The Colostomy Story

Today, I had to deal the dilemma of me being an experienced neurosurgery nurse, working in a general surgery unit. I worked in an ER and neurosurgery environment for the last seven years, and I knew that I would be faced to deal with some unfamiliar cases in a new work place.

 

I had a patient with a colostomy. Well, it may sound so simple for some general surgery nurses out there, but it was a big deal for me. It’s not that it was my first time, because I have had several patients with a colostomy. But it was my first time in several years to actually perform colostomy care – to actually touch and clean the stoma.

 

I was busy with another patient when I heard somebody screaming. When I looked out of my patient’s room, I saw one of my co-nurses coming out from one of my patient’s room. She asked me if the patient in room x is my patient, so I told him yes and asked her what’s wrong. She said the patient was complaining because he was yelling for an hour already and nobody is coming for him.

 

Since I was finished with my current patient, I decided to check the complaining patient out. I went to his room and I was welcomed with some more yelling. I asked him if he was pressing the bell since that is the proper way of calling a nurse. He said he did but it seemed the bell was not working.

 

I investigated further, and found out that the bell cord was not attached to the plug. So that was the reason nobody was coming to him. I was successful in trying to pacify him. I asked him what he needed and found out that his colostomy leaked up to his back. He said he was trying to open his colostomy because he felt it was full of air. When he opened it, he got surprised with the contents and everything leaked out and went to his clothes and sheets.

 

My patient had a colorectal cancer and the surgeons tried to remove the cancerous part of his large intestines. A new opening was made on the left side of his abdomen where his stool can come out, and will be drained to a pouch called colostomy bag.

 

I checked what I needed to clean him, and after that I told him I need to get some things in the stockroom. When I got into the stockroom, I took some fresh linens, pads, cleaning wipes and saline. To my horror, I found that there were different sizes of colostomy bag. How would I know which one is for my patient? I decided to just bring one from each of the different sizes. I thought it would be safe since I do not have to come back if one size fails.

 

When I went back to my patient’s room, I checked his colostomy so I could choose which size of bag I would need. To my surprise, none among those I brought were the same as my patient’s. I needed the biggest size which seemed not available because I did not find that size before. I knew I took one sample from each of the sizes I saw.

 

I went back to the stockroom and searched for the largest size. I did not find any, so I asked one of my seniors. He helped me search until he finally said it was probably out of stock.

 

I decided to go to another ward and asked for that size. I knew that every minute counts for my patient who was irritable initially. I found the size from another surgical unit and hurriedly went back to my patient.

 

When I got into my patient’s room, I was greeted by a frown. I explained to him why it took me a bit long to come back, that I needed to get his size from another unit. He seemed dissatisfied with my explanations, so I just tried my best to talk to him nicely.

 

I detached the old pouch from where it was connected. I placed it in the bathroom since I wanted to save the wire that closes the pouch at the end. I cleansed his stoma with normal saline. After cleaning, I tried to attach the new pouch to the connector. It seemed I could not connect it. It was either I was doing it the wrong way, or I just do not know what I was doing.

 

While I was trying to attach it, I tried to converse to him to try divert his attention from what I was doing. I explained to him some facts about colostomy, and how to take care of it. I was posing to be a pro with what I was doing, when deep inside, I knew I could not connect the bag. It was hurting him when I pressed harder on the pouch lid.

 

I then decided to ask help from a co-nurse. God probably heard my heart beating fast, and gave me a colleague just passing by my patient’s door! I asked her to help me attach the colostomy bag. She told me how to do it and watched me do it. It was the same technique as what I was doing before. But she also felt it was difficult doing it that way so she suggested for me to just remove the part that was attached to the skin, and apply a new one. The adhesive part that was touching the skin and the bag should already be connected before sticking it to the skin.

 

I actually thought of that, but I knew it was the harder way of changing the bag. But now, it seemed there was no other way but to do it that way.

 

I was successful in applying a new bag on him. I went back to the bathroom and took the wire from the old bag. It was heavily stained with stool so I just tried to clean it. I closed his colostomy bag using that wire.

 

I wiped him a bit, and brought him to the bathroom after that. I changed his gown and placed new linens on his bed. His mood has changed, and was apologetic about his attitude a while ago. I told him it was pretty understandable for him to get mad in his situation. I left him clean and satisfied with what I have done for him.

 

In the evening, before I left the unit, I checked him out in his room. He was with his family, and I was introduced to them. I told him that my shift is over and that I was leaving. He asked who’s replacing me, but I was not sure who’s taking care of him next. I saw in his face that he still wanted me to stay for him.

