Monday, August 11, 2014

Cardiology and General Surgery W3 (w/ Drs.)

I have been looking forward to my Cardiology rotation for awhile because this is a topic I felt I did more strongly on in school. I was hoping my knowledge would help me understand a lot more of what was going on around me.

Right from the start, my experience in this department was intense. There was a relatively young patient, 51 years old, who just suffered an acute myocardial infarction. He was rushed pass the rest of the queue into the catheter lab for testing. During this entire process, I felt rather alienated. I am not sure if it is because of the more tense atmosphere or for some other reason. I had to derive much of what was going on myself instead of relying on the physicians around me. I continually observed the patient's vitals as wells as the digital images of the patient's heart vasculature. This patient seemed to have three areas of occlusion where the injected dye either could not pass or was narrowed. As with most AMIs, this patient's most drastic problem was a complete occlusion of the left anterior descending artery. The doctors also said the ballooning of the occluded vessels caused reperfusion injury, which led to his continuous vommiting. What amazed me the most during this procedure was the fluctuation in the patient's vitals. I saw his systolic blood pressure drop to 50s and his heart rate plummet to 40s. Of course, these vitals were quickly compensated with drugs or volume infusions. Sometimes the opposite would occur where BP was in the 200s and heart rate 140. The doctors suspect that the patient will most likely require multiple stents. They continuously informed the immediate family of the situation and what needed to be done. The rest of the catheter lab patients was more of the same.

One of the days in this week, I asked to continue shadowing in general surgery because there was an operation I really wanted to watch. Dr. Ou was scheduled to perform a gastrectomy laproscopically. Based on the patient's condition, the surgery was deemed too risky to do laproscopically because the patient was too thin. The surgery was only a partial resection of the stomach (about 50%). The distal end of the stomach left intact was attached to the jejunum (B2 procedure, roux-en-y).

The surgery was really hard to observe. It seemed like only the physicians at the table could really see what was going on. I had to rely on the intermittent talks from the surgeons to decipher what was going on. However, I feel like I was still able to absorb a lot. My interest in becoming a gastroenterologist made this surgery particularly appealing to me. I think the most important things I learned from this operation is the need to improvise while operating. A lot of new information presents itself when you can actually observe the patient's inner workings instead of simply relying on tests. With this new information, the goals of the procedure may change. In addition, it is often best to err on the side of safety by excising more versus less in case of malignancies.

This is a rewrite of missing entries due to unforeseen technical problems publishing the original, so a lot of information might have been lost.

Thursday, July 10, 2014

Christine Le, Week 4: Heme/Onc

Day 1, Megan and I started our Hematology/Oncology (Heme/Onc) rotation by accompanying Dr. Chen on his rounds. I chose to do the Heme/Onc rotation because I felt that my knowledge about the subject was lacking and I wanted to reinforce what I have already learned, as well as gain exposure to the clinical practice of Heme/Onc.

Patient 1 was a 57 year old female with left breast invasive ductal carcinoma (IDC) that was HER 2/neu (3+). She had a modified radical mastectomy (MRM) in November 2013, which revealed metastasis to the lymph nodes. However, she refused adjuvant therapy, which is additional therapy done after the primary therapy to decrease the risk that the cancer will return. In May of this year, her CT scan showed multiple lung tumors. Her cancer is now Stage IV and she is currently being given palliative therapy, which is designed to relieve symptoms. This made us (as well as Dr. Chen) wonder what were her reasons for not accepting the adjuvant therapy, since the adjuvant therapy would have prevented her cancer from progressing so rapidly.

Patient 2 was a 75 year old female with myelodysplastic syndrome (MDS). In MDS the bone marrow is not functioning normally, thus the blood cells are poorly formed or dysfunctional. She presented with neutropenic fever and malaise. Because she is immunocompromised, she is prone to getting infections.

