Our Final Post

 

We have now reached the end of our practicums. Our adventure that we started a year ago has now drawn to a close. We are hanging up our duty dresses, and donating our shoes and scrubs in hopes they will get put to good use. After two weeks of community in rural Matag-ub, two weeks of community in urban Antipolo, one week of hospital at UERM, and three weeks at St. Paul, we feel we have learned and gained an abundant amount knowledge of Filipino nursing.  The lessons we have learned from this experience have changed our outlook immensely; we feel the extent of our experience will continue to impact us as we begin our career as registered nurses as well as in our personal lives. There are no words to describe many of our experiences, what we have witnessed, and what we have learned; we could only wish  we could  have brought you all along with us as we immersed ourselves into the Filipino lifestyle and community.

We would like to use this final blog post as an opportunity to thank those who have helped us along the way. 
To Sue, our faculty resource advisor, mentor and mother. She did her best in all of our pre-departure meetings to prepare us for our experience. But in reality,  there is no one that could have prepared us for this opportunity. We were stretched physically, emotionally and mentally on an almost daily basis; and there is nothing anyone could have done to make us realize this. Due to the distance, she encouraged and enlightened us through email. We always appreciated her insight to certain situations we found ourselves in. We look forward to meetings with her when we return from our travels to debrief with her about our experiences.

To Dean Butler and the University of Saskatchewan: we are very fortunate to attend a university that enables us the opportunity to do what we have done. We hope that a healthy relationship will be maintained between all institutions so as to give future students the opportunity to experience what we have. Also to Marlene Smadu and Elaine Maksymiw, who ensured that our experience went smoothly and ensured the legalities of the trip were understood and reviewed. Thank you also to all University of Saskatchewan faculty and staff who worked hard to ensure all the details were covered. 

To Dean Carmelita, and all our instructors at UERM, thank you for your time and effort for our time exposed in the hospital, it was short but sweet. The community nursing we did there was rewarding, however we only wished we had more time to see if what we had done had an effect on the health of those we encountered. The events we were fortunate enough to attend gave us the opportunity to further immerse ourselves in the culture and also to see a different side of nursing education. 

To Sister Carol and all the Sisters, instructors, hospital staff and administrators of St. Paul Hospital and University, thank you for your warm hospitality, kindness, instruction and patience. We were really enjoyed community and hospital immersion and the opportunity to rotate through the wards we did. 
We would definitely accept another invitation for another meal at the Sisters’ residence, it was an honor to have shared two meals with them. The instructors will be remembered for their ingenuity and for opening our eyes to the differences in health care delivery. 

To the students, at first strangers to us, you helped us, shared with us, cooked for us, and were very open to learning with us. We have learned a lot from all of you, we feel very fortunate to have been paired with such a great group of students from both institutions. Thank you also to the students who took their time to plan extra excursions for us to experience a different side of Filipino culture. 

To our family, friends and loved ones; thank you for the support you provided us with, it was welcomed many a times. 

Our final day in Iloilo we had a tearful yet enjoyable day with the students and instructors. They did a great job of ending the immersion with a slideshow, song, dance, and of course food! It really gave a sense of what sort of impact this trip has had, both for us and for them. 

It is now the end of our excursion and we felt a little hesitant to leave Iloilo. However we are looking forward to our travels; the five of us have further destinations awaiting to be explored! 

We hope the blog has been an enjoyable read, thank you all for following it! 

Brooke, Elaine, Leah, Lerissa and Sharaya 

Medical Intensive Care Unit

Our white scrub dresses clashed with the green clean flip flops we were required to wear in the Medical Intensive Care Unit.  These were a requirement by St. Paul’s Hospital in order to lower risk of infection of patients from the people outside to patients who were very sick.  The brand new 12 bed unit had 8 patients with a wide array of illnesses that we encountered on our first shift.  We were assigned to one patient each with a student nurse partner.  We enjoyed the companionship on our first day there. For the final 2 days we worked independently.  The staff and our facilitator were very supportive during these days.