 

Before I left, he said smilingly “See you on Sunday!”.

 

 

Welcome to UAE!

It’s Friday, but most offices are already closed today. Friday here is the equivalent of a Saturday back home. And so Saturday here is the Sunday I know. Here, everybody goes back to work on a Sunday, because that’s their Monday! Yup, I am in another world!

 

Welcome to the United Arab Emirates! It has been nine days now since I arrived in this foreign land to start a new adventure overseas. It was an eight-hour flight from Manila. There were 22 others on-board who were also joining Tawam Hospital. After landing in Dubai, we had a two-hour road trip to Al Ain via shuttle bus.

 

When we reached our housing compound, each of us were brought to our respective flats, as each one will be having their own units.

 

I was just amazed by the accommodation that they provided for us! My unit had a huge living room, dining area, bedroom, kitchen and a spacious bathroom! And it was completely furnished! It’s like a condo unit back home. The fridge had some food inside already, and there were new towels and kitchen utensils. This was a very warm welcome.

 

The next few days was spent basically on orientation sessions. There were lots of lectures and trainings that our group attended. We had a lot of written and practical exams that was really mind-draining.

 

We had some tour of the city, which included visits to some malls, museums and other important landmarks.

 

The city of Al Ain is a very progressive community in UAE, and is billed as the Garden City, for its year-round temperate climate, beautiful scenery, and abundant greenery. There were lots of trees that were obviously planted on soil that were made to become rich. Water was distributed thoughout that vegetation through a hose system under and sometimes on the ground. No wonder the plants were all green and flowery.

 

Al Ain is more conservative than Dubai and Abu Dhabi, so most people here still wear the traditional clothes. It’s a quite place and the traffic is not that much. I found the people here very friendly.

 

Tawam Hospital is a 468-bedded tertiary center located in Al Ain, and is considered one of the best hospitals in the UAE. The hospital is in affiliation with, and managed by John Hopkins Medicine which is #1 ranked U.S. Hospital. The institution also has the distinction of being a Joint Commission International (JCI) accredited hospital.

 

I have seen a lot of the hospital’s state of the art faciltites, and is completely amazed by the management’s drive to excellence in health care.

 

I hope to enjoy my stay here. I will be working in the Surgery Unit and I’ll be starting on Monday. I heard it’s a very busy ward so I am expecting a heavy week ahead. So having said that, let me enjoy the rest of the weekend!

 

Cheers! 

 

 

 

 

Worried Over Elevated SGPT

 

I submitted myself for a routine medical exam last Wednesday. Blood tests, x-rays, physical, eye and dental exams were done. I knew I was completely healthy, except that I was worried about my x-rays – that they might see something there because I have been having on and off cough and colds, due to weather changes. I also did not get my annual dose of flu vaccine last year.

 

I got the results today (after two days), and surprisingly, they found something else, instead of abnormal x-ray findings. They found that my serum SGPT is elevated. How much, that I have to clear tomorrow to the doctor. I was informed on the phone that I have to see the doctor so she can prescribe something for this problem.

 

As a medical professional, I know I should not get worried about it because I know it is something that can be treated. But to be honest, I got really worried. First, something is wrong with my body. Second, I might be rejected from the job I am applying.

 

Serum Glutamic Pyruvic Transaminase (SGPT also known as Alanine Aminotransferase or ALT) is an enzyme that is normally found in the liver, but not exclusively. It is released into the blood during liver damage, so it is more or less a very good indicator of liver status.

 

The first thing that comes into my mind when SGPT is elevated is Hepatitis, especially viral. But then my blood tests included hepatitis screening, and I scored negative there. So I erase hepatitis from the list of possible culprits.

 

One cause of liver damage is alcoholism. But then I really don’t drink a lot. The last time I had alcohol was about middle of last month when my barkada fetched me from the airport, after my trip in Bacolod and Iloilo. We headed straight to a bar in Bulacan with some other friends before I went home. And I only had about three to four bottles of Lights. So I don’t think that I am that alcoholic for my SGPT to go up.

 

There are two possible causes of elevated SGPT which I believe could be related in my case. One is obesity, which can cause a fatty liver. The other one is chronic medication use.

 

I don’t think that I am that obese to make my SGPT shoot up, but I think I have been eating a lot of fatty foods lately which could have caused my liver to become fatty. A 24-hour recall of my dietary intake would really suggest a very poor dietary intake. Last night, I had fried chicken for dinner. I had longganisa with fried rice for breakfast this morning. And I had pork barbeque with java rice for lunch a while ago. It is just now I am realizing that I have been eating the wrong stuff!

