are related to Motor Vehicule Accidents (19%), Falls (32%), and Assaults/Child Abuse Cases. Within this week we were exposed to all of the above. We have not had the opportunity to work with critical patients previously and St.Paul's Hospital provided our first exposure. Some of the nursing interventions and treatments provided were; neurovital sign monitoring (Glascow Coma Scale), suctioning, ventilation therapy, JP drains, chest tubes, tube feeds, measuring Cardiac Venous Pressures, and IV therapy. There were ample opportunities to enhance, reinforce and increase our confidence regarding these interventions.

On the last two days, we were joined by our Filipino delegates. Increasing our student numbers to nine students to managing a recently decreased patient load of two patients. Due to the large number of students, we utilized the "Functional Nursing Approach"of care. Fucntional Nursing is when tasks (functions) are delegated to individual nurses. For example Melanie acted as bedside nurse, Valerie as medication nurse and Cristina as Charge nurse. The following day these roles were rotated. This was challenging for us as we strongly felt that continuity of care is absent in this type of appraoch. However in these circumstances, we appreciated the alternative perspective.

After spending our week in SICU we have all developed confidence and enhanced our knowledge in managing unstable patients. We learned a great deal about head injuries and it's related clinical manifestations. The skills and comptence we have gained from the SICU will undoubtfully ease our transition from nursing students to future Registered Nurses.

Valerie administering nasagastric feeds.
Cristina preparing medications.

Melanie and the suction equipment.

Filipino & Canadian Nursing Students and Clinical Instructor.

The room set up in SICU.
The first day of our OR exposure consisted of a thorough orientation. This included a cultural survey, roles and expectations, review of the principles of sterile technique in the OR, introduction to the unit routine, and a tour. We all got to scrub in on major and minor surgeries. The major surgeries included caesarean section, cholecystectomy (removal of the gallbladder), total abdominal hysterectomy (removal of the uterus), nephrourectomy (removal of the kidney and ureter), appendectomy and much more. Some of the minor surgeries consisted of pterygium excision (removal of a conjunctival growth), cataract excision, release of trigger thumb and release of carpal tunnel ligament, arterial venous fistula (joining of the artery and vein in the arm, which is used as an IV insertion site for renal dialysis). Our role as a student nurse in the OR was the same as in UERM as discussed previously.

There was only one natural delivery the whole week that we were there. Our instructor informed us that it is more expensive to deliver in the hospital rather than at home or a community clinic. Included in our DR exposure was the opportunity to provide newborn care, this entailed, cleaning, anthropometric measurements (head and chest circumference abdominal girth and length measurements), temperature, weight, cord care, foot prints and dressing. In our observations of the labouring process, nurses in the Philippines play a lesser role and are not able to practice to their full scope when compared to Canadian delivery nurses.

Overall this week, we all experienced a steep learning curve. In the five days that we were there all of us were able to memorize the names of the most commonly used surgical instruments and this enabled us to have a very hands-on experience. The staff were welcoming, supportive and fostered an environment conducive to learning.

Tamara, Leia & Amy in one of the OR theaters.

OR team (Surgeons, Residents, Nurses, Anesthesiologist & Canadian Nursing students)

OR team.

Birthday Celebration
Tuesday, February 15th marked Melanie's birthday celebration. Our Filipino nursing student delegates had been planning a surprise celebration for a few weeks and all we were told was to be ready by 5:30 pm. The night began as we made our way to Boardwalk to watch the sunset. The students then booked a restaurant room and surprised Melanie with supper, gifts, cakes, and of course some karaoke! Each student (Canadian & Filipino) was asked to give a toast to the birthday girl. Melanie was glowing with happiness as she listened to the heart warming well wishes. We will all remember Melanie's one and only birthday in Iloilo city. Despite being busy with clinical duties, midterms, and reviewing for the nursing board exams, the Filipino students still managed to plan a wonderful evening we are sure Melanie will never forget. We extend our many thanks to all those involved in planning this special event.

