Mar 22, 2016

Unboxing the Philippine General Hospital Charity Ward, Part IV: Life at the NICU

This is the last of a series of articles about my experiences at the University of the Philippines (UP)–Philippine General Hospital (PGH) charity wards. To read the first of this series, click here: Part I, The OB Admitting Section and Delivery Room.

The War Zone

Because I gave birth to my child two months before full term, we had to stay at the PGH neonatal intensive care unit (NICU) for about a month.

It is a grim place. The doctors seldom smile. If you're used to the warm cordiality of your private consultants, you will feel the chill here.

The nurses are coldly efficient, unsympathetic, and grouchy.

But soon I realized that the NICU, by its very nature, is not a place for kind words and gentle smiles. It is a war zone, and the medical staff are fighting for their patients' lives with worn-out tools and insufficient supplies.

In the one month that my baby and I spent at the NICU, I learned that sometimes, compassion is shown not by commiserating and holding hands.

In battlefield conditions, it is shown simply by showing up every day and doing what needs to be done.

Compassion in the NICU means not giving up the fight.

This post goes out to all the NICU fellows, residents, their attending, and the nurses and nurse aides who all fought to save my baby's life.

Facade of the UP-PGH. The Oblation statue is a well-known icon of the UP system. It is a symbol for giving one's all in the service of the nation. (Image by Faisal Hermogeno Jackarain via Wikipedia)

The NICU Doctors

My first glimpse of the NICU doctor's psyche was not in a face-to-face encounter. It was in a pharmacy receipt that my husband handed me as he told me an unexpected story.

In  the receipt was the name of NICU third-year resident Dr. A.* I learned that while we were out, our baby urgently needed meds that were not available on hand.

So Dr. A purchased the meds for us.

Note that Dr. A was not our personal friend. We had not met him before, nor did we ever meet him again since we left the NICU.

He did not know whether his expense would ever get paid back. (It did.) We were strangers, but he did it for our child who was his patient.

Now tell me again that PGH doctors have no compassion for charity patients.

-----

Dr. D was the fellow who was in charge of my baby. From the very first day, she constantly updated me and my husband regarding our son's condition.

She never showed optimism, nor did she ever show despair. She simply told us what the problems were and what were being done to solve them.

One day, on our third week, when my child was finally cleared of all jaundice and infection and was just waiting to be discharged, Dr. D said, "I am so happy the phototherapy worked. I was worried we would have to do an exchange transfusion!"

It was the first time I saw that much emotion on her face, and the emotion I saw was one of relief.

"I had no idea the jaundice was that bad," I said. "Why didn't you tell me?"

"Oh," she smiled. "I didn't want you to worry unnecessarily, so I held it in as much as I could."

Thank you, doctor, for carrying that burden for me.

-----

Dr. T was not directly in charge of my child, but aside from Dr. D, she was one of the first doctors to make me feel comfortable in the NICU.

She would approach me every day on my first week, and she read my baby's chart for me.

Thank goodness she did. Dr. D was out, and the nurses looked so busy, I couldn't get the nerve to approach them first to ask my questions.

"Is everything okay, Mommy?" she would ask me while I was doing kangaroo mother care (KMC). "Is there anything you would like to know?"

There was a million things I wanted to know. Why was my baby's breathing so shallow? How can I know he was still breathing when I could hardly feel anything? Was I doing this KMC thing right?

She answered all my questions patiently.

Thank you for the gift of your time, Dr. T.

-----

Among all the first-year residents who were assigned at the NICU during my son's confinement, Dr. N and Dr. B were the ones who seemed directly involved in my son's care.

They kept track of every 0.01 digit change in his weight. They relayed all my concerns to the nurses for me. (Yes, at the NICU, the residents advocate for the patients to the nurses, not the other way around). And they exulted with me at my son's every little victory.

To this day, we have kept in touch. I am honored that they have allowed me to call them my friends.

The NICU Nurses

If the NICU doctors were generally unsmiling, the NICU nurses were downright scary.

These guardians of the wards and enforcers of the rules don't mince words. If a child is in the NICU, that child is theirs, and you are just the parents.

If you, the parent, ever does anything to threaten the well-being of a NICU child – like if you enter without a hospital gown or forget to bring breastmilk for your baby – prepare for a harsh scolding.

"If you are concerned about the welfare of your child, we are even more so," Nurse L once told me me after I gave my child milk via the orogastric tube without her permission.

"That milk could have gone to your son's lungs. He could have died!"

In this place, nothing is ever sugar coated.

"How is my son, ma'am?" a father once asked. "Is he okay?"

"Sir, if your child was okay, he would not be in the NICU," the nurse said.

-----

But behind their frowning  facades, these nurses still have times when they show a warm beating heart.

Like that time when I had to do KMC under the extremely bright, headache-inducing phototherapy light.

The nurse saw me and asked, what in the world was I doing?

I explained: My son had been prescribed phototherapy. So he needed to be naked.

But the poor kid was shivering! The incubator, as I mentioned in my previous post, was not working, and they had run out of thermal blankets to at least warm the ambient air.

So I sat under the phototherapy light with my semi-naked baby on my chest, using my own body heat as a warmer.

The nurse shook her head. Then she rearranged the babies in the NICU so my baby could have an empty bassinet with an overhead warmer and a phototherapy light at the same time.

Do I blame her for not noticing that the baby was cold in the first place?

At that time, she was the only nurse in a room with over 15 babies. If I were in her shoes, I'm not sure I would have fared any better.

Not Perfect, But...

I realize this post may sound like a mere paean to the PGH medical staff.

It is not.

I can repeat to you all the bad things you've already heard before about PGH, and I can even add more. 

