I'm posting some answers to the past year exam questions for all to review. Do comment should you notice any discrepancy or have anything to add. Also note that i have expanded on the explaination so i can squeeze in as much details as possible.

(A) Write short notes on the counts of sponges, sharps and instruments during surgery.

Importance :
Loss in any of the above mentioned will result in harm to the patient

Who to count :
Scrub nurse + Circulating nurse

When to count :
(i) Before Surgery
(ii) Before closure of body cavity
(iii) Before closure of skin

How to count :
(According to standards of practice of the institution)
* Count concurrently, audibly with the circulating nurse (or qualified staff) and use of Count Chart accurately

(i) Preop
- Loosen bundles of swabs lightly
- Pick up 1 swab at a time

- Show radio-opaque thread/ intact loop of penny towel to circ nurse
- Recount if interrupted or in doubt

- Remove/discard bundle in event of discrepancy

- Ensure circ nurse records immediately + initials on Count Chart

(ii) Intra Op

- Keep count of swabs at op site
- Maintain 2 swabs at op field at any 1 time

- Use abdominal packs/penny towels/swab sticks for large/deep wounds

- Do not remove any swabs from OT til op is over

- Pass out soiled/wet swabs to circ nurse

- Count, bag up and place aside in sets of 5s/10s (according to protocol)

- Document -> strike out bundle and initial name

- Count all swabs before closure of cavity and skin
(floor count, trolley count and op field counts)

(iii) Sutures / Sharps

- Conduct preliminary/initial count

- Give 1 at a time

- Recieve intact needle

- Suture packs to tally with needles

- Additional supplies to be obtained from circ nurse

- Needles passed out are to be accounted in Count Chart

(iv) Instruments

- Conduct prelimary checks for intactness

- Account for broken/missing parts

- Observe for intactness

- Account for additional supplies in Count Chart

* The surgical team must be informed immediately of any discrepancy, and a thorough search + xray in OT + incident report must be done.

*************************************************

(B) You are an OT circulating nurse. Give a brief account on how you would handle the specimens recieved from the Scrub nurse during surgery.

* Principles revolve around :

(i) Deal promptly

(ii) Confirm nature of specimen + correct type of examination
(iii) Correct labelling + Preservation + Despatch

Interventions include :

- Use appropriate container

- Do not mix specimens

- Correct + sufficient preservatives
(Eg . fully immerse specimen in 4% Formaldenhyde)
- Multi specimens -> label in numerical order using seperate containers

- Avoid traumatizing specimen

- Double bag item prn (must be biohazard bag)

- No preservatives for specimen if C&S or frozen section

- Ensure correct patient details + type of exam required + nature of specimen

- Despatch to respective labs with correct forms STAT

- Implants/ FBs/ Stones/ Teeth are to be returned to ward nurse/pt/family

- Amputated limbs sent to mortuary for burial/disposal

I'm posting some answers to the past year exam questions for all to review. Do comment should you notice any discrepancy or have anything to add. Also note that i have expanded on the explaination so i can squeeze in as much details as possible.

Mdm Kuek, 70y, c/o inability to delay voiding and dribbling of urine whenever she coughs or sneezes too forcefully. She seldom leaves her home because she feels to embarassed to wet herself in public. During a check up, she consults the continence nurse.


(a) List the transient causes of Urinary Incontinence
(b) Briefly discuss the general urinary assessemnt for Mdm Kuek
(c) State the specific nursing management if UI the nurse clinician would render Mdm Kuek

***************************************

(a) Transient causes of UI would include:

D - Delirium (acute confusional state)
I - Infection (increases urge)
A - Atropic Vaginitis (loss of suporting structures)
P - Pharmaceutical (eg. Lasix)
P - Pyschological (eg. Dementia)
E - Endocrine Disorders (eg. DM ->polyuria)
R - Restricted Mobility (eg. Amputation)
S - Stool Impaction (presses onto bladder)

***************************************

(b) General Assessment for UI include:
(1) Medical History
- Medical, Surgical, O&G -> any problems identified?

(2) Physical Assessment
- Esp Genitalia -> Note skin condition, presence of discharges, foul smell, prolapse?
- May indicate UTI

(3) Current Medication
- On any diuretics?

(4) Fluid Intake
- Amount and type consumed
- Identify possible diuretic properties some drink possess

(5) Urinary Habits
- Note the onset, duration, severity of UI
- Eg. Frequency, Nocturia, Dysuria, Urgency, Haematuria, Obstructive symptoms

(6) Bowel Habits
- Constipated? Impacted stools -> presses on bladder

(7) Psychological State
- Depression? Delirium?

(8) Functional State
- Immobility -> leak?

(9) Environmental Factor
- Lack of toilet facilities? Too far?

(10) Age related changes
- Weak pelvic floor muscles? Atropic Vaginitis?