Canadian Students enjoying the birthday festivities.

100 Years of Healing The Body, Nurturing The Spirit

This week was also memorable for the Iloilo community as St.Paul's hospital celebrated their 100th anniversary. Music is very much a part of the Filipino culture and what a more fitting way to showcase and celebrate this milestone than with a musical. We attended the musical for the Centennial celebration titled Faith in One Dream. Through theatrical presentation of songs and dances the vision and mission of excellent and compassionate healthcare services through the years was shown. The majority of the cast were nursing staff of St.Paul's and we were informed that they prepared for 2 months for the show! Once again we were in awe by the extraordinary talent here in the Philippines.


Fun Run 2011
The celebrations continued on the weekend as 6 of us (Melanie, Cristina, Amy, Valerie, Tamara & Lisa) participated in the St.Paul's Hospital Centennial Fun Run 2011. A 5 km run where all proceeds were donated to Madre Antoine Center Foundation. For a few of the Canadian students it was a first organized community run, but for all it was an amazing feeling to have been amagonst the 800 participants celebrating this milestone of `100 Years of Healing the Body and Nurturing the Spirit`. Many staff we have worked with during our rotations in the hospital were present and we cheered eachother on throughout the race to reach the finish line! Crossing the finish line marked this day as an accomplishement that will long be remembered. It was a fantastic way to bring the community together to promote health and wellness.  