We were able to practice and perfect many skills that were introduced to us in during our SICU immersion. These included neuro assessments, as well as Central Venous Pressure readings, general assessment, vitals, tube feed by hand, medications, suctioning, turning and position, ET and oral suctioning, working with ventilators, CPR, and hyperventilation with an ambu-bag.  Many of the patients we worked with had low consciousness (about 5/15 on the Glascow Coma Scale) or were ventilated and therefore were challenging to communicate with. We made use of note pads, body language and shaking and nodding of heads. Even when we could communicate with the patient there was a slight language barrier so we relied on patience and the help of the nurses. Sometimes verbal communication was not necessary, it was more nonverbal that was more important and meaningful for interaction. A simple touch to comfort a client or a family member of a dying patient can be more effective than words.

This rotation weighed heavily on our emotions because 3 of our patients passed away over this short amount of time.  This was the first time for 4 of us to experience death of a patient.  It was a new experience because we really saw how our responsibility during end of life care switched from focus on the patient to family centered care.  It was disheartening to see families in so much distress.  On top of this, we had to gain a comprehensive grasp in addressing these situations with barriers such as language, and cultural practice. Because of this, a few of us were able to assist with post-mortem care.

We feel fortunate enough to have had the opportunity to rotate through the different wards that we did. Each place taught us life lessons that we will apply in our practice. We learned of the caring nature, patience and kind-heartedness required for all. We may not have been able to have this same experience at home, we learned things in a different way that will forever affect us.

 

Neonatal Intensive Care Unit

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We spent 2 wonderful days in the Neonatal Intensive Care Unit.  We were all excited…and some of us more nervous than others to begin. Miss Karla was a good instructor and helped us with basics and getting over our initial fears. The NICU is a sterile area, which required us to change our scrubs everytime we left and entered the unit. We were also required to wear slippers, or as we would call them, sandals. They are used as a method for infection control. They were very uncomfortable and we felt they were not ergonomically appropriate for a nurse working a 12 hour shift. They did not support and we felt tired after wearing them, even for an 8 hour day.

The unit had space for 18 babies. There was 1 isolation room, room for 5 babies in the intensive area, and in the well-baby area there was room for 16 babies. During our two days there, there were 10 babies in the well-baby area, and 4 preterm infants in the intensive care area. In the intensive area it was 1:1 nursing care, while in the well-baby area it was anywhere between 2-5 babies for 1 nurse.

We felt slightly apprehensive at first; the bodies of some of the preterm infants fit snugly in the palms of our hands. They were so tiny and fragile, but our motherly insticnts kicked in and we provided the babies with what they needed, the sense of touch. These babies needed constant monitoring because they are so delicate and susceptible to microorganism.

On the well baby side of NICU, the babies had either come into the hospital with some kind of problem or had just been delivered via C-section. Three of the babies were under the light that filters a specific light wave to help with treatment for jaundice.  It was difficult to comfort these babies and try to keep them under the light at the same time.  Many time they would begin to cry, but even a soft touch to their body often would calm them.

On the intensive side, there were 4 babies who required the use of the incubator. Other treatments included oral and gastric tube feeding, breathing tube, oxygen monitor, and IV’s. These babies were unbelievably tiny, only taken out when a new IV needed to be started. We noticed the use of black, red and white color markers; researchers say that those 3 colors are of the first that are identified by a premie and can aid in the development of the eye and color distinction.

The importance of touch therapy really came into play.  It was hard giving the injections, as the babies would always cry. In Erickson’s Model of Development the first stages are trust and mistrust. A strategy used to help with the proper development baby was picking him/her up and calmed with the use of gentle speech, humming as well as holding baby close and rocking back and forth; it ensured security and safety in the baby.

Another new task that we learned to perform was feeding through tiny oral-gastric tubes.  The babies who required these either were having trouble sucking, or could not keep food down. Some of the babies were there due to elevated white blood cell count, which indicates infection. Another strategy used to increase infection control was the restriction of parents visiting.  In many cases parents were only allowed to view their baby from a window for a set amount of time.  Moms were allowed to come in to breast feed, but were required to change into a specified uniform.