The hospital is so understaffed, there were times when a blanket or a phototherapy eye protector would slip off a baby and nobody would notice.

When we got home, I discovered that a working scale only costs P1,500.
There were occasions when the lack of facilities was truly outrageous. At the pedia ward (Ward 9), for instance, the weighing scale would give two different readings for the same child within the span of 30 seconds. 

In the marketplace, it is illegal to possess such a weighing scale. But at the PGH, medical decisions were made based on data from that malfunctioning scale.

There were residents who went above and beyond the call of duty; but I have also encountered some who looked at their patients and failed to see persons, only diseases.

Every place has its imperfections, and perhaps the PGH has more imperfections than others.

But maybe that is why I wrote this series: We have already heard so much of the bad.

It's time to strike a balance.

*Names are limited to single initials to preserve the individuals' privacy.

The Nanay Notebook is written by Blessie Adlaon, a work-at-home and homeschooling mom of five. Check out our About page to know more about this blog's author and our policies on advertising, press releases, and reposting.

Mar 21, 2016

Unboxing the Philippine General Hospital Charity Ward, Part III: The Neonatal ICU

When I was at the OB admitting section and delivery room, one of the residents asked me, "Why did you choose [the Philippine General Hospital] to give birth in?"

I answered, "The hospital I came from did not have the necessary facilities for taking care of a preemie."

The resident smirked, "Neither do we."
By Bobjgalindo via Wikipedia
Image by Bobjgalindo via Wikipedia. This is not what the PGH NICU looks like.
It was a snide remark, but it was not all untrue. From what I've seen, the Philippine General Hospital (PGH) neonatal intensive care unit (NICU) is a poorly equipped place for caring for a preemie.

There were not enough incubators, not enough bassinets, not enough floor space, not enough medical staff, not enough milk supply, and not enough meds on hand to fully answer the needs of the patients.

But it is precisely these limitations that make the PGH NICU an amazing place. Because in this severely austere environment, the dedication and skill of the doctors, nurses, and nurse aides shine bright, like a beacon in a storm.

Entering the NICU

My husband brought me to the NICU to see our son the day after my C-section. 

Only parents are allowed at the NICU, and only one parent at a time, so my husband and my brother, who was visiting, waited outside. 

A doctor met me at the door and showed me where my baby was.

I was led towards an incubator. Most of the other babies were in bassinets, but preemies like my son needed more warmth, the doctor said.

I noticed that there was a heating pad inside the incubator. I realized that the incubator was not working, that's why the heating pad was needed. The "incubator" was really just a plastic box.

So what? For me, the main thing was that my baby was still alive. I was grateful for whatever help that plastic box provided.

Not much bigger than my hand
It was easier to look at the box than the baby. My son was so, so small. His entire torso could fit in my hand. 

He was fitted with a nasal cannula to help him breathe, an oro-gastric tube in his mouth for direct feeding, makeshift eye protectors for the anti-jaundice phototherapy, and an intravenous line in his foot for supplementary nutrition and meds.

My brother, who was also a doctor, had earlier advised me to talk to him and touch him. "Touch is a powerful stimulus," he said.

So I reached inside the box and gently stroked my baby's chest and arms, talked to him softly and tried not to cry.

Later outside, his doctor, a fellow in training, met me and my husband to discuss the condition of our child. 

She was kind but direct, giving no false reassurances. The baby still stopped breathing from time to time, she said. The enemies were apnea and infection. It was too early to tell what will happen.

But we could help improve his chances by doing kangaroo mother care (KMC) as soon as his breathing stabilizes.

Kangaroo Mother Care

KMC is when you put your shirtless baby directly onto your chest, under your shirt, and carry him skin-to-skin for at least three hours. 

Clinical trials have shown that KMC helps baby grow and develop faster both physically and mentally; relieves baby's pain from repeated blood collection; and may even help fight methicillin-oxacillin-resistant bacteria in baby's nostrils.

My baby's doctor also explained that KMC helps keep baby warm and preserves valuable calories; it exposes him to my natural bacteria, which helps to gently build up his immune system; and it limits his exposure to the multi-drug-resistant bacteria of the NICU environment.

PGH is a certified KMC institution. It strongly encourages all NICU parents, male or female, to do KMC.

Although the NICU has visiting hours, parents are allowed to do KMC 24/7. The NICU doctors, nurses, and nurse aides are very supportive. 

If you're craving to spend more time with your baby and the regular visiting hours are not enough, volunteer to do KMC. Then you can stay at the NICU every day and at all hours, and the medical staff will love you for it.

Daily Visits

I visited my baby every day after that. It was easy. The NICU was just two floors away from Ward 14B.

Then the day came that I was to be discharged from the OB ward.

I was not immediately allowed to go home. Because I was leaving my son in the NICU, I had to be interviewed by a hospital social worker first. They needed to know I could and would visit my child at least three times a week to ensure that his material needs (such as breastmilk) were supplied.

They required me to bring a barangay certification of residence so that if I did not return to the hospital, the police would know where to arrest me under charges of child abuse due to negligence.

For me, the idea of not seeing my baby for even a day was unthinkable. But that was me in my pampered middle-class condition.

For many people in the Philippines, a daily visit to the hospital is a very difficult and expensive thing to do. I have witnessed the sacrifices of these non-middle-class mothers for their babies, and I have nothing but admiration for them.

But that is another story.

When the interview with the social worker was done and the documentary requirements were completed, I could finally leave the OB ward.

It was a Tuesday evening when my husband brought me home to our other kids. The very next morning, we were back at PGH for the child we had left behind.

The NICU was at the fourth floor, so I decided to take the elevator. It would not do to be stair-climbing five days after my C-section, I said to myself.