Monday, February 14, 2011

Acute Practicum - St.Paul's Hospital Iloilo

The eight of us arrived late Sunday night in Iliolo to a warm greeting where we had a shell Lei placed on our necks from the students of St. Paul’s university. After the initial introductions we crashed in the spacious accommodations on campus that we will call home for the next 3 weeks.
Monday brought on an orientation of St. Paul’s nursing curriculum, as well as a tour of St. Paul’s hospital. We toured the many units that we will be dispersed in over the next few weeks which include; Operating room/Delivery room, Medical Intensive Care Unit, Surgical Intensive Care Unit, Neonatal intensive Care Unit, Pediatrics, Kidney/Renal Unit, and Postpartum.
Kidney Center:
Melanie, Cristina, Lisa, and Valerie were placed on the Kidney Center this week. On Tuesday morning the four of us attended the Kidney center’s 16th anniversary, which was marked by a kidney seminar. Guest speakers included Surgeons and Registered Nurses who spoke about the three treatment options for acute and chronic renal failure. That afternoon we were orientated to the Kidney Unit, learning the basics of the assessment forms, the functioning of the dialysis machines, and routines of the center.
The rest of the week we were responsible for patient care, including preparing the hemodialysis machine, monitoring vital signs of patients, and reprocessing the dialyzer. We learned that weighing the patients pre and post dialysis is crucial to evaluate the effectiveness of treatment, as it determines ultra-filtration goals of the patient (how much toxins and fluids are removed each treatment).
We thoroughly enjoyed the learning experiences on the unit, specifically the long term relationships built between the nurses and patients. This unit is unique in this area, as the patients return on weekly basis and spend long hours with the staff. This type of treatment allows for the staff to assess patients frequently, therefore evaluating the progression of their health status.
Although we spent only a short period of time on this unit, we learned a great deal from the very informative and helpful staff, students, patients and our clinical instructor. We left this unit with a positive outlook on kidney care which will be of benefit in our future nursing careers. 
Dialysis Machine (Kidney Center Iloilo)
Tamara, Amy and Leia are the three students on Pedia (pediatrics) this week. The cases on the unit that we most commonly saw were bronchopneumonia and Gastrointestinal illnesses. We were surprised that the unit was only operating at half capacity and in general their medical conditions were fairly stable. Our facilitator shared the reasoning behind this was due to the inability of families to access healthcare services which was most commonly related to limited funds.
The ward was separated into pay and service (charity) consisting of nine pay beds and five service beds. An interesting practice that we noticed was the fact that students are required to provide supplies (syringes, normal saline, gloves, etc.) that the patient’s family could not afford or did not have available at the time.
Our duties on the unit included: vital signs, medication administration, assessments, and treatments. We were paired with third year students for the first couple days and on our last day we were with fourth year students. There was a significant difference when comparing the years. We felt the third year students in the Philippines worked at much the same capacity as we did in our third year. As fourth year students we felt more equally matched in terms of clinical skills, ability to critically think through challenging clinical situations and practice independently when paired with the fourth year students.
This experience provided a good refresher of pediatric nursing, and the needs and challenges of working with this population. For example, application of medication calculations based on weight, setting IV drip rates, and working with gravity IV’s instead of IV machines. This experience gave new meaning the phrase “if there is a will there is a way.” Even with limited funds the staff and students always found a way to be innovative in meeting the needs of their patient. For example, the use of a Styrofoam cup as a way to administer aerosolized medications instead of an Aerochamber (a holding chamber to maximize the delivery of aerosolized medications, used most commonly in the pediatric population). Overall this was a great learning experience.
Neonatal Intensive Care Unit:
This week Carol was exposed to the Neonatal Intensive Care Unit (NICU). Some differences when comparing the NICU to home is that not all the patients are classified as having intensive care needs. There is a row of beds for newborns waiting for a physician’s approval to join their mothers on the obstetrics ward. This row is more like a Nursery unit. There is also a row of beds for babies that are sick, but not critical, which would be similar to our pediatric unit at home. Finally, there is also a room for critically ill babies with actual intensive care needs, such as ventilators. The entire unit is connected directly to the Delivery Room in order to immediately receive babies after birth.
I was impressed with the level of infection control in the NICU. In fact, there are even several awards hanging outside recognizing the unit for their efforts. Everyone changes their uniform and shoes upon arrival to the unit and wears a cap and mask while inside. In addition, each baby has their own supplies and instruments in order to avoid cross-contamination.
I also learned that the NICU here participates in the Mother-Baby Friendly Hospital Initiative. This initiative promotes early breastfeeding soon after birth as well as 24 hour rooming-in of the newborn with the mother. Dummies or pacifiers are not allowed in the NICU as they can interfere with attempts to establish breastfeeding and they require a different sucking pattern from the baby. There is also a policy that no bottles or formula are allowed unless a doctor deems there is a medical indication for it. Such a policy does not exist in Saskatoon. Of course I think it would be extremely difficult to implement such a policy at home due to the fact that Canadian society is strongly based on giving women the freedom of choice, which includes the choice to breastfeed or use formula. However, it was still interesting to see St. Paul’s proactive and assertive approach to promoting breastfeeding in order to create a mother-baby friendly environment.