Patient 3 was a 55 year old male with esophageal cancer (squamous cell carcinoma), stage IV, with lung metastasis and normocytic anemia. In March or April, he developed odynophagia and also experienced a weight loss of 15 kg in 2 months, and cancer cachexia. Dr. Chen told us that nutritional status is very important in the treatment, and since this patient was unable to eat solids, they tried to insert a nasogastric tube, however, due to stenosis, they had to use the parenteral route for feeding. They are waiting for approval for a gastrostomy tube insertion.

Patient 4 was a 95 year old female. A gastric tumor was found in November or December of last year, which turned out to be adenocarcinoma. The family refused a surgical resection and the patient was given palliative chemotherapy. However, the patient's response was poor and she could not tolerate the side effects. Currently, she is not receiving any treatment, but is only given blood transfusions. Since she has a blood loss of 300-500 ml/week, she cannot be discharged.

Patient 5 was a 65 year old female with a recurrence of colon cancer. 3 years ago the cancer was diagnosed as Stage III with 1 lymph node metastasis. It was removed and adjuvant chemotherapy was received. Upon follow up, liver metastasis was discovered and the tumor marker CEA was escalating. Dr. Chen told us he was deciding which regimen to give the patient because there is currently no data to support a specific treatment. This is where a doctor must use his knowledge and creativity to come up with a treatment regimen. Cases like this remind me that the field of oncology is constantly evolving and changing, as new research provides new treatments and when there is no evidence for a specific treatment, the doctor must come up with one based on his clinical expertise and knowledge of other regimens.

Day 2 began with outpatient visits. Many patients came for follow up after cancer treatment (mostly for breast cancer) or follow up for anemia. One patient that stood out to me was a 35 year old female who had 1) developmental disability, 2) seizures, 3) depressive disorder, and 4) nasopharyneal carcinoma with lung and bone metastasis. She was exhibiting rapid deterioration, as last visit she could still walk on her own, but this time, her sister had to carry her into the office. Dr. Chen suspected that the patient would pass away soon, so he suggested hospitalization, but her sister refused. The nurse told the doctor he should have pushed for the hospitalization, but he responded that she could pass away peacefully in her home. This case demonstrated to me the importance of respecting a patients' wishes, particularly in end-of-life care. While in some cases, it may be difficult to understand a patient's or his family decisions, physicians must respect those decisions.

After outpatient visits, we followed Dr. Chen on rounds where we saw many of the same patients from the day before. One new patient was a female who had colon cancer with liver and peritoneal metastasis. Because most drugs used to treat colon cancer are metabolized by the liver, use of these drugs would accelerate her liver failure. Therefore, Dr. Chen did not suggest palliative therapy.

Day 3: In the morning we did rounds. The patient with esophageal cancer had been approved for the gastrostomy, so he was being prepared for the operation. The patient with colon cancer that had metastasized to the liver had been given an increased dose of diuretic drug, but the edema and ascites did not improve. Dr. Chen suggested albumin, which is usually effective. However, if the inferior vena cava is being compressed by the liver tumor, then the venous return will be affected and the albumin may have little effect. But, the insurance will not cover the use of albumin because this patient does not meet the 4 requirements as stated by the insurance. Dr. Chen makes sure to explain the situation to each family member because lawsuits against doctors are, unfortunately, quite common in Taiwan. In the afternoon, we observed the outpatient clinic. As before, many of these patients came in for follow-up after completion of their cancer treatment or for follow-up of their anemia. Two patients came in for follow up of Idiopathic Thrombocytopenic Purpura. The doctor had recommended splenectomy for both patients and both were hesitant to undergo a surgical procedure. They had opted to remain steroid dependent, despite the risks. These cases were another reminder of how Taiwanese culture can influence patient perspective regarding surgical/invasive procedures.

