Critical Care on the Pay Ward at UERMMMCI

University of the East Ramon Magsaysay Memorial Medical Center Incorporated is a busy hospital in the middle of the bustling Quezon City, Manila. The medical center is located across the street from the University of the East where medical, nursing and physiotherapy students attend classes. The tertiary center engages in the practice of medicine, nursing, physical therapy, public health, biomedical and health services research. The Medical Center is composed of six major units namely: University Hospital, (which has both pay and teaching/clinical divisions & the University Health Service),  the four academic units, namely: Colleges of Medicine, Nursing, Physical Therapy and the Graduate School for Nursing. The sixth unit is the Research Institute (UERMMMC website).
Leah had the opportunity to work on the Critical Care ward. This is an 8 bed ward that has the capacity for 5 patients requiring critical care, 1 room that is used for hemodialysis, and 2 rooms that are used for stroke watch. The ward was not very busy during her days there with 2-3 patients during the week. The patients in the stoke bay are monitored by staff members from the neurology ward. They conduct neuro assessments hourly to ensure that the patient who has experienced a stroke does not suffer any further deficits.
The Critical Care ward is part of the pay division of the hospital. This ward is well enclosed with features including air conditioning, good lighting, and individual rooms that provide a sense of privacy for the patient and their family members. All beds on the ward are within the visual field of the nurses desk, providing for the nurses to monitor the patients at all times. The equipment found here may not be as advanced as what we have at home but it is effective and the Filipino’s use what resources they have to their best ability. For example a patient who requires feeding through a nasogastric tube does not typically use a continuous infusion pump, a resource that, at home in Canada, is utilized most of the time as we have the resources. A patients family must pay for all pumps used so typically they opt to not use them so the nurses must manually feed, which can be time consuming but is very essential that the patient receive the adequate nutrients.  The patients family must pay for everything, depending on how much oxygen therapy is required is an added cost; ie. 10L/min would cost more than 6L/min; for an IV catheter to be inserted, there is an insertion fee on top of the fee for the supplies used; every medication, feed, treatment, bandaid, linen change, diaper used, etc. is tallied and recorded on the computer system that regulates the amount the patient and their family owes. This was quite astonishing to look at and when Leah voiced her thoughts about this, the Filipino nurses were also astonished that people do not have to pay for hospital services in Canada. To them that is a norm but coming from Canada, providing equal and dignified treatment to all citizens, no matter what their income may be, is the norm.
On the pay ward all medical care is provided by the doctors; the residents are working under direct supervision of the doctors. Leah was limited in some opportunities as to what she could do as the medical students were there practicing their skills, as UERMMMCI is a teaching hospital.
The nursing care provided on critical care is one patient to one nurse. Hourly assessments are done and the type of nursing functions Leah was able to carry out included feeding via nasogastric tube, medication administration, suctioning and patient comfort measures. The nurses were helpful, many of them going the extra mile and were great teachers. They brought in a Filipino treat of banana milk, ice and tapioca, unfortunately the name has been forgotten but it was well appreciated. It was great to begin the hospital immersion on this ward, many lessons were learned when the opportunities presented themselves and were sought. It is great to see another side of health care delivery; it really makes one appreciate what the Canadian health care system can offer to those when they need it the most.
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Operating Room Photographs

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Sharaya and Brooke in the OR – hats on, masks on, booties on!

Just working on the self-directed learning!

The area where you do your scrubbing before surgery!

The largest operating room – OR 3.  In this room was the first operation we were able to observe and also take part in.  It was a TABHSO (total abdominal hysterectomy with bilateral salpingo oophorectomy and Brooke scrubbed in while Sharaya circulated!

Difficult Encounters

Sometime as nurses we are faced with difficult situations that challenge us personally, morally, and cognitively. One opportunity that was presented to us during our community rotation was to partake in the Tuberculosis Directly Observed Therapy, also known as the DOTS program. TB is a common disease here in the Philippines, in Canada we also have a higher prevalence in certain areas. It is something that Canada no longer vaccinates for; however the incidence and prevalence of the disease are increasing. The plan for us was to be observing the counseling and the medication administration of the TB drugs to new active TB cases.