Tuesday, February 8, 2011

Week 4: Quezon City

Our first day of our acute practicum started bright and early, with us waking at 0430 to be exact. We arrived at the University of the East Memorial Hospital and our group of eight went our separate ways, having been divided into separate wards. This week; Amy and Leia were in the Operating Room (OR) and Tamara joined them later in the week, Cristina was in Medical Intensive Care Unit (MICU), Melanie in the Critical Care Unit (CCU), Carol was in Labour and Delivery (L&D) and Obstetrics (OBs) and Tamara, Valerie and Lisa were on the Medical Pediatric Ward (MPW).
Our first day we were orientated to the unit, staff, and the most commonly used surgical instruments. As students back in Canada, we get only observational experiences in the OR but in the Philippines; students get the opportunity to scrub in. Scrubbing in includes: sterilization of the nurses hands up to the elbow, gowning yourself and also the doctors for the procedure, putting on sterile gloves properly,  preparation of the surgical instruments, and passing the instruments to the surgeons. Also on the first day we were already scrubbing into surgeries, we assisted in a caesarean section, and a vaginal hysterectomy. The second day on the unit we were scrubbed into a total abdominal hysterectomy for the full eight hours. On the third day one of us scrubbed into an open cholecystectomy, and one was only allowed to observe the laparoscopic cholecystectomy. On the fourth day we only observed a removal of a urinary stent, cataract surgery, and a polypectomy of the nasal cavity. On our last day at the OR there were two major cases, one was a neck dissection (removal of cancerous lymph nodes), and an unilateral mastectomy with a split skin graft (with stage four cancer) also one student got to observe an incision and drainage of a right inguinal abscess.
In Canada the policies and procedures regarding the OR are very strict and are required to be adhered to, otherwise nurses are reprimanded. In Canada it is required to wear closed toed shoes with disposable shoe covers, no food or drink are allowed in the OR and cell phones, all personal protective equipment (PPE) needs to be worn (gloves, mask, hair cover, goggles and gown), surgeons double glove, patients are screened for HIV/AIDS, and anyone who enters the OR is required to wear all PPE. Here in the Philippines these policies and procedures are not as strictly enforced and some are even omitted. Overall, this experience was an amazing opportunity and we are grateful to have had it.
I have been in the Philippines for nearly a month and this past week was my first experience with culture shock.  I was assigned in the Medical Intensive Care Unit (MICU) which is a four bed facility with one registered nurse and one nursing aide. Typical cases or diagnosis seen in the MICU are hepatitis, chronic kidney disease, and communicable diseases such as streptococcal meningitis to name a few. This was my first experience in intensive care and on a charity ward which is also known as a service ward.  Charity wards are for patients who cannot afford to pay for private health care service. Thus requiring the patients and families to purchase all supplies such as medications, dressing supplies, gloves, needles, etc. The MICU unit being that it is charity ward has limited resources and higher patient to nurse ratios as compared to Canada there is typically one nurse to one patient in ICU.  On MICU staff have explained that everyday proves a challenge to provide ‘ideal’ care due to lack of resources and limited supplies. The realities of a charity ward is that if a patient cannot afford a routine test or medication they will not receive treatment.  In Canada regardless of a persons socioecnomic status everyone receives standard care. This past week has impacted my practice and taught me to become resourceful to limit waste of supplies. I will forever remember the first day I stepped foot into the hospital here in the Philippines because it challenged me both personally and professionally.;
The Critical Care Unit (CCU) has a six bed capacity which also includes a hemodialysis room. The CCU nursing care is managed by two RN’s and one Nursing Aide. This unit provides care under a private delivery system – meaning that patients and families are required to pay for all services (blood work, x-rays, bed, gauze, gloves, suction tubing, medications etc.). It was a mini challenge at the beginning not only to nurse the patient, but also to tally and bill patients for any supplies used during their care. I had to make a conscious effort to fulfill this role as it would be easy not to think twice about grabbing extra supplies. It was my first experience in an ICU environment, and unfortunately it is difficult to make a comparison as I have not yet been exposed in this area back home. However, most of the equipment on the ward was modern and similar to what I have seen and used in Canada. The patients in CCU are acutely ill, and the complexity of their conditions were unlike anything I have experienced in my nursing undergraduate. One of my assigned patients had a number of treatments with which I have had experience managing previously, however never have I managed all these interventions at once. Some of the treatments managed were: nasogastric feeds, total parenteral nutrition, hemodialysis, JP drains, abdominal incision dressings, colostomy, foley catheter, cardiac monitor, ventilation, suctioning and numerous IV infusions. It was the first time I managed a patient under ventilation, and with the assistance of the Registered Nurses and Respiratory Therapists I was able to learn all about the necessary care involved which further increased my critical care knowledge. Overall I was challenged with the complexity of client conditions, and due to the guidance of the nursing staff was able to piece the puzzle of CCU!