***************************************

(c) Nursing Management
(i) Assessment
- As abovementioned to exclude/determine factors contributing to UI

(ii) Plan
- Explain prior commencing interventions for cooperation and consent

(iii) Interventions

1. Diagnostic Investigations
   - Eg. In-Out catherization to measure Post Voided Residual (PVR) volume
   - Post void bladder scan
   - Blood Tests -> High WBC indicative of infection
   - Urine C&S + FEME to exclude UTI
   - MMSE to determine mental state
   
2. Bladder Chart/ I&O Chart
   - Useful assessment tool to describe voiding pattern
   - Provides enhanced self awareness of fluid intake and elimination pattern
   - To record findigngs for at least 3 days
   - Pt able to keep this record by themselves at home
   
3. Behavioural Techniques
   - (a) Bladder Retraining
   -> Helps pt to postpone voiding to a fixed schedule
   ->Requires pt to resist sensation of urgency to void
   -> Recommended for STRESS & URGE incontinence
   
   - (b) Habit Training
   -> Involves matching toileting schedule to pt's own voiding habits
   -> Freq, Vol, Patterns of continence & incontinence are adjusted according to pt's pattern
   
   - (c) Timed/Scheduled Training
   -> Includes techniques to trigger voiding
   -> Eg. Suprapubic tapping, Stroking inner thigh, Running a tap
   -> Recommeded for pt's who require assistance for toileting
   -> Usually 2hr intervals
   
   - (d) Prompted Voiding
   -> Asked at regualr intervals to empty bladder
   -> Form of positive reinforcement
   -> Recommeded for pt's who can respond when prompted to void
   
   - (e) Pelvic Floor Exercises
   -> Improves tone of muscles which aupport bladder neck and urethra
   -> 1st line treatment for STRESS & URGE incontinence
   -> Must be practiced daily
   
4. Introduction to External Collection Devices
   - Eg. "All-in-1 briefs", Continence pads/aids, urinals, commodes
   - Affordable, easy to apply, ranges in sizes and varies according to absorbency
   - Socially acceptable, discreet
   - Minimal skin irritation
   
5. Skin Care
   - Maintain perineum hygiene
   - Ensure right continent aids used with proper application
   - Cleanse skin well after leakage
   - Change continence pads/diaper regularly
   
6. Diet & Fluid
   - Adequate nutrition & Fluids
   - Debunk myth that low fluid intake will help incontinence
   -> Truth : Less fluid intake will result in concentrated urine, in turn irritate bladder wall and worsen incontinence
   - Encourage at least 8 glasses of plain water unless contraindicated
   - Limit drinks near bedtime
   - Reduce consumption of stimulating beverages (ie. Tea with diuretic effect)
   
7. Environmental Modification + Physical Safety
   - Convenient toilet location
   - Addition of grab bars, good lighting, non slip tiles/footwear, velco pants
   - Use of ambulating aids (eg. walking sticks)
   
8. Medication
   - Use of medication to treat Incontinence
   
   -(a) Urge :
   -> Anticholinergics (eg Propantheline Bromide) acts on bladder wall
   -> Tricyclic Antidepressants (eg. Imipramine Hydrochloride) acts on bladder muscles
   -> Bladder Relaxants (eg. Oxybutymin Chloride) acts on bladder wall
   
   - (b) Stress:
   -> Alpha-adrenergic Agonists (eg. Ephedrine) act on bladder wall and urethra
   -> Estrogen act on urethra
   
9. Address problems related to UI
   - (a) Physical
   -> Discomfort r/t dampness
   -> Unpleasane odors
   -> Skin rash/breakdown
   -> Falls
   -> Dehydration
   -> Insomnia
   
   - (b) Psycological
   -> Loss of independence (req aid for voiding)
   -> Fear of embarrassment
   -> Depression -> Suicide
   -> Loss of dignity
   -> Withdrawal
   -> Feeling of being a 'burden' to caregiver/family
   
   -(c) Social
   -> Reduced social interaction
   -> Isolation r/t embarassment/smell
   
   -(d) Sexual
   -> Avoidance of sexual contact r/t smell etc
   
   - (e) Occupational/Financial
   -> Unemployment r/t absence from work
   -> Change of job
   ->Money spent on treatment
   -> Refer to MSW/Psy/Skills traininf options
   
10. Catherization & Surgery
    - For serious cases
    

I'm posting some answers to the past year exam questions for all to review. Do comment should you notice any discrepancy or have anything to add. Also note that i have expanded on the explaination so i can squeeze in as much details as possible.

Qns :
Mrs Lim, 29y, is admitted for drug overdose. She mentioned that she has taken 60 tabs Paracetamol 1hr ago, after a quarrel with her husband. She is under considerable stress as she has recently lost her job and the family is in financial dificulties. Her husband has been unemployed for 6 months. Mrs Lim has no history of psychologicla illnesses, suicidal tendencies or any medical illness.

On examination,

• She appears fearful and anxious
• Cognitive status - conscious and normal
• VS - BP : 100/65mmhg, HR : 100/min, RR : 25/min
• c/o nausea and abdominal cramps
• Vomitted 200ml of whitish fluids

Discuss the emergency management for Mrs Lim. Give rationales for the management taken.