We were informed that we would be provided with a simple mask for our protection. As we have learned, TB is transmitted via the aerosol route. At home in Canada we use N95 respirators and reverse isolation rooms that are used to prevent the transmission of TB. N95 respirators are masks that are more finely woven compared to a simple mask, ensuring that the bacterium cannot permeate the mask. We were told that in order to lessen the chance of transmission we could use techniques such as turning of our bodies, standing at the back of the room, using the simple mask, and that the positive cases will not be talking. We didn’t feel that the simple mask would be effective enough for our protection. We do realize we have more than likely been exposed to TB already, having worked in the community but felt that more cases in one location meant a greater chance of being infected. We took the information presented to us and discussed it amongst our group using our emic perspective and felt that the risks outweighed the benefits of us attending the program.  We were really conflicted as we did want to offend anyone by not attending the program but we also did not want to put ourselves into a position where we felt uncomfortable. In the end we decided not to attend the program. 

After making this difficult decision, we discussed with Susan Fowler-Kerry, our faculty resource advisor and mentor, she enlightened us with her view of the situation. We knew when we signed up for this trip that we would be exposed to infectious diseases  and that we would experience personal difficulties however we did not know to what extent. There was no way that she or anyone for that matter could prepare us for what we would be experiencing. What we have learned from this situation is that TB is but one of many communicable diseases that we will be exposed to. TB is less contagious than other diseases such as influenza or chicken pox. A person needs more than one exposure to be infected, exposure may not always mean you will get TB. We do not exhibit risks factors which include being immunocomprised, living in cramped conditions, being Aboriginal, and being homeless, or incarcerated. Rates are higher among children and that is who we were working with in Janiuay. 

What we have learned from this is that we should have looked outside of our emic view, researched and informed ourselves in greater depth. Had we known, we would have felt more comfortable bringing our own N95 masks in order to protect ourselves and not miss out on an opportunity. 

This experience has given us the opportunity to use our critical thinking abilities and make decisions on our own. This will help us in our practice as we are working towards becoming autonomous nurses. We will continue to question our own thoughts, actions, and feelings in order to better our practice; to live each day with the goal of being a lifelong learner.

 

Community Nursing

For the past two years of our nursing schooling we have been required to take a class on community nursing.  In our final year we participate in a clinical rotation in an area in our Saskatoon community.  Each of us experienced various clinical settings, but would agree that none of them can compete with the experiences we have had here working in the Filipino community.  After sitting through endless hours of classes where we were lectured on community and related theories we saw and experienced firsthand data in action.

Community health nursing is defined as a nurse who works in the community where people live, work, learn, meet, and play in order to promote health (NEPS 427 Notes).  Once this was just a definition to us, but now it has become a way of nursing.  For the past four weeks we spent every day in the community working in various roles and capacities.  When we were in Iloilo we hiked to our adopted community through very muddy rice paddies and endured the suns extreme heat.  It was new for us to actually leave the hospital or health center and see people in their homes.  For each of us we learned that in order for health to improve with individuals/families we need to go directly to the people.  The people of this community would not normally seek medical help, because it is too far to travel thus their current health status is poor.  Even with our visit only 3 times a week, the health of the community has seen improvement.  People opened their homes to us and were interested in what we had to offer in terms of health teaching and physical assessment.  It was an incredible experience to participate in community nursing at the very core of what it was intended to be.  In Canada we would never have had this opportunity to learn and for the reality of bringing health care to the people became so real.  It has forever changed the way we view community nursing and the phrase “health care for all”.  We believe that bringing health to the people where they live is essential in seeing long term medication compliance and positive health outcomes.

We also learned and applied the nursing process for community nursing, which consists of:

a) Assessment

b) Planning

c) Implementation

d) Evaluation

It is one thing to learn about this process in class and memorize it for an exam, but it is even more worthwhile when we use it.  We applied these important steps with our adopted community in Antipolo in the Barangy of Inarawan.  Here the process became real for each one of us and we gained a greater understanding of how to use it and why it is important.

The Process in Action:

a) On our first day of assessment we walked through the community and did an ocular survey.  This means we noted the type of people who lived there, the living conditions, environmental hazards, and other important factors what would affect our plan of action.  We then did home visits which means going into homes where people live and interviewed them using an assessment sheet we were given.  Here we looked at the number of people who lived in the home, their education status, age, and health problems.  We looked at the living conditions, income, community involvement, and other relevant information.  In total we interviewed 10 families.