There was a long queue. The single working elevator serviced seven floors.

After 10 minutes at the queue, I discovered that the elevator stayed about 45 seconds at each floor, so a round trip took around nine minutes.

When the door finally opened, only one-third of the queue could get in, so the rest of us had to wait again.

By simple calculation, a person at the end of the line would have to wait approximately 27 minutes before she could get an elevator ride.

The next day, six days after my C-section, and every day thereafter, I decided to take the stairs.

NICU Rules and Routine

Before entering the NICU, everyone has to wash their hands and put a hospital gown over their street clothes to prevent outside dirt from coming into direct contact with the NICU facilities.

My advice: as much as possible, always look for a freshly laundered gown, i.e., one that is still neatly folded.

Remember, NICU parents tend to cry. Heaven only knows what unsanitary body fluids are in those gowns that were simply hung up for reuse after the earlier visitors left.

---

Before you enter the NICU, make sure you have expressed breastmilk with you. The doctors and nurses will ask for it because it is the only thing they can feed to your baby. The Milk Code forbids hospitals from giving babies infant formula.

Without your precious milk donation, your baby will go hungry.

Although PGH tries to make sure the NICU babies always receive enough breastmilk through the milk bank, there are times when the milk bank supply runs dangerously low.

In the four weeks I was there, I witnessed two weeks in which milk was so scarce, babies who had no supply from their mothers and relied fully on the milk bank received only half of what they needed to thrive.

The babies were fed, yes, but they were obviously still hungry. They cried and cried and cried.

Imagine a room echoing with the wail of 16 hungry babies and you would have a good idea of what the NICU sounded like 30 minutes after feeding time.

The staff was visibly distressed. The nurses and midwives often muttered, if only they could produce milk themselves, they would. And you could see that they meant it.

To get more milk, they coerced, cajoled, and bullied every mother who came to the NICU to breastfeed one other baby in addition to their own.

Because I stayed at the NICU for 32 hours at a time, with only 16-hour breaks in between to get some sleep and take a bath at home, I was able to make sure my baby always had all the milk he needed. On good days, I'd have milk to share as well.

But how can anyone produce enough milk to feed 16 babies?

-----

PGH NICU's KMC chair (Image owned by St. Joseph Trading)
If you're doing KMC, it's a good idea to arrive before 12 p.m. This way, you will have at least three hours to do KMC with your baby before 3 p.m., when the nurses begin endorsing their wards to the nurses whose shifts are just beginning.

The nurses seem to prefer having no parents around during endorsement time, so I used the 3–4 p.m. endorsement period to take my snack and bathroom break.

The most comfortable way to do KMC is by wearing a tube blouse. This will ensure that your baby will stay securely in place even if you fall asleep.

PGH nurses usually wake mothers up when they doze off during KMC because the baby is in danger of falling. But if you're wearing a tube blouse, they will usually let you nap.

The next endorsement time is at 11 p.m. The nurses will ask you to take a break from KMC again because it's time for the nurse aides to bathe the babies and check their weight.

I used this time to have my dinner. My baby and I would resume KMC after midnight. I'd sleep in the plastic KMC chair inside the NICU. My baby and I would stay this way until morning.

-----

If you want to express milk on site, PGH NICU has a lactation station.

I hated using it.

Hear me out.

Before you express milk, you have to wash your hands. Of course.

You could use a sanitizer too, but any healthcare professional will tell you, nothing beats the cleanness of properly washed hands.

If your baby's most likely killer is infection, you will not rely on sanitizers. You will wash your hands.

But there is no sink at the lactation station. So before you go there, you need to wash your hands at the sink near the NICU entrance.

Then you have to walk all the way to the lactation station, about fifty meters away.

Then you knock and cross your fingers.

The lactation station's door is always locked. It cannot be opened without a key.

Only the nurses and nurse aides have access to the key. So you'd better hope that when you get there, there will be somebody to open the door for you.

Often, there is not. What I used to do was, after I washed my hands, I would try to find a nurse or nurse aide who would open the lactation station for me.

They would tell me to go ahead and they'd be right behind.

But with all the things that go on in the NICU, it often happens that they forget that somebody was waiting for them. And the door would stay locked.

How did the other mothers get in, you ask.

Most of the other mothers kept vigil at the bench right beside the lactation station's door. I never found out why they were not inside doing KMC.

When a mother's baby cries inside the NICU, a nurse would call the mother to go into the lactation room to feed her baby and then express milk for the milk bank as well. Perhaps the other mothers went in at the same time.

I noticed the mothers there usually did things en masse: have lunch, go to church, sleep, express milk.

I didn't join them for only one reason: I have always preferred to do things alone. That's all.

But I digress.

Should you succeed in entering the lactation station, you'll find hospital gowns on the chair. You're required to put one of these over your street clothes.

But you can't really express milk while wearing a hospital gown, can you? So nobody really wore those gowns.

To avoid being scolded by the nurse, we put the gowns across our laps.

Some rules just don't make a lot of sense.

Then there's the milk pump. The first time I used it, the collection bottles and breast flanges were newly washed.

But that was the last time I saw them clean. They were apparently passed from mother to mother without being washed in between.

Got milk?
I understand the limitations. There just weren't enough replacement breast shields/flanges and bottles to keep up with the parade of moms using the pump, I guess.

There was only one or two pairs of bottles that fit the pump. The expressed milk was stored in repurposed specimen bottles.

One cannot help but suspect that the hygiene standards of the lactation station somehow contributed to the rate of infection spread in the NICU.

Trying to avoid that risk, and also because I got so tired of knocking on a door that seldom opened, I learned to hand express my milk and did my milk letting directly beside my baby's bed in the NICU instead.