* Note : Mrs Lim's VS is indicative of shock

***************************************

(A) Assessment

(i) Triage Priority
- Based on given scenario, vital signs, other factors (eg. age, GCS) -> Cat 2

(ii) VS + SpO2 + GCS + I&O + Physical examination
- To determine current condition for baseline comparison
- Highlight possible deterioration (Eg. renal failure, respi distress)
- Observe for subsequent vomitting

(iii) Reason for Admission
- Poisoning -> intentional, suicide
- To ensure police report is made
- To handle specimens obtained as per hospital protocol (intact police seal)
- To inform next of kin on whereabouts of individual

(iv) Severity of Poisoning
1. Drug - Amount and type. Also note TIME consumed
2. Route of Poisoning - Oral/ingestion
3. Host Susceptibility - Body weight, extent of distribution/ absorption

(v) Medical History & Medication
- Underlying medical conditions? (past and current)
- Drug/Food Allergy
- Addiction?
- Psychosis?
- Identifies factors that may worsen condition

(B) Investigations

(i) Blood Tests
- Blood for toxicolgy, Biochem studies for drug levels
- FBC, PR/PTT, LFT, GXM, U/E/Creat, Glucose, ABG

(ii) ECG
- Assess cardiac rhythm and function

(iii) CXR

(iv) Urinalysis

(v) Vomitus for toxicology/drug analysis
- Ensure intact police seal and proper despatch protocol


(c) Interventions

1. Principles of Poison Management
(i) Maintain Vital Function (ABC) + I/V Access
(ii) Clinical Evaluation
(iii) Decontamination
(iv) Neutralize Poison
(v) Enhance Elimination
(vi) Prevent Re-exposure

(i) Maintain Vital Function (ABC) + I/V Access
a. Remove from contaminated source if possible
b. Establish ABC
c. Oro-airway + O2
- Via non re-breather mask
- To flush out inhalants
d. Continous monitoring of VS + SpO2 + GCS + I&O

(ii) Clinical Evaluation
- Clear history of individual's medical condition, medication, allergies etc
- Type of poison? Mode of exposure? Time of ingestion? Specimen of poison?
- Symptoms the individual manifests (eg. drowsiness, ab cramps)
- Identification of psychosocial problems?
- Evidence of abuse?

(iii) Decontaminate
a. Topical Decontamination
- Remove from source
- Brush excess powder off skin, taking care not to break skin
- Remove contaminated clothing + others
- Flush with plenty of H2O
- Save H2O for proper disposal + testing

b. GI Decontamination
(1) Dilution (H2O)
- Aim : To decrease gastric irritation
- Child 100-200ml, Adult 200-400ml

Contraindications :
- Capsules, Tablets
- Drowsy, Coma, Seizures
- Absence of gag reflex
- Corrosive substances
Rationale : Increase risk of aspiration

(2) Emesis
- Only done when the substance is suspected to still be in the stomach (eg. under 4hrs post ingestion)
- Done when a potentially toxic dose is ingested
- Done via pharnygeal stimulation/ medication

Contraindications:
- Drowsy, coma, seizures
- No gag reflex
- Under 6months old
- Corrosives

(3) Gastric Lavage
- Indications : 1-6hr post ingestion
- Up to 12hrs for salicylates, barbiturates, carbamazepines, tricylic antidepressants
- Precaution - To insert CUFFED ETT prior to commencement to prevent aspiration (esp for comatose)

Procedure :

1. Left lateral position
2. Insert appropriate sized NGT
3. Aspirate contents til clear (and send for investigation with police seal)
4. Intro 250ml h2O (adults)
5. Wait 2min
6. Aspirate contents
7. Repeat till clear

Contraindications :
- Parraffin + Corrosive solutions, as NGT may perforate esophagus

(4) Oral Adsorbents - Activated Charcoal
- Aim : To reduce poison absorption
- Given post gastric lavage/induced emesis
- Adult : initial dose 50-100g , subsequently, 15-20g 4-8hrly x24hr (PO/NGT)
- Most effective within 1hr of poisoning (up to 12hrs for salicylate or tricyclic antidepressants)

- Indications : Paracet, Aspirin, Phenytoin, Phenobarbitones, Theophylline, Digoxin

Contraindications :
Methanol, ethanol, corrosives, heavy metal, Antidotes

(5) Catharsis
- Aim : Induce diarrhea to hasten elimination of poison from GIT (although there is controversy over efficacy)
- Currently used to neutralize constipating effects of activated charcoal

- Indications : Paraquat, Salicylates, Iron, Digoxin
- Agents used : Mg Sulfate, Na Sulphate, Sorbitol

- Precautions : F&E must be replaced as diarrhea -> low K/Na

Contraindications :
Paralytic ileus, Corrosives

(iv) Neutralize Poison - Antidotes

1. Paracetamol -> N-acetylcysteine (NAC), Methionine
2. Opiates (ie. Morphine, Pethidine) -> Naloxone, Narlophine
3. Organophosphates -> Atropine, Pralidoxime
4. Benzodiazapines (ie. Diazapam) -> Flumazenil
5. Anticholinergics (ie. Atropine) -> Physostigmine

(v) Enhance Elimination
(1) Forced Diuresis
- Aim : Increase excretion of poisons
- With or without manipulation of urine pH

Indications : Aspirin + other salicylates, Phenobarbitone
- 1 cycle = 3 x 500ml infusion in following order
- At rate of 500ml/hr