We were conflicted with this practice only because of our beliefs in the importance of touch therapy, but understood the importance of decreasing the chance of spread of infection, especially with lives that have just begun.  It was hard for some of us to terminate with these patients because they were so vulnerable, and our maternal desire to protect them had kicked in.  All in all this was a great rotation, learning the importance of safety not only for the protection from outside sources, but also ensuring our tiny patients felt safe and secure

Kidney Service Unit

Our last rotation was on the Kidney ward where we learned how to set up, monitor, and terminate dialysis treatment. There is a lot of steps and tubes to use. We cannot say even now after 2 days we would remember how to do it. It was a challenge for sure. It is great being able to learn the information and have the knowledge base so you can explain to your patients what they will be experiencing. The rest of the time we spent taking vital signs. 

The interesting thing is we had to wear nursing caps. We do not wear them in Canada, because they are an infection risk. In a few years we also think they will be phased out in the Philippines as well for this reason. It was nice to be able to actually experience what the caps feel like and to work wearing them. They were not heavy and if you pinned them well they would not fall. We liked wearing it because it identified us as a nurse and people knew who we were.
 
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Operating Room at St. Paul

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For the second last rotation at St. Paul we were assigned duty in the operating room.  This was a great experience for us as we do not normally have the opportunity to work in this area back home.  However,  we also lack the essential knowledge needed for working in such an area.  The first day we spent orientating to the unit and learning new skills such as:

- How to sterile glove and gown oneself

- How to sterile glove and gown the doctor

- Sterile Scrubbing

- How to set up a sterile field

- Common equipment, tools, and their names

- Cleaning the equipment

- The 13 rinciples of sterile technique

- Role of scrub and circulating nurse

- Pre-op, intra-op and post-op care of patients

- Delivery room (prenatal care, delivery, and postnatal care)

We were each able to see surgeries and either assist as a scrub nurse or circulating nurse.  This was a good experience for us all as we gained greater knowledge of the OR and general anatomy and physiology.  On our last day the head nurse and the preceptor gave us a parting gift of nursing stickers/pins and pizza.  They really enjoyed having Canadian students working with them.  As well we also enjoyed them as we found them welcoming and helpful.

The Delivery Room Suite

One of four delivery rooms

The OR had a gallery where we could view surgeries from above.  This was neat as you could better visualize the surgical area without being in the room.  Here we met with out instructor for conferences.

The Or staff gave us gifts upon our departure. They included gifts of nursing pins and stickers.  We also had pizza (pictured here).

Us with our clinical instructor (Miss. Rossaline) and the head nurse (Sir. Miguel) and preceptor (Miss. Gly)

One of the four operating rooms 

Charity Wards at UERM

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Walking into the white walls of UREMMCI Monday morning at 5:45am sent feelings excitement and nervousness into our stomachs.  We had not been in a hospital for a while and we were apprehensive about this busy, urban, public hospital.  We met briefly with our clinical instructor who then took us to our respective wards for the week.  Three of us were left in the cool, air-conditioned Pay wards, while Lerissa and Elaine took the bridge across to the Charity building.

Lerissa was dropped off first onto the Neuro ward.  This cramped ward held 12 patient beds down a long corridor that branched off into surgery recovery.  The only privacy given to the patients was one green portable screen that was used during morning care and shared with the surgical unit.  Elaine was dropped off next, into the ICU.  It consisted of a tiny room off a busy 30-bed medical ward.  The room had three beds, a nursing desk, some outdated equipment, and a lot of people in very little space.

We were shocked when comparing these units to our Canadian ones, where patient privacy is an important design incorporated into each ward, even if it is only a curtain separation.    The equipment on the units was very old in comparison to the technology in Canada, though it was still in good working condition.  Also, the few fans and open windows could not rid the unit or us of the heat.

We were definitely on Charity wards.  These wards are units that have been subsidized for patients that cannot afford the Pay wards such as described in Leah’s blog.  These wards are typically overseen by residents, student nurses and experienced ward nurses.  A bed that would cost you to rent on a Pay ward is free on a Charity ward, but the medication and other equipment cost money to use.  The amount of money needed for the improvement of health is very expensive when you set out the figures.  The patient’s family would be sent out to buy medications prescribed by the Nurse under the Doctor’s orders.  Even supplies as simple as wash cloths are brought in by the family.