Continued in Part IV: Life at the NICU


The Nanay Notebook is written by Blessie Adlaon, a work-at-home and homeschooling mom of five. Check out our About page to know more about this blog's author and our policies on advertising, press releases, and reposting.

Mar 19, 2016

Unboxing the Philippine General Hospital Charity Ward, Part II: The OB-Gyn Ward (Ward 14B)

(Source: Ramiltibayan - Own work,
CC BY-SA 4.0)
This is the second part of a series of articles that chronicle my experiences at the Philippine General Hospital (PGH) obstetric, neonatal ICU, and pediatric charity wards. 

On September 30, 2015, the twenty-ninth week of my pregnancy, I went into preterm labor. My OB-gyn advised me that if my baby was alive at birth, he would likely need to stay at the neonatal intensive care unit (NICU) for a month or two.

My husband and I were financially prepared for childbirth but not for a month's stay in the NICU. That's how we ended up at the PGH charity ward.

Part I is about the OB admitting section and delivery room.

Ward 14B

From the delivery room, I was brought to Ward 14B.

It was a big, clean, attractive, airy, high-ceilinged room. There was no air conditioning, but the ceiling fans were usually enough to keep the room comfortable. Patients were also allowed to bring their own electric fan, for a P25 fee.

Compared to the OBAS, Ward 14B was heaven. My husband was allowed to stay beside me, so I could tell him directly what I needed instead of playing pass the message with the nurse and the security guard. But best of all, the beds had mattresses! 

Oh, how I almost kissed those four-inch-thick mattresses. The unforgiving OBAS beds had so numbed my poor backside that when I got to Ward 14B, I could no longer feel my buttocks and inner thighs.

(Not everyone stays so long at the OBAS. But when your case is premature labor, they try to delay childbirth as long as possible to give your baby a better chance of survival. So I stayed at the OBAS for nearly 48 hours.)

At Ward 14B, the patients were allowed to have one companion stay beside the bed all the time. But make no mistake, the companion may not sit on the patient's bed or even on a vacant bed. A chair was provided for them beside the bed.

Come nighttime, the companions would lay cartons or thin mattresses on the floor beside or beneath their patient's bed, and that's where they would sleep.

At 6 a.m., a nurse would walk along the halls clanging a bell, signaling the companions to wake up and put their "beds" away. 

At 7 a.m., the breakfast cart would arrive.

At 8 or 9 a.m., the nurse would call out to the parents to line up their babies. Then the nurse would give the babies a bath. 

The lunch cart comes at 12. Then the dinner cart at 5 or 6 p.m. The man delivering food also sold juice in tetrapacks and coffee and Milo powder in sachets.

I ate pretty well. I've been to several hospitals in my life, including that hotel-like one in Ortigas Ave., but the PGH hospital food is the best tasting I've ever had!

Overall, it was a very comfortable place. In fact, the obstetric wards are, without question, absolutely the most pleasant wards in all of PGH because there is no sickness here, only recuperating mothers and their adorable babies.

There was a lactation room for mothers who wanted to pump milk. Since my baby was a preemie who couldn't suck yet, I used that room a lot. There was never a queue to deal with. Most mothers had their babies with them, and they fed directly from their mother's breasts.

The Bathroom

The main ward was like heaven, but the ward's bathroom was like hell.

To this day, I have nothing but spitting contempt for the maintenance team of that bathroom. They could never blame the patients for the pathetic condition of those bathrooms, because the patients actually cleaned up too, as much as they could.

Charity ward or not, you should never expect patients to clean up the bathroom.

And knowing that those wards were partly funded by my exorbitant taxes, I am frankly disgusted by its lack of maintenance.

But I'm getting ahead of myself. Let me tell you what the bathrooms were like.

There were three toilet stalls and three shower stalls.

Of the three toilet stalls, only two had a door. Of the two that had a door, one had a clogged bowl, while the other bowl had a broken pipe.

I preferred to use the one with the broken pipe because it sent your business directly down the drain, so you could flush with just one dipperful of water.  

The only problem was, because that pipe was broken and waterless, all the odors from the stuff beneath it wafted upwards, making the whole bathroom smell like a septic tank.

I mentioned flushing with one dipperful of water. That's because the flushes don't work. You had to fill a bucket with water from the shower room, carry it to the toilet, and pour it down the bowl to flush.

It's really not so hard – unless you're a woman who had just had a C-section. Then you're bound to spill a little and wet the floor. This makes the bathroom floor slippery and muddy and just plain yucky in general.

It could have been largely avoided if they had working flushes.

Of course, if your husband was there, he could flush the toilet for you. But your big, strong man is probably out trying to decode and complete the amazing array of discharge paperwork, so you're on your own most of the time.

Did I just say your husband can enter the ladies' room? No, I said he could enter the bathroom. There's no ladies' room or men's room. One bathroom for both sexes, sister. 

So you can imagine how awkward things can get should you ever decide to use that toilet stall that has no door. 

As for the shower stalls, well, they don't actually have showers. They have buckets. You know how that works: fill the bucket, bend down, scoop water, pour on self. 

It's a good time to mention that all mothers in the OB ward were required to take a bath before they could get a discharge order.

So start bending and scooping in those shower stalls. It's actually pretty easy to bend and scoop – unless you're a woman who has just had a CS. 

I stayed in Ward 14B for four days. I could have gone home on the third day, but my husband was not done with the paperwork. 

It's the same story you hear in every bed: 
  1. You ask for instructions.
  2. They send you to a long queue. 
  3. After two hours, you reach the head of the line where they give you a checklist of documents and filled-out forms you should have brought. 
  4. You leave the line, get the stuff, join the queue again. 
  5. Repeat for each of the three-or-so forms you have to complete.
In the meantime, the patient has recuperated and is raring to leave her bed so somebody else can take it. But the paperwork is not done.