1. 500ml D5% + NaCHO3 8.4% (alkaline)
2. 500ml D5% + 30ml KCL 7.45%
3. 500ml N/S

- Number of cycles are dependent on the amount of poison in the blood
- I/V Frusemide 20mg at the end of each cycle

Nurse's Responsilibilties
- To monitor VS + GCS + CVP + output (insert IDC)
- Test urine for pH (expected to be alkaline due to bicarb infusion)
- Observe for complications : Eg. Fluid retention, electrolyte imbalance, cerebral/pulmonary edema

(2) Dialysis
- Aim : To remove high levels of poison in the bloodstream
- Types :

1. Haemodialysis
   Indications - Renal Failure, Barbiturates, Lithium, Ethylene Glycol, Methyl Alcohol, Salicylates
   
2. Charcoal Haemoperfusion
   Indications - Paraquat, Digoxin, Phenobaritone, Tricyclic Antidepressants, Theophylline

- Indications : For severe clinical intoxication, grade 4 coma, hypotension, hyper/hypothermia

(vi) Evaluation
(1) Effectiveness of intervention
- Stability of VS + GCS + SpO2

(2) Handling of specimens under appropriate protocol
- Intact police seal

(3) Prevent re-exposure
- Through education, counselling, referral to Psy to address underlying emotional issues

(4) Provide Psychogical Support + Suicide Precaution (Safety)
- Overt and Covert monitoring
- Suicide Chart
- Notify all staff of status
- Observe for signs of depression
- Medication to be taken in STAT in presence of nurse
- No isolation

(5) Accurate Documentation
- Medical legal issues

(6) Apply for transfer to ward/ICU as appropriate

***************************************

Please note that the answers provided are written with the help of open lecture notes. I have compiled most of the interventions, and management typically goes beyond the given scenario.

This was done as a revision booster for me and all those who are stuck wandering online. I hope i have been of some help. Cheers to all those who have unselfishly shared their slides =)

I'm posting some answers to the past year exam questions for all to review. Do comment should you notice any discrepancy or have anything to add. Also note that i have expanded on the explaination so i can squeeze in as much details as possible.

Qn : Mr Khoo has colo-rectal carcinoma stage III. He is admitted to your ward with wide spread metastasis. His pain is partially controlled with oral analgesics.

(a) Describe how you would assess Mr Khoo's pain.
(b) Discuss the pain management strategies for Mr Khoo.

I always thought that metastasis automatically renders the individual into stage IV. Someone please confirm. Thanks. Below are my answers with the help of an open text.

*************************************

(a) Assessment strategies would include the following:

(i). Accurate classfication of Pain

Acute - Sudden onset, warns of imminent tissue damage
Chronic - Prolonged, complex and more difficult to control

* Note : Cancer pain may be chronic with acute flare ups

(ii) Use of the Pain Phenomenon as a guide:

1. Physiologic
2. Sensory
3. Affective
4. Cognitive
5. Behavioural
6. Socio-cultural

1. Physiological
- Associated with direct tumor involvement (eg. tumor pressing on nerves?) or cancer therapy (eg. Side effect of RT/chemo)

2. Sensory
- To note the following : * Location - Site, diffused/localised/generalized? *Intensity - As percieved by individual (how bad?) *Quality - Ask individual to describe nature of pain (Eg. Pulsating, aching, burning)

3. Affective
- To identify psychological factors that may contribute to pain - Eg. Deteriorating condition -> depression/anxiety -> more pain - Also note the personality traits of the individual (type 1/2) as this will also affect pain perception

4. Cognitive
- Highlights how pain affects the individual's thought processes
- Eg. more pain -> more anxiety -> depression - Individuals with positive attitudes reported less severe pain

5. Behavioural
- Identifies behaviour related to pain (Eg. level of activities) or intake of analgesic

* Note : Behavioural response to pain may or may not coincide with the individual's report to pain. Eg. The patient may report of a pain score of 8, but may still be able to continue with his ADLs.

6. Socio-cultural
- Include demographic, cultural, ethnic, spiritual and other related factors that influence the perception of pain
- Eg. It may be socially acceptable in some cultures to have outward bursts of emotion when experiencing pain

(iii) Use of a Comprehensive Assessment Tool
- Includes subjective (eg. verbalization of pain) and objective (what the nurse observes) data

Onset
Location
Description
Intensity (use of pain scales)
Aggravating & Relieving Factors
Previous treatment
Effect on pain on daily activities
Vital Signs

- Pain Scales (eg. Wong-Baker's Face, Numerical)

*************************************

(b) Firstly, the Nurse must understand that pain perception is a personal and subjective evaluation. Therefore, it is important nit to impose their own personal views which will be likely to obscure the assessment process. Continual pain assessment with the following guidelines should be beneficial:

1. Pharmacotherapy
2. Complimentary Therapies
3. Other Therapies
4. Role of the nurse

1. Pharmacotherapy
- Use of the WHO's 3 step Analgesic Ladder



- Examples of Analgesics
(i) Non Opiods - Aspirin, Paracet, NSAIDs (naproxen, diclofenac, Ibuprofen)
(ii) Opiods - Weak - Codeine, Buprenorphine - Strong - Pethidine, Morphine, Fentanyl

- Examples of Adjuvants
(i) Anxiolytics - Diazepam
(ii) Antidepressants - Amitriptyline
(iii) Anticonvulsants - Sodium Valporate, Carbamezapine, Neurotin
(iv) Neuroleptics - Haloperidol

- Common Routes of Administration :
-> PO (preferred), S/C (bolus/continuous), PR, Transdermal, I/M, I/V, Epidural

* Rationale : The WHO's 3 step ladder aids in determining type & strength of analgesic required for effective pain relief.