The resources on these wards were then very limited and in some cases supplies used were not ideal.  For example clean gloves are often used during sterile procedures due to cost and availability issues.  Additionally, if a new endotracheal tube was needed, the family would have to go buy one.  If residents inserting the tube were unable to make it the first time, due to lack of experience, the tube would be re-inserted multiple times or the families would have to go buy another one, costing them yet more money.  Furthermore, this increases the patient’s chances of infection.

The idea that you have to bring your own wash cloths or worry about what every pain pill would cost seems like a reality out of this world.   It unearthed another harsh fact that became reality for us; many people could not afford to pay for everything and as a result some patients died.  This was a very challenging concept for us to accept, coming from a system where death is not usually directly associated with a lack of resources.

Although there are limited resources there was great ingenuity in creating something from nothing.  The staff on the Charity wards made their best attempt to reduce waste while using highly innovative ways of caring and treating patients.  The ways that certain items were reused with successful patient outcomes made us question again if our system was wasting certain equipment.  The creativity seen here we find may sometimes be lacking at home because only in rare cases is there a deficit of resources.  This fact also made us appreciate the abundance of supplies we have at our fingertips in Canada.

It was very difficult for us to work in an environment knowing that someone may die because they cannot afford medication or lifesaving equipment.  We struggled to cope with feeling helpless, and seeing how a health care system can fail its people in which everything could be lost in the process of healing.  Then a set of wise words were spoken by one of our preceptors: “If you have helped someone today, even if it’s the only person you will ever help in your life, consider yourself lucky because you made a difference for someone.”  So even though we cannot change the whole system, we can make a difference to one person and that is what nursing is about.

Roxas and Boracay: A Weekend Away

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This past weekend we travelled north of Iloilo to visit the other parts of the island of Panay.  On Friday after we finished our duty on Medical ICU, the five of us along with eight St. Paul students, and four clinical instructors hopped into a van and we drove, and drove and drove!  We ended up in Roxas, which is about a four hour drive north of Iloilo city. It was a nice drive, winding through the roads of the country side, seeing the mountains and rice patties is a beautiful change from the prairies of Saskatchewan, although there were times the wide expanse of our homeland would be welcome. There is little break between town and city, there is a large numbers of houses that are right off the road from the busy highway. The drivers drive along at break neck speeds, sometimes in the wrong lane; quite unsettling at times. We really appreciate the traffic laws and enforcement that we would find at home in Canada. Arriving safely at our destination called Espacio Verde (meaning green space in Spanish), we were treated to soup, oysters, kabobs, rice, and chicken, and one of the best desserts we’ve ever tasted. But, like many of the foods here, the names are hard to remember! It was authentic Filipino and therefore delicious, but even more so because we were so hungry! Espacio Verde is a water-park that has open areas for bumper boating, water-sliding, and a large entertainment area that we assumed does functions such as weddings. It was a beautiful little oasis that was welcomed following our long drive.

After dinner we had a Filipino-style tour of the city of Roxas. We enjoyed the pace of it, very laid back compared to the larger cities we have been in. After our tour, it was a short 20 minute drive to the house of Hannah Morales. She is a fourth year nursing student at St. Paul and had us all stay at her house for Friday evening. Her home was beautiful, and, like all Filipino people, her family was very welcoming. We were shown our quarters and took them gladly, as we were informed that we were to be up at 4:30 am the following morning to attend a fish harvest. 4:30am seemed like a lot to ask for when we had had such a busy week. But being gracious guests, we got up in the wee hours of the morning and hopped in the back of a big truck that took us to the edge of a big pond; we didn’t know about it at the time though as it was still dark out. We walked for about a kilometer through the mud and grass and arrived at a house that was perched on the side of a damn. The men were harvesting the fish that funnelled through the open damn. The men then caught the fish in a net and used a human chain to sort the fish with their counterparts. The type of fish that were caught included milk fish, crabs, and prawns. It was a very cool process to watch and we were very lucky to see it happen, as this harvest only happens once every four months! As the sun was rising, we watched the men harvest and pick through the muddy water for the fish. It was absolutely beautiful and after the harvest we were treated to the fresh fish, prawns and crab that were caught, bananas, mango, papaya, and roast pig! It was a great start to the day.