Day 4: We started off the day in the outpatient department. Cases included macrocytic anemia, lung adenocarcinoma with meningial metastasis, ovarian cancer, ecchymosis, and colon cancer. After OPD we went on rounds where we saw some of the patients we had been seeing all week (myleodysplastic syndrome, esophageal cancer, colon cancer with liver failure, gastric cancer patient receiving blood transfusions). Other patients included a patient who was to receive a colon fibroscopy to determine if his anemia was due to GI bleeding, a patient who is receiving her first chemotherapy treatment, and an ovarian cancer patient who was admitted after her visit to the OPD earlier. This week in Heme/Onc has really expanded my limited understanding about the treatment of cancer patients. Practice in this field requires a physician to stay on top of all the new research so that he can provide the most appropriate care for his patients. And when there is no current evidence to help the doctor determine a treatment route, the doctor must combine his clinical knowledge with whatever data is available in order to create a treatment regimen for his patient. Additionally, I have gained more insight into the Taiwanese health care system.

These past 4 weeks with the Taiwan International Healthcare Training Center at Taipei Hospital have been so great. This experience has really demonstrated to me that medicine is both a science and an art and has inspired me to learn more about medical fields that I may not have considered before. I have been able to see how social, cultural, and economic factors can affect healthcare delivery and have been able to learn about the triumphs and flaws that exist in one of the so-called best health care systems in the world. I will use what I have learned in this experience as motivation to pursue my academic and career goals.  I would like to thank all the doctors for giving us their time and for their willingness to teach us. I would also like to thank the TIHTC staff for helping us throughout the internship.

Thursday, July 3, 2014

Anny Xiao Week 4 Endocrinology Day 3 & 4

Yesterday we were with Dr. Lin in the morning and Dr. Tsai in the afternoon as they saw endocrinology patients in the outpatient department. Interestingly, some of the patients did not appear to have any endocrine-related issues, like one patient who mainly had hypertension but had been seeing Dr. Tsai for a few years. Dr. Tsai only recently started working at Taipei Hospital a couple months ago after previously working as an endocrinologist at another branch hospital in a different part of Taipei. However, we saw a handful of patients today who had followed him to this hospital in order to remain his patient and it soon became clear that Dr. Tsai is a respected and well-liked doctor. One thing that stood out to me is that he always encourages his diabetes patients when they have improved their blood glucose control or have lost weight. Almost all of the patients seen in the endocrinology outpatient department were diabetic or had thyroid disease.
One diabetic patient was told she would need to start injecting insulin to supplement his oral diabetes medication and she asked Dr. Tsai if insulin was harmful to the kidney. Apparently, many patients have this notion because they know of or hear of friends who start injecting insulin and then start dialysis soon afterwards. Dr. Tsai explained that insulin is not harmful to the kidney but often when patients have been diabetic for a long time, diabetic nephropathy and decline in pancreatic islet cell function occur concomitantly, resulting in a need for dialysis & insulin therapy around the same time. Additionally, Dr. Tsai said that when patients are prescribed insulin, it is usually because their blood glucose control is inadequate on oral agents. However, it may be that some patients are actually noncompliant with their oral agents and choose to take Chinese herbal medicine instead, which contributes to kidney failure requiring dialysis. It is not only the compounds found in herbs that can potentially damage the kidney but also the fact that patients use them to replace (instead of supplement) the western medications that they are prescribed and damage their kidney further by forgoing those medications.
Another interesting patient had previously come in for an exam and lab tests because he had noticed that there would be ants in his bathroom around the urine in his toilet. This prompted him to think that perhaps his urine was sugary, so he made an appointment to be evaluated for diabetes and was subsequently diagnosed with T2DM. After starting metformin, the patient's fasting blood sugar had improved since his last visit from 223 to 151 and he reported that there were no more ants in his toilet now that his blood sugar was better controlled.
Dr. Tsai had to educate many of his patients on when to take their oral diabetes medications. They were instructed to take them immediately before eating and not before cooking to avoid hypoglycemia. However, if they forgot to take them before the meal, they could also take them immediately after eating. Dr. Tsai also told patients to be aware that hypoglycemia is most likely to occur at 10-11am, 4-5pm, and in the middle of the night.