* Nursing Responsibilities
(i) Medication must be given as presribed and on schedule (5 rights)
(ii) Dosage should be titrated to meet the individual's needs
(iii) Assess the need of adjuvant drug therapy
(iv) To observe and manage the side effects/complications of Opiods
- Eg. Constipation, N&V, Sedation, Mental CLouding, Respi depression, Urinary retention, xerostomia, pruritis, sleep disturbances

(2) Complimentary Therapy
(i) Psychological and Behavioural Therapy
- Eg. Distraction, Hypnosis, Relaxation, Guided Imagery, Music, Art, Muscle relaxation

(ii) Cutaneous Therapy
- Eg. Accupuncture, Massage, Transcutaneous Electrical Nerve Stimulation (TENS)

* Rationale : Improves coping strategies to deal with pain.

(3) Other Therapies
(i) Interventional
- Only 2-5% of Opiods direct to the CNS
- Individual may consider Nerve Blocks

(ii) Supportive Care
- Eg. Pastoral Care, Supportive Care

(iii) Anti-tumor Strategies
- Eg. Radiation, Chemotherapy, Surgery

(4) Role of the Nurse in Pain Management

(i) Believe in the patient's complaint of pain

(ii) Careful assessment
- detailed hx, physical & psychosocial assessment

(iii) Provide Psychological Support
- Encourage active participation in self care, verbalization of needs/feelings
- Include the family and social network (if possible)

(iv) Educator
- Teach effective coping strategies
- Discuss options of Pain management (safe and effective methods)

(v) Evaluation
- Individual's response to therapy, after initiation of treatment, at each new report of pain, and at suitable intervals after intervention
- Accurate documention of pain, S/E or treatment etc

* Rationale :
- Continual Assessment is important as it highlights the changes in pattern of pain, any new development or persistance in pain which will require either modification or change of current treatment.
- Failure to assess is the main cause if under treatment.

Cherlosophy's Current Playlist

1. Internal War - Unearth
2. Welcome To The Black Parade - My Chemical Romance
3. Broken - Seether Ft Amy Lee
4. Just Show Me How To Love You - Sarah Brightman & Jose Cura Ft The London Symphonic Orhestra
5. Secret Garden - Bruce Springteen
6. Secret Love - Jim Brickman
7. Through The Fire - Chaka Khan
8. Boston - Augustana
9. Yue Lao - Andy Lau (Canto Version)
10. She's No You - Jesse McCartney
11. Braveheart (End Credits) OST performed by the London Symphonic Orhestra
12. Little Girls from Annie the Musical
13. Heal Me, I'm Heartsick - No Vacancy
14. Faithfully - Journey
15. Welcome To Wherever You Are - Bon Jovi

That's all for now folks...

Here's wishing everyone a very happy Raya =)
And to my classmates, great luck for the upcomming exams.

@#*%@!# EXAMS @#*%@!#

Haha. That's all i have to say about exams.

I used to like exams.
Seriously. I know, i'm such a pervert.
But the notion of exams is less frightful
when you have the confidence of knowing a topic or topics well.

Alas, times have changed.

And i know shit about things.

Blardy hell.

Ok, i shouldn't be here in the first place.
I shouldn't be posting.
I shouldn't be checking up on people's blogs.
I shouldn't be visiting youtube.

I SHOULD be studying.

Piss ass shit.

Haha.

Bleah.

Ok, this is a senseless post.

So what??!!

It's my therapy and i't's my blog.

This is my entitlement.

I feel a story growing in my head.

Ok, that is so random.

I guess i'll leave it for a better time.

Bleah.

PUI.

out.........

I woke up early to go visit my Dad's grave today.

An event that mimics a certain undisclosed sense of familiarity.

We passed the people hawking flowers and scented water. Passed the many gravestones that dotted the plains (the surroundings made me feel as though i was in driving through some rural part of malaysia). Finally arriving at 9plus in the morning, with the weather hot and humid. The grave yard was unusually busy with activity. There were lots of people there, hoping to get the graves cleaned in time for Raya.

I was there just to say hi.

I pulled out the stray weeds. Wiped down the green tiles. Changed the white cloths. And after the usual cleansing routine, they left me alone for some private time with my Dad.

6 years have past. 6 long years.

And i sat there, going through some things in my head. Starting with small talk trying to lighten the mood (as if it was even neccessary). That didn't work. And it escalated into a full outpour of pent up emotions. I'm a little teapot, short and stout. Lalala......

Tears flow freely there.