b) We then used the information from the assessment and looked for common themes.  This is the basis we used to figure out what was our health care focus.  From our data we concluded that high blood pressure, or hypertension was the main issue we needed to address.  We took this topic and created a program for the members of the community that we would present to later in the week.  Our program consisted of: a registration table where blood pressure was taken, heart healthy exercises to get people moving, a pamphlet (we made in English and was translated to Tagalog) for further reading to take home with them, verbal teaching of the information in the pamphlet, and education about proper meal planning. We concluded with some fun, dancing with us Canadian students (taught them a line dance), laughing yoga for stress relief, and a healthy culturally appropriate snack.

c)  We met the leaders of the community and asked their permission to run the program at the main “covered court”.  We were granted permission and thus implemented the program.  In total we had forty people attend the session.

d) Due to the lack of time in this area we were unable to go back and evaluate the effectiveness of our program.  We did leave our information we gathered on the community with the students so they can do some follow up with the residents later.

Overall it was a very fun and worthwhile experience.  It is one thing to learn about the community development process in class, but it is another thing to go out and apply our skills that can raise awareness and better the health of those we encounter.

Side Note:  Hypertension and strokes are very common here as the poor high salt diet and lack of exercise are a precursor for these conditions.  In the hospital they are some of the main issues.  Many people dies from both.

Lerissa and Sharaya holding the invitation posters for our Hypertension program

Lerissa and Brooke walking through the community during our ocular survey for the community assessment. 

The Posters we created and used to teach the members of the community. 

 

Indigiousness Filipino Community: Barangay Matag-ub

Throughout this entire practicum we have been looking forward to visiting the Aeta community in Barangay Matag-ub. The Aeta people are indigenous Filipinos, who are known for their curly hair and dark skin tone. They were the sole Filipinos before the Spanish colonization. The Aeta are nomadic, meaning they move often and rarely live in the same location. In order to get to the community we travelled via tricycles, took a 20-30 minute hike up a tropical mountain, and crossed a river. The terrain, at times, was difficult to trek through because the rice patties were very slippery, as evidence by Shawn’s muddy pants. We were amazed by the beautiful scenery, and felt that this was the epitome of community nursing!

Walking through the river to get to Matag-ub Community (Permission granted to post pictures)

 

When we arrived in the community we were taken on a hike to the location where the Aeta retrieve their drinking water. It was a 10 minute walk through the forest, across more rice paddies, and several bamboo tree bridges. The bridges had broken and often no side rails testing our stability and required team support. We found this difficult carrying nothing, let alone that the Aetas community members have to carry water while tackling this course!

Water Supply (permission granted to post pictures)

 

At the community chapel in Matag-ub, we implemented IMCI with the help of the students, and socialized with the children. In the afternoon we went on home visits within the community. We assessed the health needs of the families and gave appropriate counseling and health teaching. Also, we noted that several families shared a communal toilet facility which consisted of a hole dug in the ground near their homes because the houses were to small to accommodate. When assessing and counseling the families we thought of Maslow’s Hierarchy of Needs, and how our main focus was to assist these families to meet their basic needs, food, water, shelter, and clothing. Despite, their lack of resources and wealth they were consistently welcoming, had smiles on their faces and even treated us to fresh BUKO. A nursing student explained to us that even if Filipinos are lacking, they are always wanting to share and give, which sometimes is a burden. Being in this community, it really made us reflect upon what we have, what we should be thankful for, and lessons we will bring home.

Meeting the children in the community (permission granted to post pictures)

 

The Aetas people had many issues that the clinical instructor, Miss Maebelle, and St. Paul University nursing students are trying to address. The most prominent issues needing to be addressed include the garbage disposal method, water supply, sewage disposal method, sanitation, and lack of resources such as shoes. Financial restraints are linked to many of the listed concerns because they live off the land and for many the only source of income is selling handmade brooms. To illustrate, a majority of children do not wear shoes because their family can not afford them. A common health problem in the community is intestinal parasites which are picked up by the children from the soil they walk on. Also, access to care is a major problem in the community which is being targeted by the St. Paul University faculty and students. They have developed a rapport with the community and are working with them to implement programs along with IMCI. St. Paul University is in the process of raising funds to buy proper toilet facilities and supplies for the community. This was a great example of community development and making these resources sustainable. At times we found it difficult when we encountered a situation where they were unable to afford treatment, and we had the money in our back pockets. However, through our cultural orientation and immersion we soon found out that giving them money, is not helping them because it is not sustainable. By educating, counseling, commending, and working with the Aetas people, we can opt for sustainability with in the community.

Using the Integrated Management of Childhood Illnesses tool (permission granted to post pictures)

 

Culminating Activity: Our Final Day in the Philippines.

