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

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