At that lovely but expensive hospital in Ortigas Ave., they give you a brochure with a detailed checklist and instructions for completing the discharge procedure before you even reach your room.

I can't understand why the same cannot be done here. Give the checklist early! The expense for the paper would be the same.

In any case, my husband and I were finally able to figure out how to complete all those forms. I can't believe we had so much trouble despite our maroon-and-green Iskolar ng Bayan backgrounds. How do those with only elementary school diplomas manage?

I was discharged but the story is far from over. My baby was still in the NICU, fighting for his life.

The Nanay Notebook is written by Blessie Adlaon, a work-at-home and homeschooling mom of five. Check out our About page to know more about this blog's author and our policies on advertising, press releases, and reposting.

Mar 17, 2016

Unboxing the Philippine General Hospital Charity Ward, Part I: The OB Admitting Section and Delivery Room

Backstory

On September 30, 2015, the twenty-ninth week of my pregnancy, I went into preterm labor. My OB-gyn at St. Victoria's Hospital in Marikina advised me it would improve my baby's chances of survival if we went to a bigger hospital such as the Manila Doctors or the Philippine General Hospital (PGH).

She also told me that if my baby was alive at birth, he would likely need to stay at the neonatal intensive care unit (NICU) for a month or two.

My husband and I were financially prepared for childbirth but not for a month's stay in the NICU. So we decided that our best option was the PGH charity ward.

(Image by Trixiedawnie via Wikimedia Commons)

Entering the OB Admitting Section

I was brought to the hospital by an Ace Cor ambulance. The ambulance nurse escorted me to the OB Admitting Section's (OBAS) examination area.

One look around confirmed what I already knew: this was not The Medical City.

My stretcher was parked beside the examination table. The intern asked me to move into it.

It was an uncovered, unmattressed slab of stainless steel. 

But here's the part that shocked me: the surface of the table I was asked to move onto was still stained with a four-inch-diameter splotch of someone else's dried blood.

At the ambulance, I had been mentally preparing myself for charity ward conditions. I knew I had to shed my finicky, nitpicky, microphobic tendencies.

Still, I don't think anything could have prepared me for this.

In my most quiet, unaccusing, almost-conspiratorial tone, I said to the intern, "Doctor, I am not complaining. I know this is the charity ward. Still, doesn't that blood stain heighten the risk for pathological cross-contamination?" (I wasn't even sure that was the right term, but it sounded right, so...)

The intern was friendly and candid. In a similarly conspiratorial tone, he answered, "The truth is, ma'am, we expect everyone here to be dirty anyway."

Thus began my one-and-a-half months in the PGH charity wards.

The OBAS Interns

The Ace Cor nurse was very kind. He went to the front desk, asked for a bottle of alcohol and a wad of cotton, and wiped the examination table clean. Only then did he allow me to move out of the stretcher. (Thank you, nurse!)

Then the interns began my physical examination and preparation for admission. One of them brought out a soft rubber tube.

"Mommy, I need to insert a catheter. This will hurt," the young doctor warned. "Take a deep breath."

I steeled myself, waiting for the pain to come.

"Okay, you can breathe now," she said.

Was she done? Where was the part that was supposed to hurt? I voiced out my puzzlement to the doctor.

"It didn't hurt?" Her tired face took on a smile.

But I don't think she could have been as happy or relieved as I was. A catheter insertion that did not hurt – and to think, she was just an intern.

That kid will make one heck of a consultant someday. I already loved her as she was.

I soon realized that this "not hurting" thing was pretty common in this place.

When they took my blood sample, it didn't hurt. When they did an internal examination (the dreaded IE), it did not hurt. They had to reinsert my intravenous (IV) line – it did not hurt (well, not as much as it usually does).

One idea began to grow in my mind: this place may not offer decent accommodations, but if your main concern is to be in the hands of world-class medical practitioners, this must be a good place to go.

After all, look at how good their interns are!

The amazing interns were done with their work. My drug allergies had been checked, and I had on my catheter and IV.

Next stop: the delivery room.

The Delivery Room

Before I was brought into the charity delivery room, the physician in charge told me, "Mommy, I must warn you. It's very crowded in there. Are you very sure you want to enter as a charity patient?"

I was sure. So they wheeled me in.

It was, to my surprise, a well-airconditioned room. There were many stretchers, but the room did not look half as crowded as I expected. I told that to the resident nearby.

"You have not seen the other section yet."

The other section was a sort of waiting room for

  • mothers who had already given birth, waiting either to be sent to be sent up to the OB ward for recuperation or to be discharged directly, and
  • mothers who were still waiting for their C-section schedule.
I was wheeled into the second section.

It was like a refugee camp. 

In one bed, you would find three people. Some women who had just undergone CS were sitting on plastic chairs. There was no place to lie down comfortably to take a nap.

Having undergone CS several times in the past, I could not help but gape in awe at these women. Despite being a CS "veteran," I still much preferred spending my first 24 post-operation hours flat on my back.

These women sat, stood, and walked. Everyone was barefoot. Slippers were not allowed.

Imagine women who had just given birth walking around barefoot. Going to the bathroom barefoot, stepping on a cold, wet, and dirty floor. 

Apparently, PGH does not believe in ge lai.

A Day at the OBAS

At the OBAS, it was very important that you knew the schedule of your meds. The nurses were so busy with so many patients, it was often up to you to remind them it was time for your next shot of dextromethorphan.

My adult diaper needed to be replaced. I informed the nurse. She gave me an adult diaper and left me to take off the old one and replace it with the new.