Today, Dr. Tsai didn't have many patients scheduled for thyroid ultrasound so he showed us how to properly perform a thyroid ultrasound exam. Although we've practiced using ultrasound a few times this year, I hadn't yet had a chance to examine anyone's thyroid so I appreciated this opportunity to learn from Dr. Tsai. To see the right or left thyroid gland in a coronal view, the probe is placed horizontally/transversely to the patient's neck. The strap muscles, trachea and carotid artery can also be seen in this view and the artery is differentiated from the jugular vein by its pulsing and the fact that it does not compress under the ultrasound probe. To see the longitudinal view of the thyroid gland, the probe is rotated to line up with the sternocleidomastoid muscle. The isthmus can also be seen on thyroid ultrasound, and Dr. Tsai explained that while a normal parathyroid gland is not visible on ultrasound, patients with parathyroid lesions will have visible abnormalities on the bottom of the thyroid gland sonogram while in coronal view.
Dr. Tsai preparing to teach me how to perform a thyroid ultrasound scan on student doctor Jonathan Go

Thyroid ultrasound anatomy

Megan Lung Heme/Onc Days 3-4

Today we shadowed Dr. Chen in OPD and inpatient. This post will be about interesting OPD cases as well as progress on Dr. Chen's patients.

Pt. 2 had left cancer DCIS. She is on adjuvant hormone therapy and SERI (selective ER inhibitor). There are two types of estrogen receptors that can be targeted: ER(alpha) and ER(beta). ER(alpha) is found in breast, endometrium, ovarian cells, and the hypothalamus . ER (beta) is found in granulosa cells, kidney, bone, heart, lungs, intestinal mucosa, and endothelial cells. Tamoxifen is an antagonist against ER(alpha) in breast tissue but an ER agonist in the bone (decreasing risk for osteoperosis). However, Tamoxifen is a partial agonist in endometrium, increasing the risk of uterine cancer.

Pt. 4 was a 57 yo female who had right breast cancer IDC with HER 2 overexpression. CEA/CA 153 ratio was within normal limits. This ratio is important in tracking the progress of chemotherapy. While she had no side effects after chemotherapy, her daughter insisted that she under go plastic surgery after her MRM (modified radical mastectomy) and is now experiencing pain and numbness in her right shoulder. These types of plastic surgeries can lead to a deformity. The patient regrets breast reconstruction as it is causing unnecessary complications.

Pt. 5 was a 67 yo female who had extranodal lymphoma and ileus with an ileum mass. After surgery to remove the mass, the pathologist determined it to be a low grade B-cell lymphoma, so Dr. Chen decided not to treat with chemotherapy. She has had complete remission for 2 years. She has pernicious anemia, which is a macrocytic anemia. Pernicious anemia is the most common cause of vit. B12 deficiency: it causes autoimmune destruction of parietal cells that lead to IF (intrinsic factor) deficiency. IF combines with iron to be absorbed in the ileum.

Clinical Pearls:

  • PET/CT scan using a radioactive form of glucose can detect malignancies and infections. Cancer and infections will use glucose. However these imaging studies take 2-3 months and the patient may become anxious waiting for results. 
  • Uncooked foods and yogurt drinks should be avoided before chemotherapy. Chemotherapy causes leukopenia which increases the risk of infection. Uncooked foods are more likely to have bacteria and yogurt drinks include forms of bacteria that would be good for people who are not immunocompromised, but may cause infection for IC patients.
  • CEA (a tumor marker) can detect disease status in prostate and ovarian cancers. CEA can be monitored before after chemotherapy to determine if treatment is working. 
  • dementia due to chronic disease in old age is common 
  • prophylactic levofloxacin is given to neutropenic patients after chemotherapy
55yo male with esophageal cancer receiving parenteral nutritional supplement and had a gastrostomy today (an artificial external opening into the stomach for nutritional support). Surgery was initially delayed due to tracheal stenosis that would make it difficult for intubation for general anesthesia. However it was decided he would receive spinal anesthesia for the operation. He now has abdominal pain due to lack of muscle tone from spinal anesthesia. He was given laxatives. 