After this, we got into the van again and drove the three hours to Caticlan, the port city that is the gateway to the famed Boracay . Just about everyone that we have met has asked us if we have visited Boracay , and if not, asked us when we will be going there. After the 15 minute boat ride, we realized why. The island of Boracay  is a seven kilometer stretch of white sand beach surrounded with clear ocean water, and breathtaking. The island is very touristy and commercialized, but it very understandable why people come here: to bask in the sunshine on one of the world’s most beautiful islands. Us Canadians were able to soak up some sun and appreciated the opportunity to relax and take in the surroundings. We made friends with Australians, Koreans, and enhanced the bonds of friendship that we have formed with our Philippine students.

The weekend was very tiring but worth every minute due to the opportunities we were given. We appreciated all the work the students and clinical instructors put in to taking the time to plan the excursion.  On Sunday we felt hesitant to leave the island oasis, but glad we were given the opportunity to visit the places we did.  Between the work we do for duty, the research, journaling, and blogging, it leaves little time for rest, so when we are given the chance to unwind we enjoy ourselves very much.

Brooke and Leah enjoying the food at the resort where we had supper on Friday night. Brooke, Leah, Sharaya, Lerissa, and Elaine at Honie’s house in Roxas

Supper out with the students on Saturday night.  We wanted an “American” supper so we had burgers and fries. The fishery in RoxasThe sunset at the fishery.  This area is normally covered with water, but is drained when they open the dam in order to catch the fish.  Boracay beach sunset

Medical Intensive Care Unit: St.Paul Hospital

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Our white scrub dresses clashed with the green clean flip flops we were required to wear in the Medical Intensive Care Unit.  These were a requirement by St. Paul’s Hospital in order to lower risk of infection of patients from the people outside to patients who were very sick.  The brand new 12 bed unit had 8 patients with a wide array of illnesses that we encountered on our first shift.  We were assigned to one patient each with a student nurse partner.  We enjoyed the companionship on our first day there. For the final 2 days we worked independently.  The staff and our facilitator were very supportive during these days.

We were able to practice and perfect many skills that were introduced to us in during our SICU immersion. These included neuro assessments, as well as Central Venous Pressure readings, general assessment, vitals, tube feed by hand, medications, suctioning, turning and position, ET and oral suctioning, working with ventilators, CPR, and hyperventilation with an ambu-bag.  Many of the patients we worked with had low consciousness (about 5/15 on the Glascow Coma Scale) or were ventilated and therefore were challenging to communicate with. We made use of note pads, body language and shaking and nodding of heads. Even when we could communicate with the patient there was a slight language barrier so we relied on patience and the help of the nurses. Sometimes verbal communication was not necessary, it was more nonverbal that was more important and meaningful for interaction. A simple touch to comfort a client or a family member of a dying patient can be more effective than words.

This rotation weighed heavily on our emotions because 3 of our patients passed away over this short amount of time.  This was the first time for 4 of us to experience death of a patient.  It was a new experience because we really saw how our responsibility during end of life care switched from focus on the patient to family centered care.  It was disheartening to see families in so much distress.  On top of this, we had to gain a comprehensive grasp in addressing these situations with barriers such as language, and cultural practice. Because of this, a few of us were able to assist with post-mortem care.

We feel fortunate enough to have had the opportunity to rotate through the different wards that we did. Each place taught us life lessons that we will apply in our practice. We learned of the caring nature, patience and kind-heartedness required for all. We may not have been able to have this same experience at home, we learned things in a different way that will forever affect us.

Surgical Intensive Care Unit at St. Paul’s Hospital in Iloilo

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We are back in Iloilo after three weeks of clinical in Manila.  The rotations were a great learning experience and we are thankful for our time there.  Our last three weeks in Iloilo will consist of five acute care areas, which include Surgical Intensive Care, Medical Intensive Care, Neonatal Intensive Care, Delivery Room/Operating Room, and the Kidney Ward (Dialysis).  Each of us are thrilled at the opportunity to work not only in one area, but several. At home in Canada doing our senior practicums, we would only be exposed in strictly one area for six weeks. We are hoping the time in these areas will give us a greater understanding of them and help give us some direction in possible areas where we would like to work.