We concluded our time with the St. Paul students by venturing to Demires Hills, a beautiful resort outside of Janiuay.  The landscape was riddled with banana plantations, rice patties, papaya trees, and myriad of buko trees (coconut).  We spent our morning conversing with the students poolside in the beautiful sun and gorgeous scenery.  After our scrumptious lunch, Shawn enjoyed zip lining across the picturesque hillside to end the morning.  It was a great way to wrap up our memorable immersion in Janiuay.

Our journey to the Philippines was unforgettable.  We had so many incredible experiences which have changed our perspectives on our own lives.  We have gained such an appreciation for what we have but also, an appreciation for what others have.  The friendships, bonding and relationships made will always be remembered. Although we must say, there is truly no place like home.

Nipa Hut: Our New Home

Throughout our time in Janiuay, we had the joy of staying in a two-story Nipa Hut on stilts, which is a traditional house made from bamboo and the Nipa plant used for the roof. We slept on mattresses laid across the floor while using mosquito nets to protect ourselves from the many critters which lingered. We were housed with seven Filipino students for one night and joined by six more the following night making a total of 17 Paulinians (St. Paul University students and faculty).  The outdoor kitchen where we prepared all of our meals, consisted of small charcoal stone pits, iron woks, and removable grills.  All of the ingredients for our meals were purchased at the local market and wet market (which stimulated our olfactory senses) by Filipino students and ourselves, and maintaining a monetary budget.  Often, the students would wake at 5:00am to fetch the necessary ingredients and begin cooking breakfast.  Also, the students would begin preparing other meals as early as two hours prior due to the extremely long process of cooking over charcoal. The traditional meals consisted of a variety of meats, locally grown vegetables and fruits and of course, their staple food, rice.  We were asked to prepare Canadian Dishes.  We realized how difficult it was to distinguish what exactly constitutes “Canadian” food due to our multicultural identity. Thinking of what reminds us of  home, we decided to cook up chicken shish-kabobs with eggplant, red peppers, and onions.  Also, we introduced two classic dessert items,  s’mores and banana boats.  They absolutely loved the treats.  After supper and cleanup, we participated in a post conference activity, ARAS (Active Reflection, Active Sharing). We would perform songs and dance to introduce ourselves and reflect what impact the days happenings had on our learning experience.  It was a powerful way to interact amongst each other and also stimulate great reflection.  ARAS is an effective tool that we could implement in our own nursing programs in Canada, to debrief our clinical experiences, but at the same time having fun and to de-stress.  The busy group of students were absolutely incredible and cheerful, but we have discovered that they do not sleep! They ensured we had not only our basic needs met, but went above and beyond  to make it an unforgettable experience in every way.  They went out of their way to buy us Filipino delicacies such as balot (15 day old unhatched chicken), chicken intestine, chicken liver, and chicken feet.

This experience truly opened our eyes and built our empathy for the millions of people around the world who simply do not have access to the luxuries we expect at home.  We gained an immense gratitude for what we have. However an even greater lesson was an appreciation for the simple life.  Countless individuals and families are happier than many of us with this way of living. We could learn a huge lesson about not relying on material objects to make us happy. The bonding with each other and the Filipinos assisted us in this learning process.  Our stay at the Nipa Hut was memorable. The lessons learned and friendships made will not soon be forgotten. We identified that the hospitality of the Filipino’s is unmeasurable to other cultures.

Welcoming New Life into the World in a Filipino way

The delivery room:

One of the most memorable experiences of our final community practicum was the births that we were apart of in the Janiuay community. Shawn, Sarah, and Chantelle were eagerly waiting 24 hours a day for the short notice to run to the clinic and assist the midwife deliver the baby, perform baby care, monitor, and assess the mother.  No matter what we were doing, we would drop everything and run for the deliveries. We were able to participate in a total of three births over our two day stay in the community rotating through the required roles during the process. Jaclyn was struck by a plague of E Coli and ameba, despite precautions, putting her on bed rest for one of the days we were in Janiuay causing her to miss two births. Our first call came in the late afternoon when we were at the staff house so we quickly put on our uniforms and grabbed our bags while one of the Filipino students stopped a tricycle outside the house. We jumped in the tricycle and rushed to the clinic not knowing what a community birth would entail. We were quickly able to distinguish the differences in the birthing process between the Filipino culture and what we have experienced in our own communities in Canada.