And it sure as hell felt good. Except for the fact that a small number of people were nearby wondering what in the world this person was doing at a grave alone and weeping. Haha. I see dead people...?

So yeah. I don't really give a heck. Crying is my therapy. I'm not seriously ashamed of my tears. I cry too much and too freely. And if they wanted to stare, they should have just come straight up and asked me to audition for the media =)

I had the opportunity to spend some time with Candy and Lydia the other day. I had to wile time away during the long break on wednesday.

A long, agonizing 6hr break.

I joined them in the library to study. The lovely ladies printed out the past year exam questions for me. I'm glad to have joined them. Simply because i have never remembered having much opportunities to mingle with these people before.

And after a mind numbing (though short) session of revision, we started to talk. Candy posed a question to me - 'Eh cheryl, are you close to your patients?'

Reflecting, i can't say i am. Neither can i say i'm not. I do love them. Even though some can really get on my nerves with their drama. But i do care. And it's hard not to form bonds with someone when you're feeding them, cleaning them and spending so much of your time with them. Day after day. And i hate the goodbyes. Ask anyone that has ever worked with me.

It's like being a babysitter. You do so much, and then they leave. All that's left is an empty bed to remind me of a friendship that used to be.

Heartache Vs Happiness.

But exactly how much do they know about me? On one hand, it's a one way friendship. Superificial in a sense, simply because i'm still walled up whereas they're exposing themselves. They confide in me, i listen. I don't really divulge much about myself. We crack jokes about life, we gossip about the other nurses, we bitch about others. And sometimes, tell me their life stories, like how they met their spouses, wars they've been through, share secret recipes, how disappointing children can be, or simply how afraid of death they are.

The uncertainty of Life Vs The freedom that death brings

And on the other hand, its a deep relationship that focuses on the current day-to-day activities, with no emphasis on past or future. Only the present counts. To hell with the past. Each day is a blessing by itself.

But i guess the best judge of whether i'm liked is the patient themselves.

And for some friendships, i've allowed it to be taken out of the boundaries of the hospitals and into the real world. Some have slowly erased away, whereas others continue, their lives merging with the daily actitivies of mine.

LIVE ONCE. LIVE WELL. LIVE STRONG.

The following entry is inspired by Zul's entry in his blog where he writes about the people and situations that have helped shaped him.

Yes, the same lame fella who squirted normal saline on me after debate practice and gave me a cutting-edged look of a wet crotch. The same guy with the 'dandruff eyebrows' (a moniker lovingly bestowed by Fara). The same man who feeds his toyol living in his bag with a burger, half eaten no less. And the same person who projects an image of happiness but hides his inner most emotions.

Don't we all?

******************************

I too, am a firm believer that everything happens for a reason.

And i seek solace in the fact that there IS a God. And that God loves me. Seriously loves me. During the darkest days of my life, when all i could hear was death beckoning me. I contemplated suicide with every waking moment.

Every breath drew blood.

I was unable to envision any road other then death. And i hoped that death would stop all emotions. I pleaded for the pain to stop. Help me to ache a little less. It didn't. I hated the world. I cried. But no one heard. I vented. But all they saw was rebellion. I withdrew. But all they saw was pride. When i talked, all they heard was silence. When i called out, no one answered.

Or so i thought.

And all i was left with, were the taunted whispers. Nagging little voices that egged me to cross that line. Just die, they mocked. And i almost did.

Patrick saved my life.
Sharon Lee gave me strength to continue life.
And i gave myself up to God.

And in an instant, i saw the world from a different perspective. A dimension that was there all along. I just didn't turn the other way. I saw myself arched over the rim of the toilet bowl. My abdomen convulsing. Mouth agape, allowing a passage for the greenish secretions to escape. I pushed my fingers into the back of my throat until i could vomit no more. I could not allow myself to disappear just like that.

I wanted to live. Badly.

There was too much in life to give up. To many what-ifs and could-have-beens. Too many questions unanswered. And too many people i loved to leave behind.

I spent the next few hours in drunken stupor, slipping in and out of consciousness. And when i regained some awareness, i worried about the after-effects of my folly. The questions faded as the voices from loved ones grew stronger. I could finally see their faces. Their faces contorted, testifying the shock and horror of it all.

What the hell happened?

How did things go so terribly wrong?

I could have let myself succeed with the suicide. I didn't tell anyone. I had it all planned out. I had a cocktail of pills and booze. I fed myself the rainbow colours and textures with robotic momentum. This will help, i rationalized.

It was the easiest method to end it all.

But what would that change? Nothing. It would have made things even worse. It was a selfish act that stifled out all the people that meant something to me. And would have erased all possibilities of change.

A paradigm shift ensued. I finally had the courage to lift up my head and open my eyes. I saw people that loved me all around. Their arms out-stretched, their lips curled into a smile. I heard their voices calling out.

They were there all along.

I was the one who didn't realize it.

******************************

Zul puts it simply :
"And sometimes things happen to me at the time that may seem horrible, painful and unfair, but in reflection I realized that without overcoming those obstacles I would have never realized my potential, strength, will power or heart."

"Without these small tests, life would be like a smoothly paved, straight, flat road to nowhere. Safe and comfortable but dull and utterly pointless."