Melanie and the nursing staff on CCU
L&D and OBs:
The first four days of my rotation were spent between the Rooming In Unit (RIU) with postpartum mothers and the Nursery with newborn babies. In the RIU, I got lots of practice conducting postpartum assessments using the acronym BUBBLESHE. This meant assessing the breasts, uterus, bowels, bladder, lochia, episiotomy, signs and symptoms (infection, pain, vital signs), homan’s sign, and emotions. In the Nursery, I did several umbilical cord dressings throughout the week, which involved cleaning, clamping, and cutting the cords. I also got experience with oral suctioning, baby baths, newborn assessments, and oral-gastric tube feedings. On the fifth day, I had the opportunity to spend the whole shift in the Delivery Room with three labouring women. The Delivery Room is a very different environment here than back in Canada. It reminded me of an operating theatre with a sterile field during the birth and restricted access. I was able to scrub in during the deliveries and perform bulb suctioning on the newborns as well as deliver the placentas. All in all, it was a great week of exposure to maternal and child health, and I am looking forward to gaining more knowledge and experience in these areas in the coming weeks.
Our experience on the MPW (Medical Pediatrics Ward) began with a tour of the ward. MPW was on the service side of the hospital and we were surprised by the low number of patients occupying the ward. We entered the ward with the preconceived notion that charity or service hospitals were crowded and hectic, however, we were then informed that there are differences among all hospitals. In some charity hospitals, only some things are free, which is the category UERM hospital fell under, than there are other hospitals in which everything is free, and it those hospitals that are overcrowded and busy. We were then orientated to the ward, and this orientation gave us the opportunity to observe and become familiar with the routine of the ward.  Throughout the week, we all had opportunities to perform assessments, prepare and administer oral and IV medications, with supervision, chart using the SOAPIE format and be Charge Nurse for the day. As Charge Nurse, our responsibilities for the day consisted of receiving endorsement, assigning patient loads, and transcribing doctors’ orders and overseeing all patients care.  There was a variety of cases present throughout the ward, Dengue was the most prevalent, however, we also seen a client that had a periorbital mass on the right eye, and there were many cases of fever with unknown causes. There was also one patient who had a unilateral cleft palate and a unilateral cleft lip. He was scheduled for surgery soon, so this provided us with an opportunity for patient education. We constructed a storybook for him that had told a story about a boy going to have a Palatoplasty surgery. We provided him with crayons, which led to a participative patient education experience and we were thrilled to hear from his relative that he did not want to go home because of the nurses on the ward.
Last Day on the Medical Pediatric Ward
We each had different experiences this week but we each felt we learned so much.  Our greatest learning came from the discussions we had about our days on the wards; There were moments on the wards when we found that the language barrier would challenge our ability to build rapport with our clients and their families. However, this obstacle encouraged us to be more creative in how we communicated with our clients and their families.  We also noticed that independent nursing interventions were implemented first before resorting to medical interventions. We do practice this back home however with the nursing shortage it has become more practical for nurses to implement medical interventions first. Although the emphasis on this practice in the Philippines may be due largely to the limited amount of resources, we think that involving the family to implement the independent nursing interventions would be most ideal for Canada. This practice would increase collaboration among patients and nurses. We also noticed that there is much emphasis on management and utilization of all resources. This entails being mindful with current and lack of resources, as well as creating resources out of nothing. One example includes us witnessing the use of an old IV bag to measure a patient’s vomitus.  Our knowledge gained from this week of acute exposure was due greatly to the staff and students, who assisted in our learning by answering all our many questions and we are thankful for that.
After our last day of clinical,Miss Jenelle, Miss Joy, and Miss Jenni spoiled us once again with their amazing hospitality and treated us to supper and dessert, as a last get together.