If your IV line stops dripping, nobody will ever notice. It's up to you to get up the nerve to approach a super-busy nurse and ask him or her to adjust it.

Don't be scared. As busy as they were, the nurses at the OBAS were, in fact, the least grouchy bunch of nurses I had seen in the 1.5 months I had stayed at the PGH.

By the way, I almost forgot to tell you about the OBAS beds. 

Like the examination table outside, the OBAS beds were unsheeted and unmattressed slabs of steel. There were no pillows and no blankets, but you are allowed to keep your own blanket if you had the foresight to bring one.

My husband had a friend who worked at PGH. The friend lent me a blanket. In that over-airconditioned place, I don't know how I would have fared without it.

My attending physician sent me to the ultrasound room so the radiologist could check the remaining volume of my leaking amniotic fluid. Another doctor wheeled me there. 

"This is the only hospital I know where the porters have a medical degree," I kidded. The doctor laughed.

Back at the OBAS, they checked my baby's heartbeat for the fifth time since I arrived over 24 hours ago. On the monitor, I watched as my baby's heart rate dropped below 120 ... below 90 ...

The medical intern beside me spurred into action. She started manipulating my cervix, pleading, "Wake up, baby. Wake up." 

Her alarmed tone caught the attention of the other medical staff. Soon there was a circle of very young doctors around my bed. 

For one reason or another, baby's heartbeat normalized eventually. The young doctors drifted back to their own business, but the intern who had been with me earlier stayed with her eyes glued to that monitor for about half an hour.

Then, at around 4:30 in the morning, she made a cellphone call to my attending physician, another medical intern, Dr. A*, who had just gone home for the day. 

"Nonreassuring fetal heart rate," I heard her say. "You need to come back now."

It was time for them to cut me open and bring the baby out.

CS Time

If there's one thing scarier than the thought of being cut open, it's the thought of being cut open by a very young doctor who has already been on sleepless duty for probably 48 hours and had just gone home hoping to get some sleep, only to be called back immediately so she can cut you open.

But all that fear was needless, because as you can see, I am alive and well. Thank you, doctors!

Now let's back up a little. Before they wheeled me into the operating room, I wondered aloud where the postanesthesia care unit (PACU) was.

The nurse chuckled at my naivete. He pointed to the narrow hall leading to the operating room. That, apparently, was what served as the PACU for the charity ward.

The operation went as it should, as far as I know. It was pure bliss to hear my 29-weeker wail as they took him out. When I heard that cry, I was satisfied. I closed my eyes and went to sleep.

I woke up at the "PACU." There was nothing to do there, nothing to look at. So I went back to sleep.

The next time I opened my eyes, I was back at the "waiting room." Strangely, it was far less crowded now. Apparently, beds had been vacated at the ward upstairs, and mothers had either been transferred there or sent directly home.

My incision was starting to hurt. I asked the nurse for a pain killer but specifically asked for tramadol. I am allergic to ibuprofen, and on my last CS, I swore I would rather live with the pain of the incision than let anybody inject paracetamol into my veins again. That stuff burns!

The nurse came back with a syringe of paracetamol. I balked.

"Don't worry," she said. "I promise it won't hurt."

She inserted the needle. It did not hurt – yet.

And then she started to push the nasty liquid in. I winced and held my breath.

Something was wrong. The shot wasn't hurting. The evil paracetamol wasn't burning a trail down my arm veins. How was this possible?

Thirty seconds later, the nurse was still there. I realized she was slow-pushing the medicine. That's why it didn't hurt like before!

Bless you, nurse!

An hour or so later, I heard my name called. At last, I was to be transferred to the OB-Gyn charity ward upstairs.

Continued in Part II: The OB-Gyn Ward

*Name has been limited to a single initial to protect the individual's privacy

The Nanay Notebook is written by Blessie Adlaon, a work-at-home and homeschooling mom of five. Check out our About page to know more about this blog's author and our policies on advertising, press releases, and reposting.

Sep 29, 2014

Kidz Gear Volume-Limiting Headphones: Protection for Our Kids' Ears [REVIEW]


Product Specifications

Maximum volume: 108dB 
Max. vol. with limiting cable: 88dB 
Cord length: 1.5 meters (4.5 feet) 
Speaker size: 30 mm 

Out of the Box

A pair of Kidz Gear Volume Limiting Headphones for Kids came in the mail today.



The kids eagerly tore into the box, and here's what came out:

Kidz Gear headphones (blue) and volume limit cord (black)
Of course, we all tried it out. (Even I did.) Since the kids weren't presentably dressed, here's a picture of their visiting cousin Zach Besin instead.

Comfort 

The tiny ear pieces felt a little strange on my ears, but they were comfortable and light – and soft!

They didn't press uncomfortably against my head (unlike my large headphones), so I think I'll be borrowing these for my own use once in a while. 

The headband length is adjustable, so it fits all head sizes.

Sound

We took turns listening to some songs from YouTube. The bass is pretty good!

Without the volume limiting cable, the sound can get pretty loud, but with the cable on, the volume is kept just below ear-piercing level. I never have to worry anymore if the kids have the volume on too high.

If you want to turn the volume down even more, it's easy and convenient with the volume-control dial.

Material

The product has so far been sturdy enough to withstand the chaos of my four kids and their cousin. They've been using it for three days now, and it's still in great condition.

A closer look at the headphones revealed very clean edges and snug connections. The plastic is flexible, not brittle. The parts are neatly screwed on to each other and not simply snapped on.

Availability

You will be pleasantly surprised to find that these headphones' suggested retail price is only P1,190.