(available online: http://pui5t3r-zlack3r-z30.blogspot.com/ 2006)

******************************

This particular entry was difficult to write and even more difficult to come to a decision to publish. It exposes a side that i would rather remain dormant. And in a perverse way, it refreshes wounds that i thought had healed and become scars.

I still carry the burdens i did before, but this time, i hold no fear, for i am no longer alone.

Thousands of people brave far worse conditions every single day of their lives. I have no reason to end mine. Instead, there is an obligation for a person as fortunate as me, blessed with health and opportunities, to return to society.

And with this, i hope is a start.

I'm thankful that this episode helped awaken a need in me to seek out my religion and in turn, allowed me to find myself.

"I am all i am because of you."

******************************

Come live in me
Take over
Come breathe in me
Take over
And i will rise on eagle's wings
I will rise on eagle's wings

- Eagle's Wings -

I'm supposed to be studying. Trying to make the most out of whatever little time I have left to cram in all the theoretical components of what the semester has bestowed. Instead, I'm more like an actress now.

I'm only acting as though I'm studying.

The world continues to revolve.

I drape myself over the chair in the library. My head hangs over the books. My eyes furiously trying to comprehend the words that skip, hop and dance - mocking me as I try to chase after them.

Apathy envelopes.

I glance up and try to shake away all the madness.

People come and people go. Moving along with frenzied pace. It's as if they're heading towards the same unsaid destination.

Someone tell me where is mine.

The world continues to revolve.

For a large part of the student body, it's the 1st day of their 2nd semester. And their fresh faced, virginal enthusiasm exposing their youth. It's not a bad thing though. I've been there before. Believing I had the power to change any shit just as long as I was determined enough.

Just not so much now.

Lionel talks about friendships and his dreams in his blog.

Moonie writes of sending her aunt off.

Fara updates us with a summary of an outing we had the other day.

And Zul, he continues to explore the option of confessing his feelings towards this girl he likes. Even though it's largely known just who this protagonist actually is.

The world continues to revolve.

Everyone tangled in their own personal drama.

At this time, I realize that I'm not going anywhere just by pointing my face to my open lecture notes. My mind is in an unknown whirl with a magnitude of confusion.

I wonder why.

There's so much that needs to be done. Yet so little time left. As reality starts to burn it's way into my mind - like a farmer searing the hot iron onto the body of a lamb.

An absence of a physical scar does not mean there is an absence of pain.

I feel an emotional callousness seep in.
Pulsating deep through the veins carrying the life blood within me.

And the world continues to revolve.

Someone tell the world to stop.

Someone left me behind.

If you can't help a ten people,
Help 5.

If you can't help 5 people,
Try your damn blardy best to help 1.

And if you've no means to do anything,
At the very least, INSPIRE.

There is no reason to sit back and not do anything.

When you don't say what you mean,

Expect people not to know.

And when you do say what you mean,

Expect people not to understand.

That is what i should remember.

Cherlosophy 2006

Anger is the only thing you'll never rid yourself of, even if you lose it.

Thus far, anger is an emotion i have tried very hard to curb. A habit that's hard to break. And the week has been filled with much drama.

Too much.

Seriously so.

And when mixed with lethal doses of a nagging deadline, the stress of assesssments, failure, smart-ass comments, relentless long days at school and a lack of sleep... it blows even the minor situations into one of unparalleled holocast.

For one, i'm not particularly proud of the way that i handled the group work with Fad. I had blurted straight up that she had to get down on her hands and knees and take an active stance with the group. Afterall, we only had one and a half freaking days to prepare for the damned presentation. And i've realized that spitting (though not literally) at her in front of everyone else is simply not acceptable.

The only salvaging point is that : she did manage to see the light and come through.

A little.

But more needs to be done. And my groupies did do wonders for the presentation. Even though our work was blatantly discriminated against. I'm apologetic towards my group mates - because it's largely because of the vandetta the Black Witch harbours towards me.

Number two - I screamed the daylights out of myself (until i was dizzy with the lack of oxygen feeding my brain) to the woman who was manhandling her young child in public. Pointing and hurling threats at her to make her stop.

She didn't. Even as she climbed into the back of the cab, pulling a large wad her little girl's hair.

In retropect, i had instead, just mimicked her atrocious behaviour.

Violence begets violence.

What i should have done was to run up and speak to her calmly and hopefully, instill the virtue that things could be done in a different way.

In a manner of civilized calmness.

I'm aware of the pressures a parent faces - i should know, purely because i can reflect on how i used to treat my Dad. And how irritating children can be - same reflection, i was so damn out of hand. But shaking your child, pulling her hair and pushing her into the backseat of a vehicle is simply - damn blardy unacceptable.

There is a difference between discipline and abuse.

But before i bury my face in my hands in self pity. I will not find any excuse for regrets. Simply because i have learnt my lesson in all these.

And having witnessed the drama of battered egos of unreciprocated love, the foul moods of the hungry (yes, i'm mentioning you clearly here) and the continued torments of Lionel (who happened to turn '41' this year! Happy Birthday dude), remembering the young teen who was beaten up at the staircase by a gang a few months ago, among others...