On Sunday, we packed our belongings once again and were about to leave to Iloilo to begin our next adventure, for some of us this will be a reunion with old friends and for others it will be an opportunity to make new friends. We are excited for this next lag of our journey and are looking forward to the new experiences to come.
We cannot believe how quickly four weeks has gone by. We would like to take this moment to send out our many thanks to all the people who have made this a wonderful experience for us. First off we would to thank Dean Carmelita Dela Cruz-Divinagracia and all of the staff and students from the University of the East Ramon Magsaysay Memorial Medical Center incorporated and St. Michael's Retreat for hosting us. We also want to thank everyone who helped make the cumulating event happen. We are grateful for the opportunity to see our new friends one last time. We will greatly miss all of our new friends.
Last group shot at our cumulating event

Saturday, February 5, 2011

Farewell Philippines

Friday the fourth was a day that came far to fast. For the four of us just doing our community practicuum our time in the Philippines has come to an end. In the morning we gathered members of the community to implement our program which invovled health teaching on the topic of hypertension, which we had identified as an issue during the assessment phase of our community organization week. Our program, which we had been working on throughout the week, had the goal of  providing the community members with knowledge on hypertension that could help lead to a reduction in the incidence and prevalence of hypertension. Our assembly began with information on what hypertension is, its possible consequences and effects on a person's health and well being. A large number of people in the community believe that medication management is all that is needed to treat their hypertension. We provided information to the community about the influence of a healthy lifestyle can have on blood pressure. We prepared posters that depicted proper portion sizes of health foods and snacks. Unfortunately a lot of the snacks that the community members are eating are unhealthy, however they are boughten from the locally own family stores. This was an ethical issue for us to provide information on eating healthier snacks as our goal was not to take away from the source of income that the store owners rely on. Lastly, in regards to diet we provided food preperation modifications. For example; cutting off the fat from the meat and not eating it. Next we went into discussing the effect exercise has on blood pressure. We provided a number of physical activity suggestions. Some of which could be done while seated, as several comunity members have already suffered consequences of hyertension like stroke and have residual weakness. We were fortunate enough to collaborate with several physiotherapy students that helped in the exercise portion of our program. We ended the assembly by providing a healthy snack of fruit salad and a carrot papaya and tuna salad, that everyone enjoyed. We all had a great time interacting with the community members and were greatful to end the practicum with such a success.

That afternoon our instructor Miss Joy informed us we would be enjoying a culminating activity. We assumed this meant a get together to visit and say goodbye to all our new friends. However, we were mistaken. In the Philippines events are always done on a grander scale and we entered the auditorium to find a whole program dedicated the our West meets East experience. There were many amazing speeches given about our time spent in the Philippines and all the great things we had learned from one another. We also were entertained by beautiful songs and several dances too, of which both the Filippino and Canadian students took part in. There was also a heartwarming slide show presentation on our experiences. The Filippino students presented us with parting gifts and kind words about the friendships we had created. It was an emotional and moving exerince to see the impact that 2 to 4 weeks can have on a person. The activities were finished off in true Filippino style with a delicious array of foods.

The four of us cannot fully express in words the grattitude that we feel to all the people who have nade our experince as rewarding as it was. We had been looking forward to this trip for such a long time, years even, that we cannot believe it has come to an end. It has truely impacted each of us on both a professional and personal level. We would like to send out our many thanks to all the people who have made this experince such a success. First off we would to thank the University of Saskatchewan and Dean Lorna Butler from the college of nursing for providing us with this great opportunity to expand our horizons and learn at an international level. We would also like to thank Sister Carol and all of the staff and students from the University of St. Paul Iloilo for hosting us for our first two weeks. Another thank you to Dean Carmelita Dela Cruz-Divinagracia and all of the staff and students from the University of the East Ramon Magsaysay Memorial Medical Center for hosting us for our second two weeks. The hospitality from both schools was overwhelming and they both provided us with truely beneficial learning experinces. We will greatly miss all of our new friends. We would also like to thank the remaining eight students for making our trip so memorable and wish you all the best on your remaining four weeks, you girls are amazing. We would also like to thank any of you out there that have been taking the time to follow our blog and share in our experinces. And last but not least, we would like to send a big thanks to Dr. Susan Kerry Fowler for being the spearhead of this program as we could not have done it without you.