It's very affordable, compared to the price of regular adult headphones of similar quality. And compared to the cost of good-quality hearing aids – which our kids will need if we don't protect their hearing this early – P1,190 looks like an excellent investment.

Kidz Gear Volume Limiting Headphones are locally available at Astroplus, Astrovision, Beyond the Box, and Digital Hub. Overseas shoppers can get their Kidz Gear Volume Limiting Headphones for Kids from Amazon.com.

To learn more about this product, check out its website, www.gearforkidz.com, or Like Kidz Gear on Facebook for updates.



DISCLOSURE: This is an unpaid review. A sample of the product was provided for free for review purposes.

The Nanay Notebook is written by Blessie Adlaon, a work-at-home and homeschooling mom of four. Check out our About page to know more about this blog's author and our policies on advertising, press releases, and reposting.


Sep 24, 2014

BMBE Frequently Asked Questions

I've been receiving so many questions about BMBE, I decided to post this FAQ for quick reference.

If you have questions that are not answered here, please ask them in the comments box below and I will update this post.

What is BMBE?

The Barangay Micro Business Enterprises Act of 2002, or RA 9178, is a law that (theoretically) allows businesses with assets worth less than 3 million pesos to be exempted from paying income tax.

Aside from a few other benefits, BMBE also exempts you from the minimum wage law.

Am I qualified?

If you are a sole proprietor or corporation with assets worth less than P3 million, you are probably qualified.

I am a sole proprietor. What assets are we talking about here?

If you are a sole proprietor, we're talking about your personal assets, since your business assets and personal assets are one and the same.

The only thing that is not included in the computation of assets is the value of the building and land on which your business is located.

I am registered as a professional. Do I qualify for BMBE?

According to my conversation with the BIR contact center officials, probably not.

I operate a branch/franchise. Can I apply for BMBE?

No. Only main offices can apply for BMBE.

How do I apply for BMBE status?

Please see my detailed post on that: http://www.nanaynotebook.com/2013/01/the-bmbe-in-real-life.html.

And how much does it cost to apply?

P1,000 is the maximum application fee.

If I am approved as BMBE, does that mean I won't have to pay taxes anymore?

Well, first, BMBE applications are approved by the municipal hall, but tax exemptions are approved by the BIR.

Just because you are approved as a BMBE by the municipal/city hall does not necessarily mean you will be granted income tax exemption by the BIR. The DTI knows this situation, and apparently, it's not illegal for the BIR to do that.

Now even if the BIR does grant you income tax exemption, it only means you won't have to pay income tax anymore. You still have to pay the 3% monthly percentage tax.

Will I still need to issue official receipts (ORs) or sales invoices (SIs)?

Absolutely. By the way, make sure your ORs and SIs are printed by BIR-accredited printers. Click the link for the official list of BIR-accredited printers for 2014.

Do they sell ORs/SIs at the BIR?

There may be BIR employees that act as middlemen for these printers. It will save you money if you avoid middlemen and refer to the list instead and contact the printers yourself.

If I get income tax exemption, will I still need to file my ITR?

You won't be required to file your ITR anymore, but you will need to file your annual information form instead.

Nevertheless, you might still want to file your ITR even if you are not required to, because you may need an ITR to secure a loan or apply for postpaid lines, etc.

Note that if you are a BMBE, you won't have the option to compute your income tax using the optional standard deduction method (OSD). You'll have to itemize your expenses.

If you don't have an accountant, computing taxes through the itemized expense method can be a headache. This is why I chose to forgo filing my ITR as a BMBE.

I've gone to my municipal/city hall to apply as BMBE, but nobody seems to know what it is or how to do it.

That always happens. Keep asking and go where they tell you to go. The employees usually want to help, they really just don't know or remember the process.

If you pester the people at the municipal/city hall long enough, somebody who remembers the process will overhear you or notice the hullaballoo, and you'll finally get the help you need.

What if the official I end up talking with really has no idea what the BMBE law is about?

When this happens to you (and it will), call DTI's Bureau of Micro, Small, and Medium Scale Enterprises Development (BSMED) office and let the BSMED official talk to the municipal/city hall official, government office to government office. That should work.

Here are BSMED's numbers: 751-0384 / 890-4968 / 897-7596 / 897-1693. Save those on your phone.

Any more bad news?

Why, yes! When you get your income tax exemption, many of your clients' accountants will not know how to handle your payments as a BMBE entity. They will still insist on withholding tax from you because that's the only way they know how to report the payments they give you as an expense.

To prepare for this scenario, make sure you also get a special certificate (cost: P50) that specifically states you are exempted from income tax and, therefore, from tax withheld at source. Here is mine; you can use it as your template (click to enlarge):



Also, in all my invoices, I add the following note:
This subcontractor is registered as a Barangay Micro-Business Enterprise (BMBE) sole proprietor under RA 9178. Income tax is not part of her registered tax activities, and her withholding tax rate is 0%. A copy of her certificate of exemption from tax withheld at source is available upon request. To report this payment as an expense through Form 1601-E, please mark item 13 in the form as YES and specify RA 9178.

With all these hassles, why again do I want to apply for BMBE?

Because the income tax rates in the Philippines are incredibly high, and if you can be exempted from paying them, you will save a lot of money.

Is there no other way I can save on taxes?

There is! If you are operating a very small business with an annual gross income not exceeding P100,000, you are exempted from paying the monthly percentage tax of 3%.

For more information, read Revenue Memorandum Circular No. 7-2014.

The Nanay Notebook is written by Blessie Adlaon, a work-at-home and homeschooling mom of four. Check out our About page to know more about this blog's author and our policies on advertising, press releases, and reposting.