In Canada, pain medications are commonly used in the labour process, we may even call it the norm. However, the Filipino women do not use any pain medications and see pain as a normal part of the process that they must manage on their own.  We were forewarned about this but seeing the women cope with the pain in a natural way during the labors truly put it into perspective. The women were very stoic and made little to no noise unless asked a question; we were surprised and commended their strength. Another significant difference we quickly picked up on was the that the women were alone in the delivery room and the husband or significant other waited outside. In Canada we allow two family members in the room to support the pregnant women at this difficult time. We strongly encourage a support person and have shifted towards an emphasis on family centered care because it has proven to be beneficial for the client. Over the course of our stay in the Philippines we noted that their culture has a strong emphasis on family which left us dumbfounded that they do not have any family members in the room with the patient. There is a lack of space in the clinic rooms which can influence this rule along with their traditional nature. The births we witnessed took place in the community at the health clinic therefore we can not generalize our findings through out the Philippines. We observed that the labour room was small, had basic resources, and dated equipment; it was very primitive. Also, the births that took place here were performed by midwives. This was a very new environment to us because we are used to the obstetrical wards in our hospital in Canada, so we learned to use what they had available. Another prominent difference was that the women are discharged from the clinic approximately 6 hours after the birth of the baby. In Canada however, they are required to stay in the hospital for a minimum of 24 hours.

By taking in all the differences of the labour process and their way of doing things, in regards to the birthing process, we knew what to expect for the two births that were yet to come. We were informed that the majority of births occur at night which proved true when we were awoke at 02:30 am to make a mad dash to our second birth. We all jumped out of bed, got ready in a matter of a few minutes, and took off running down the street to the clinic because there was no transportation at this time. Our instructor followed behind and yelled for us to slow down because she could not keep up. She jokingly emphasized that us Canadians are taller so one of our strides equals two of hers. Our last call came at 06:30 in the morning on our last day, where we repeated the process. It left us exhausted but was a great way to end our exposure in Janiuay and is something we will never forget.

Shawn holding the newborn     Sarah administering Vitamin K Chantelle holding a newborn

 Clamping and  cutting the cord                  Jaclyn giving a back massage 

All photos posted with permission

Orientation: Monday January 30, 2012

We spent our morning getting orientated to St. Paul University and in the afternoon we drove 30 kms out of Iloilo City to a town called Janiuay “honey- why”. This community health clinic is very busy tending to a variety of health issues and needs. In particular delivering infants, rabies, immunizations, leprosy, tuberculosis, parasites, etc. This week we will be staying the staff house there, where we will be living traditionally and cooking over a fire.

A particular disease that sparked our interest was the ancient disease known as Leprosy. This disease causes skin sores, muscle weakness, and nerve damage. The nursing students explained that a lot of misconceptions about Leprosy exist within their culture. Therefore, it is common for families to abandon the sick individual when they learn they have Leprosy. The patients then go to a Leprosy Sanatorium in Iloilo City, where they stay until they are recovered. However, because of the stigma and visible deformities of Leprosy the patients often end up staying in the Sanatorium permanently, fall in love, and have a family of their own. They created a community and even have a school within the Sanatorium. At first we were very shocked that their was a facility that exists for such a disease. This showed us the importance of health education and clarifying myths. We could relate to a lot of health misconceptions in Canada, such as HIV and sexual transmitted infections. We were not able to visit this community, but hope to some time this week.

On our way back to the University, we stopped at the Mere Monique Home, a long term care facility for Sisters that was built 3 years ago. This home was the epitome of the Eden Alternative, which we are striving for in Canada. This home was absolutely beautiful, we were in awe! The home was a mix between a tropical resort and long term care facility. The home consisted of beautiful chapel, ICU, spacious resident rooms, and wide open dining rooms, and hallways. The grounds had a vegetable garden, a pond, and fountain. This home was a beautiful sanctuary for The Sisters

We are in Ilo Ilo!: Sunday January 29, 2012

We have officially arrived to Ilo Ilo for the final week of our community practicum. We were greeted at the airport by the St. Paul entourage caring a large sign and smiling faces to welcome us into there community. We checked in to the dorms at St. Paul University and then set out to the spa. At the spa we had a relaxing afternoon indulging in traditional helot massages. To complete our Sunday we were treated to supper at the oyster house with fresh seafood dishes and bukko soup. We look forward to spending our week with the students and staff from the St. Paul University.