Female patient with colon ca. suffering from malnutrition. Dr. Chen prescribed albumin and explained to the family that they would have to pay out of pocket for each albumin treatment since she does not fall under the criteria (over 70 yrs old or nephrotic syndrome). Today studies show that she has a liver abscess. Dr. Chen says that if infection isn't the cause of death, hepatic encephalopathy will develop in 1-2 months. Dr. Chen said that all doctors have memorized the guidelines for drugs because they could get fined for subscribing it unnecessarily. He also expressed that it is frustrating to consider insurance guidelines which do not always match up with international guidelines. Dr. Chen also thought it was laughable that America wanted to adopt a universal healthcare system similar to Taiwan - he thinks that competition between insurance companies and hospitals will improve care. I thought it was interesting to hear that although Taiwan's healthcare system is based off of studying the best healthcare from all over the world there are still many shortfalls and frustrated physicians. 

Dr. Chen also told us that truly top of the line treatment and medicine cannot be found in Taiwan. The insurance company uses the cheapest drugs to keep costs low. In America we think that healthcare should be a right and shouldn't be a product that we buy. Yet, in Taiwan, the low costs of healthcare for patients leads to waste and abuse that negatively affects patient care indirectly. Doctors fear getting sued by the NHI and the patients and practice defensive medicine. The NHI is currently running under a deficit. 

Dr. Chen often sites recent studies to determine what kind of chemotherapy to give to his patients. I think oncology is a difficult field because they are still trying many methods to target oncogenes. When I asked what he thinks are the most promising therapies out there, he says that immunological therapies might be a new way to target oncogenes. Simply put, it is the idea of getting B-cells to specifically target cancer cells. There has also been documented studies on introducing p53 genes into cancer cells, but that has been unsuccessful. 

Hematology and Oncology rotation was one of the more difficult fields that I have shadowed. Cancer seems to still be relatively misunderstood and individualized treatment is a necessity for each patient. New therapies are constantly coming out and one must be up to date with treatment options all the time.

Gastroenterology W4D3 (w/ Dr. Wang)

I was able to shadow abdominal ultrasounds, gastroscopies, and colonoscopies today. The latter two was pretty much more of the same from the prior two days except that I was even more attuned to what was happening. Abdominal ultrasounds are on a completely different level though.

In class, we have "played" with ultrasound while Dr. Wang was actually employing it as a method of diagnosis. I never really thought of the detail that ultrasound can give. During our use of ultrasound equipment, we were happy to find the heart, its chambers, the liver, and compress vessels. Dr. Wang was able to differentiate organ densities, cysts, organ segments based on tracing vasculature, and much more. He diagnosed many ailments such as masses, fatty liver, gallstones, kidney stones, and pancreatitis amongst others. Dr. Wang tried to explain a lot of the reasoning behind what we were seeing on the ultrasound. I understood some of it but I also got very accustomed to the "smile and nod" so as to not waste too much of his time. I was pretty amazed when he was able to quickly recognize that the pancreatic duct was 0.2 cm larger than normal... This just demonstrates the level of expertise that can develop over time. Not only was Dr. Wang finding the most minute abnormalities, he was conducting a thorough abdominal exam (checking all liver segments, kidneys, gallbladder, pancreas, aorta, and more) in under 5 minutes each. Despite all the information ultrasound supplied, it is not a very high resolution imaging modality, and thus, many patients were referred for CTs to confirm or clarify any problems.

I'm not completely sure how things are done in the states regarding abdominal ultrasounds, but I think ultrasound technicians trained in certain areas conduct them. In Taiwan, as I noted above, the doctors perform all these ultrasounds themselves. I am not sure which method is better, but it definitely seems like Taiwan's system works pretty well except for the fact that doctors are worked down to the bone. Another difference I noticed is the timing of appointments. In all the departments I have observed already, any patient that received a referral or needed more work ups done were able to be scheduled within 2 weeks. (sometimes even that same week!) In America, I am pretty sure most patients have to wait weeks to get appointments. Many of those who received ultrasound exams were scheduled tomorrow for colonoscopies!