As we say farewell to all of those we have had the honor of meeting in the Philippines we would like to leave you with a quote.                                                                                                                           

Some people come into our lives
and leave footprints on our hearts
and we are never ever the same.
-- Flavia Weedn

                                                All photos are posted with permission

Thursday, February 3, 2011

Last week in Antipolo

This past Monday we were lucky enough to have been asked to join a Barangay health workers graduation ceremony in Antipolo. The graduation took place in an outdoor community hall. Those in attendance included a Dr. from Chicago that works in partnership with UERM, the community midwife, barangay health workers and the ceremony was conducted by the junior residents of UERM. This was a very exciting time for both the barangay health workers graduating and for the community. The graduates consist of members of the local community who were interested in helping their community and therefore chose to become health care volunteers. They then went through six months of training to learn assessment skills such as taking vital signs and health teaching about common illnesses such as colds, fevers, and diarrhea. Since there is a lack of nurses, doctors and midwives especially in remote neighbourhood’s barangay health workers fill a gap in the delivery of health care and become one of the most valued members of the health care team focusing on Primary Health Care. The graduation ceremonies consisted of introductions, speeches and the presentation of the graduation certificates. The health care workers then presented a dance they had worked on. After it was time for a snack and picture taking. It was a very interesting event and we could really see how the community works together for the good of its people. That afternoon we were off to UERM for orientation.  The eight students staying for their acute practicum received their hospital orientation while the other four met their buddies and learned what they would be doing in the community for the week. Both groups had an opportunity to take a tour of the hospital at UERM. There are two types of hospitals in the Philippines, private and government/charity.  The hospital at UERM is classified as both a private and public hospital because it is affiliated with the university.  If a patient is able to pay for the medical services needed then they will be placed on the private side.  However, if for some reason the patient is unable to afford the price of treatment they will be placed on the public side where the government pays for the bed and the doctors but the patient is still responsible for paying for any medicine and tests they may need.  We learned from our Filipino buddies that it is common for patients on the public side to attempt to leave without paying the bill for services during their stay and if this occurs it is the nurse that is responsible for paying the bill for any medication that she/he administers. After the tour we were invited to an alumni supper were we were treated to good food and entertainment.
Tuesday morning we went into the community to perform assessments involved in the Integrated Management of Childhood Illnesses (IMCI). We assessed a couple children with coughs and colds and identified 3 children with Tuberculosis. After lunch we all sat down to discuss subjects to talk about with the community members on Wednesday afternoon at our focus group. We then surveyed a couple houses with regards to a major health problem in the community which we were able to identify as hypertension.
Wednesday we once again had the opportunity to practice giving immunizations through the Expanded Program of Immunizations (EPI) at two health units in the community. In the afternoon we conducted our focus group were we gathered community members together and discussed what they felt were some of the major health issues in the community.  We also enquired about what we could do to help them become empowered to engage in a healthier lifestyle and ultimately reduce the prevalence of health problems such as hypertension.  Through our discussion we identified that they were interested in learning more about healthier food choices that they could make and exercise activities that they could perform during their daily routine that did not involve making a commitment to organized activity because most are unable to leave their stores which for many is their only source of income.
Thursday morning we went to the Broadway Health Center where we were able to help with prenatal assessments. We assessed 4 mothers by performing Leopalds Maneouvers and listening for the fetal heart beat. In the afternoon we planned for our implementation of health teaching regarding an appropriate diet and exercise routine for a person with hypertension that we will be delivering to the members of the community on Friday morning. Following this planning session we went back out into the community to perform the Metro Manila Development Screening Tool (MMDST) which is an assessment tool used to screen for developmental delays in children under the age of five.  It is an adaptation of the Denver Screening Tool used for assessing children in Canada and the United States.  We were able to assist with the assessment of a four year old girl who we had encountered earlier in the week during our home visits.  We were informed by her aunt that the child has not spoken since birth.  We concluded that the child was within normal limits in all categories except that of language and we were able to inform her mother that it would be beneficial to have a referral to a speech therapist.  The mother was very receptive to our suggestions and it was a good way to end off the day.