 

Add to that, I have stopped going to the gym since late last year. A combination of lack of exercise and poor food choices could lead to a fatty liver.

 

Another factor that could have caused my elevated SGPT is my chronic medication use for the last few months due to on and off cough and colds. I initially treated myself with a self medication of antibiotics. When that did not work, I went to The Medical City for consultation. I was then subjected for two rounds of antibiotics, plus other cough medications. I have stopped taking those medications though, as I am only having my usual multivitamins and a supplemental dose of vitamin C.

 

Well, I can only wonder what really caused my present problem, till I see the doctor tomorrow. But starting this very moment, I think I should look after my health in a different perspective.

 

Maybe you should, too.

 

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FOOTNOTE:

17 May 08 - I got to speak to the doctor. She also suspects fatty liver. She suggested for me to take Essentiale three times a day, and a low fat diet. I will repeat the blood test in a week. Good luck to me!

 

 

Teaching as a Nursing Profession

I was not into teaching until my alma mater hired me as a part-time clinical instructor last semester to handle third-year nursing students. I had my doubts at first, as to whether I will be an effective teacher or not, since I know that teaching in a hospital setting is a lot different from teaching inside a classroom. It is very different from having your students seated on rows, than having students who are walking around the hospital, performing health-risk, if not life-threatening procedures. And that my professional nursing license is at stake every time students take care of real-life patients.

 

Following up nursing students inside the hospital was not really new to me. I handled foreign nursing students when I was in the Middle East. Patients there were quite demanding, and meticulous, and so I learned how to make sure that the students were knowledgeable of the procedures they were performing even before going to the bedside, otherwise I end up being reprimanded by the patients themselves.

 

I had three groups last semester, most of them were fresh from high school (meaning, not second-coursers). Some were still having doubts as to whether they should continue with their nursing course or not. Some were just influenced to take their course by the people who are financing their studies. Some were just plain pasaway.

 

After finishing the first semester, I learned a lot of things about clinical teaching. First, I realized that even if my job as a teacher should focus on making sure the students gain enough knowledge during their clinical exposure, it is still the patient lying on the bed who should be my utmost concern. Before making any procedures to the patient, I should make sure that he is comfortable and that he is confident with his caregivers, even if they are just students.

 

I also learned that student nurses can be taught self confidence by actually making them perform procedures by themselves (with supervision, of course). I sometimes get doubts as to whether I should allow the student to perform the activity or not. But by initially assessing the student’s knowledge on the procedure, I get enough trust on the student that he will finish the task successfully. And by making him actually complete the job, he builds the confidence necessary to gain the patient’s trust.

 

Lastly, I learned the value of sharing knowledge to the people who are thirsty of it. It is indeed a privilege and honor to be part in molding young minds who will become professionals someday. When my students thanked me after their clinical rotation ended, I felt that they gained a lot of knowledge and skills, and that I made my own contribution in uplifting the standards of the nursing profession.

 

I should say that I enjoyed my stint as a clinical instructor. The experience was worth it.

Euthanasia and Nursing

When I was still in the neurosurgery unit, I had a Bangladeshi patient who had a history of being hit as a pedestrian by a speeding car. He was apparently on his way to his second job as a car wash boy. I later found out from his friends that his stay in the country was illegal and he has no legal papers about his entry.

 

Ahmed (not his real name) suffered a severe head injury and some multiple fractures all over his body. He had a skull fracture, brain hematomas and his Glasgow scale dropped to 3 out of 15. He was intubated and was attached to a respirator. He was paralyzed from the neck down. No relatives were available since he was an expatriate with an illegal entry to the country. Only his co-workers visited him once in a while, but none were always available. He was basically left alone most of the time, under the care of the nurses.

 

By some miraculous interventions, Ahmed recovered from an acute stage. He was weaned from a respirator and he was shifted to a tracheostomy collar for breathing. A big portion of his skull was removed though, so his brain was left open with only the scalp covering it. He had a nasogastric tube for his nutrition, which was later changed to a percutaneous endoscopic gastrostomy (a tube directly connected to the stomach). His multiple fractures healed but he had some contractures. He was still a vegetable though - unable to move, unable to eat, unable to talk. His breathing was supported by a tracheostomy through a hole in his neck.

 

The doctors decided to put him on a “No Code” status. This meant that if the patient goes into a cardio-pulmonary arrest, he would not be resuscitated anymore and that reviving measures would be very conservative.