It highlights on the ill effects of letting your emotions get the better of you.

There's a lesson to be learnt here i tell you. An a very valuable one.

I'm reliving the methods i used to manage my anger. Digging out my old cross stitch needles and thread, and engaging in repetitive distraction. Jewelry making. Reading. Blogging even.

All with a good cup of thick, sinfully rich, iced cold milo.

Though i admit there have been highlights to my week - i'm lucky enough to experience Ms Tan Chin Hong's care for her students, my supportive classmates, Joey being in a fab mood and such a gentleman (hohoho), a good week for Sharon Lee after her own mini series of drama, and my family - who's always and forever there.

It's time to allow the storm to pass through and settle into calmness again.

I failed my assessment yesterday. I thought i would cry (knowing my drama self) but i didn't. Normalcy prevails. In fact, after the bitter taste of failure, i found enough energy to go Bishan to window shop with Zul and Fara, then head onto another round of debates.

Life goes on.

The world continues it's orbit around the sun.

Nothing is knocked out of place.

I'll just have to work harder.

Lionel writes in his blog that "the tables have changed" and how many of the so-called smart ones have come to face failure. He predicts that success is upon him. Maybe he peered into a magic crystal ball. With all the knowledge and the chance to experience life, he has blatantly failed to exercise restraint on gloating over others' misfortunes.

However, i am not angry. Disappointed that he chose this subject to poke at, but not angry. Frankly, it's not really worth the bother. At the very least, my nipples are well hidden. Unlike his. Now that's NEWS.

More importantly for now, i need to pass my re-test.

My interest in debate seems to be wavering. OK, more like wilting.

Though re-learning history has helped me to expand my horizons allowing me to better analyze situations; Debate has also showed me how plastic people can be. Whilst one can seem pretty normal in a normal environment, one can or may also morph into a totally different character during debate. It's a disease i call "Acute Debateritis".

Bathed in the battles of tension, i find myself looking at debaters in an unflattering light.

Why isn't there a clear segregation between right and wrong?
Why do people slang during speeches?
Why do people contort into such evil leeches in a competition?
Why do people exercise no form of comradery?

And why do i feel increasingly disappointed?

Where does this root of disappointment stem from?

Perhaps the veil of denial can no longer hold through. And there leaves little but the wind to lift away the facade and see these people for who and what they are.

And if you ever catch me turning into something like those factory churned debaters, Far, pls.. pls kill me.

My week has past with an unusual taper towards relationships between people, and with it, the courage (or perhaps the lack off) to react in a certain manner.

In an unthinkable fashion, i had shot off my thoughts to friends regarding my view on the abovementioned sentiment. The seed had been sown, but the yield was beyond what i could have ever expected.

1. Some people automatically assume that just becuase they like someone, the other party has to like them back. I cannot but highlight the absurdity in this premise.

Firstly, let me point out that we are not living in a storybook utopia. This is reality. Who ever said that anyone would be deemed as the ultimate Mr/Ms Popular? Liking, or maybe having a soft spot for someone doesn't translate into the other party being obligated to return the emotion. Sadly, for some reason, the other party may already have a special someone wedged into her/his heart.

An irreplaceable foothold?

A case of clashing times? Or you're just ain't her/his type?

I know of this person, who expects his relationships to be perfect. And even though he has experienced failure time after time, refuses to come to the understanding that relationships will never be that way.

For the simple logic that there is an absence of perfection in humanity.

And when faced with repeated rejection, suddenly mutates into such an uncivilized sorry state, he has to resort to immature tactics to get back at the object of his now-soured desire. Anything to vent his bruised, sorry excuse for an ego.

My question is : does it require such drastic lengths? Especially when the world is kind of small and the opportunities of bumping into each other is frequent.

********************************

2. To select a cowardly stance and sink into the fear of rejection, even before anything has been said or done, is also completely far too difficult for me to comprehend.

You see, i have a friend who has conjured enough courage to proclaim his feelings online, but chose to leave out the name of the person whom he's trying to tell, everything except the hint of a 'princess'. Leaving the reader to read between the lines.

I call it selective editing.

You see, i shared my personal views to these 2 friends of mine, though I can't say that i'm impressed by the outcome of it all.

Let me reiterate my stance on the subject. Courage.

cour·age (kûrj, kr-) noun
The state or quality of mind or spirit that enables one to face danger, fear, or vicissitudes with self-possession, confidence, and resolution; bravery.

http://www.thefreedictionary.com/courage

The courage to express what you really feel.

The courage to face rejection.

And the courage to move on.

What is life when one lacks the courage to walk through the process of learning? Translating into simply, time shamelessly wasted. And to live with a lifetime wondering about the wasted chances?

The what-could-have-beens. The what-ifs. Closing off avenues of any possibilities.

Endless possibilities.

And though i am fully aware of the consequences that may follow the course of my actions, it is afterall, my own. My singular interpretation of the matter. And my life is not theirs.

-< Courage >-

the courage to see life as it really is .........

and face the reality that follows

Note:

This entry echoes my personal outlook on matters. Readers are advised to apply discretion.

I love my friends. Even though i may always agree with them