Surgical ICU was intimidating for us initially as none of us have cared for a patient as acute as the ones admitted to this ward.  Our clinical instructor, Mrs. Marianne was amazing!  We told her that as students in Canada we are not given the opportunity to be exposed in the ICU. She understood this, as working within the intensive care takes skill, time, and a good grasp of basic life support measures. She took the time to review important pathophysiology, acid base balance, and other vital concepts with us prior to our time on the ward.  We felt much more prepared and ready to provide care after our orientation.

Initially after receiving endorsement, or as we call it in Canada, report, we felt it was quite  challenging due to the language barrier and difference in charting.  Charting is done differently than we are used to as in this hospital they are using DAR (data, assessment, response), but we are learning and adapting to their system.  There are certain things we like about their charting and others we will be happy to have back in Canada.  One thing we noticed when giving insulin, there is a specific sheet to mark where you injected as not to use the same spot over and over and you rotate effectively through all areas.  This is beneficial to the patient as they are at less risk for developing subcutaneous skin problems due to needle pokes in the same area.  We thought this was a great documentation tool.

Ms. Marianne is not an instructor we will soon forget. We enjoyed her patience, kindness and respect for patients. Her goal for us is to become nurse who have “the eye of an eagle, the hand of a lady, and the heart of a lover”. Anyone can carry out basic nursing functions, however it is our heart and kindness that can set us apart from robots. We learned more than just suctioning and how to take a set of neurology vital signs from her, which of course are important, but when we apply the compassion we have, that is when we can and will make a difference for the clients we encounter. This is something that no book can teach, but it is something that we must find in ourselves and learn the skills to become better nurses.

Operating Room at UERMMMCI

Brooke and Sharaya have had the opportunity to work in the operating room (OR) for this rotation.  We start our day at 6am sharp, which means a very early morning.  Our attire consists of white shoes, white tights, white scrub dress, and hair in a tight bun.  We walk to the hospital in these dresses and change into our normal “Canadian” scrubs for the OR.

Our initial reaction to the hospital was a feeling of being brought back into time.  The hospital is not as modern as we are accustom to, but rather “war time” looking.  The hospital has open windows for air flow and ventilation.  There are no automatic doors.  The machinery is archaic and does not always work that well except for the odd looking modern machine.  As well the beds are not automatic, but crank.  However, it has been a good experience for us to work in this type of environment as we will have a greater appreciation for our “wealthy” hospital system at home.  It is also beneficial to see how other hospital system in the world run.

Our second day was better and more eventful (as the first day we had no opportunity to watch a surgery).  First thing in the morning we assisted with a Total Abdominal Hysterectomy with Bilateral Salpingo and Oophorectomy.  Brooke assisted as a scrub nurse and Sharaya assisted as a circulating nurse.  The role of the scrub nurse is to maintain sterility of the equipment and hand tools to the doctor.  The role of circulating nurse is to count the equipment, document, and gather extra supplies as needed during the surgery.  During this time we both learned the names of the tools used and familiarized ourselves with them.  The nurses gave us a test at the end of the day ensuring we knew them.  We also had a training session at the university later in the day where we had to demonstrate proper sterile gowning and gloving.  We are thankful to be able to have this experience now as we have not previously in Canada.  Even though the learning has been steep we have found it very beneficial.

We are intrigued by how resourceful Filipino people are.  Even though they may not have access to all the latest equipment they use what they have to its full potential.  We think this can be a benefit as we often rely too heavily at home on equipment to provide us with information.  A manual blood pressure can sometimes be more accurate than BP taken by a machine.  They also acquire a lot less waste than we have in Canada.  We can gain a lot from working within their health care system.

Overall, this OR experience has been amazing.  We have both had the opportunity to scrub in and circulate for different surgeries.  We feel very grateful as this is not an option in Canada and we believe something that could be very beneficial to students.  By seeing the surgery your patient goes through you can better understand why they may be in so much pain or having troubles with ambulation, etc.  It may have been difficult at times as we saw them do things in a different way we may at home but we had to remind ourselves that we are in a developing world and they are doing the best that they can!  It was a very worthwhile experience and we had a lot of fun throughout the week!

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