 

The patient did not recover further. He was supposed to go to jail if he recovers, but his health condition did not permit him to go out of the hospital. He maintained a stable vegetative status although there were times he almost coded due to instances of tube blocks, increased secretions, and aspiration problems. But because of the excellent nursing care Ahmed was receiving, he continued to live. He was always fed on time. His medications were always provided. He was given bath daily, sometimes even twice a day. He was always turned from side to side. His basic nursing needs were always met.

 

Taking care of Ahmed, I sometimes thought of the kind of life he was having in the unit. Although my co-nurses would always talk about how pampered he was in the ward, being provided with excellent services for free, I still feel how miserable to be in his situation. His face was badly scarred, and he had no skull on the top of his head. He will not be able to walk anymore. And I imagined how his family back home was suffering. How they always thought about how he was doing, what his status could be.

 

I sometimes felt that as nurses, although we were able to keep him alive, we could also be prolonging his agony. I knew that he would never get a quality life anymore. Because he was unable to talk, we could not assess the amount of pain he was receiving every time we had to give him his daily injections, every time his NGT needs to be reinserted, every time we need to move him in and out of his bed. What about the pain he had every time he needs to be reintubated? Or could he still feel the pain? Is his thought processes still working?

 

The most terrible pain he could be suffering must be the pain of loneliness, of being alone in that place, of missing his family back home. I would always see some tears roll down from his eyes. Could he be begging for us medical professionals to stop prolonging his suffering and just to let him go in peace? That was always the million-dollar question.

 

The issue on euthanasia is still a controversial topic up to this day. Most hospitals practice it especially if the family members are available. The decision is given to them after the doctors have informed them about the patient’s irreversible condition, and that only the supportive devices are maintaining his life. The family’s decision would sometimes base on how they perceive the situation was – whether continuous medical measures would just prolong the amount of pain and agony of their loved one, and whether they could still support the amount of expenses the situation is causing them.

 

I realized that although as nurses, we don’t have a direct influence on a decision for euthanasia, we are greatly involved in providing the care the patient needs for him to be able to live longer. This means that whether we like it or not, we are the ones who keep them here in this world. And yeah, whether that is a good idea is still a debate.

 

Ahmed still continued to live until I resigned from that hospital. Whether he died later or not, I still believe that the extended life given to him was not as useless as other people would think it was. By just lying on his hospital bed, he touched so many lives, including mine, making us realize how lucky we are to still be able to communicate with our loved ones, to be able to eat whatever we want, to be able to sing and dance under the sun, and to be able to dream our ambitions. We had a greater appreciation for the blessings that we receive each day.

 

I loved my life all the more, and I started to enjoy even the tiniest source of happiness. I think, Ahmed’s extended life served a very noble purpose.

The Incredible Nurses of Ward 11

For some personal reasons, I recently resigned from my nursing job in a military hospital in Riyadh. Leaving the work place was quite difficult for me, not because of the place itself, but because of the wonderful people I worked with and I have to leave behind.

I worked in the neurosurgery unit (ward 11) of the hospital for five years. The nursing team I worked with was so amazing. My co-nurses work very fast and they act so quick. Our unit has a very busy surgical set up and I guess the staff just got acquainted with how things work in the unit. Everybody just got used to the fast-paced ward. We dealt mostly of comatose and bed-ridden patients who are acutely-ill, and that explains why we have a very demanding work place.. Add to that was the multi-cultural mix of the staff which in one way affects work relationships, and work itself. The challenges in our department were vast. I myself would not realize how quick the day would finish because I was working every minute of the shift.

 

But despite of the busy routine, my colleagues were still able to find time to reach out and go beyond what’s needed to be done for the day. In between lifting patients, turning bed-riddens, and answering phone calls from doctors, my co-nurses would ask each other how their families were doing, how their last shifts went, and what their plans were for the next off. There would still be time to share a smile. And for some good laugh.

It was also quite amazing that no matter how busy the unit was, everybody would still be ready to lend a helping hand if somebody needed one. I was impressed with one of my colleagues who would always go room-to-room to check all of her teammates for the shift, just to make sure everybody was doing okay, if anybody needed a lift. And that was despite her also being busy with her own patients. The other nurses, in return followed this splendid example. It was so nice to work when you know everybody was looking after each other. You feel as if you are always standing on a safe ground.

It was easy to have a bad day in the unit especially when you deal with arrogant doctors, complaining sitters, hectic diagnostic schedules. But how could you frown if there was somebody behind you, telling you to maintain your smile and to keep your sanity. By the end of the shift, everybody would be very tired, but were all still cheerful and in high spirits.

And since I have left that hospital for more than three months now, I can only wish to meet nurses as incredible as my nursing friends in Riyadh. To them I owe a great deal of knowledge. To them I owe my present attitude towards work.