Aug 13, 2014

Is Homeschooling for You? And if It Is, How Can You Do It? [FREEBIES AND GIVEAWAYS]

CONTEST RESULTS 

After ensuring the validity of entries, The Nanay Notebook is happy to announce that the winner of the raffle is NADIA DE LEON

Congratulations! See you at the Homeschool Conference 2014! 

Please email me your full name and mobile number so I can submit them to the contest organizer, Manila Workshops.

Warm regards,

Blessie Adlaon

On a signal-number-2 day in August, my kids are all in "school."

  • My 9-year-old is learning Java Script. 
  • My 7-year-old is doing typing lessons (currently at 15 wpm), and later she will make loom band bracelets, which she will sell to our neighbors at P50 each. 
  • My 5-year-old, who has never been inside a formal classroom, is reading aloud the Act of Contrition.

Welcome to our world. This is what homeschooling in the Adlaon residence looks like.

Why Homeschool?

Every homeschooling family has its own reason. In our case, our three main reasons are
  1. protection and preservation of the children's innocence;
  2. the freedom to teach our kids what we believe is truly important, in the way we believe children should learn; and
  3. financial flexibility.
I will discuss each of these very briefly:

Preservation of Innocence. In school, away from teacher supervision, I saw and heard a lot of things that I now know children should not see and hear. In other words, garbage freely entered my mind – and once garbage enters, it's very hard to take it out. 

Now is not the time to discuss what happens when one's mind is sullied. But I know it is something I do not want for my kids. Homeschooling is one way I am able to protect them until they are discerning and spiritually strong enough to protect themselves.

Freedom to Teach. Do you ever feel that your child's school is teaching too much too soon? Does your child wake up extremely early, sleep very late, and have little to no time for play, because there is schoolwork to do? Do you feel helpless in the midst of it all?

My husband and I refuse to feel helpless in the way our kids are educated. That's why we chose to take full charge by homeschooling.

Financial Flexibility. My husband and I are both freelancers right now. Income is unpredictable. We don't always have money in June. 

By homeschooling, we can enroll in September or December or whenever the money comes. We decide what books to buy, what field trips to take, and we never have to spend on PTA fund raisers. 

Want to Learn More?

Click image to enlarge
Manila Workshops, The Learning Basket, and Unilab, supported by the Homeschool Association of the Philippine Islands (HAPI), are proud to present the Homeschooling Conference of 2014, entitled Educating for Life: Homeschooling with Passion, Purpose and Confidence. It will be held on September 6, 2014 at the Bayanihan Arts and Events Center (8008 Pioneer St., Kapitolyo, Pasig) from 8 a.m. (registration) to 5:30 p.m.

The speakers and topics are
  • Irma Chua (Educating for Life). Irma is a mom of six and has been homeschooling for 20 years.
        
  • Dennis Poliquit (The Hands-On Homeschool Dad). Known as “Big Daddy Jake” over the radio airwaves, Dennis is a hands-on homeschooling dad of two sets of twins and one singleton.
        
  • Moira Bunyi (The Confident Homeschool Mom). Moira has a postgraduate degree in Family Life and Child Development and has been homeschooling for five years now.
       
  • Yen Galagnara (Learning in the Digital World). Yen was a “housemate” at Pinoy Big Brother Season 2. She homeschools her three children while she runs a Korean language school.
       
  • Jen Bellosillo (Introducing Filipino Arts, Culture, and Heritage). Jen has been homeschooling for six years now. She mentors other homeschooling parents as a CFA (Catholic Filipino Academy) parent coach.
       
  • Tina Rodriguez (Homeschool 101: Getting Started). Tina, mom of three, is a work-at-home and homeschooling mom who advocates her faith through her blog, Truly Rich Mom.
       
  • Donna Pangilinan-Simpao (Conquering Homeschool Fatigue). Donna is a medical doctor. She homeschools her three children. She is also the founder of the Facebook group "Homeschoolers in the Philippines."
       
  • Ivy Marquez (Nurturing the Love of Learning). Ivy homeschooled her three children up to high school.

Learning Fee (and How You Can Get a Seat for FREE!)

The cost of attending the conference is as follows:
  • Php 1000 per participant
  • Php 1500 per couple (We encourage both parents to attend!)
  • Php 500 per child (7 to 18 years old)
  • Php 500 for PWD
  • Php 500 for groups of homeschoolers; with a minimum of 5 persons per group
However, you have a chance to attend the conference for free! (Yes, FREE!)

Simply join our contest via Rafflecopter below and win TWO FREE SEATS to the conference! (Yes, TWO!)

But wait. There's more. You'll also get a heaping bag of craft goodies, sponsored by Bee Happy Crafts.

So of course you want to join the contest. Now here are the mechanics. To join:
  1. Like Bee Happy Crafts on Facebook.
  2. Like Manila Workshop on Facebook.
  3. Like the Learning Basket on Facebook.
  4. In the comment box below, leave a comment using an email address we can use to get in touch with you in case you win.
Each of the above equals one entry, for a total of four. (The more entries you make, the bigger chances of winning!)

Now if you want to further increase your chances of winning, please also like my Facebook business page, Facebook.com/WishPhilippines, the first local online wishlist publisher in the country, and follow me on Twitter, @WishPH.

This contest runs from August 13 to 22, 2014, Philippine time. Winners will be chosen through Rafflecopter and announced on August 23. Prizes (free seats and craft materials) will be given at the conference site on conference day.

Now if you can't wait for the contest results and want to register right now, please visit homeschoolingconference.com.

a Rafflecopter giveaway


The Nanay Notebook is written by Blessie Adlaon, a work-at-home and homeschooling mom of four. Check out our About page to know more about this blog's author and our policies on advertising, press releases, and reposting.