To be honest, the amount of knowledge that Dr. Wang employed while performing ultrasounds was a little daunting. He tried to explain to me some things about the liver and to illustrate these points he brought out a textbook of ultrasound. The book was at least 1500 pages... Ultrasound is no joke.

Jonathan Go Week 4 Endocrinology Whole Week and Conclusion

     It has been a hectic week.  This post will cover the week so far as well as an extra rotation in the cardiac catheterization department.  But first, let’s talk about endocrinology rotations.

     Our first day in our endocrinology rotations started off with nutritional education.  I have observed diabetes nutritional education in the US and although the information presented is similar, the effectiveness of communication of the information is vastly superior in Taiwan.  This is because they communicate the information in such a way that makes it readily applicable to the patients.  For example, portions would be described in finger lengths and hand areas instead of grams or cups in the US.  In addition, the nutritionist utilized plastic models of all of the most common foods to allow the patients to see an actual model of the portion size.

The guidelines were as follows:

·       4 Portions of Carbohydrates/Meal for Women or 6 Portions/Meal for Men (Following are 4 portion measurements)
o   Bowl of Rice – Flat and not heaping
o   Bowl of Noodle
o   Toast

·       2 Portions of Fruits per day – Following are 1 portions
o   10 grapes
o   ½ banana

·       Milk – 1 cup/day

·       Vegetables: 2-3 portions/meal
o   One hand area is 1 portion

·       Protein: 11g protein/kg body weight per day
o   2-3 portions of meat per meal
§  3 fingers is 1 portion
§  1 egg is 1 portion
§  2 soybean products is 1 portion
§  Chicken leg is 2 portions
§  Fish – 1 portion
·       Female – 3 fingers
·       Male – 1 hand area
o   If have diabetes and CKD, limit meat to 0.8g/kg/day
§  Along the same lines, avoid ginseng if have CKD

·       Remember to exercise 30 minutes per day 5 days a week: following is what is recommended:
o   <30 years old --> run 1 hour/day
o   >30 years old -->   can just walk 30 minutes/day
o   Check sugar before exercise and if <150, eat a fruit or milk or toast but if >200 no need to eat anything before exercise

·       Water – 2L/Day

·       If hypoglycemic, eat 50g sugar --> check after 50 minutes --> Still hypoglycemic, eat 30g sugar --> Still hypoglycemic, eat 30g sugar again--> Still hypoglycemic, go to the ER

·       Taiwanese diabetes patients seem to like nutritional supplement shakes but the nutritionist says that there are not enough calories and will lead to weight loss.  Also there is too much fat and sugar in the macronutrient breakdown.

 The above 2 photos are plastic models of portions.  They are not real food!

^Taiwan's Cuter Version of the US Food Pyramid^

     Our next blocks in endocrinology were thyroid ultrasound and outpatient clinic.  Throughout these couple days, we saw a variety of patients in both the ultrasound lab and outpatient clinic.  In the ultrasound lab, most patients were coming in to check if there were nodules in the thyroid, and if there were, to have them aspirated.  Most patients in the outpatient clinics were Diabetes Mellitus Type II patients.  There was only one type 1 patient and only a handful of thyroid disorder patients.

     We were told that we examine 3 things regarding the thyroid: Size, nodules, and function.  Our first ultrasound patient had Graves Disease, an autoimmune disease causing development of a goiter and hyperthyroidism.  Elevated Anti-TPO seems to clue us into some sort of autoimmune thyroid dysfunction; however when asked, the doctors said that it is not an etiology for the disorders.  There was a 49 year old female who had a total thyroidectomy 30 years ago to ressect a goiter of unknown etiology; however, Dr. Liao said that it was probably an iron deficiency goiter because during that time, the salt was not yet fortified. 

Some things I learned from a powerpoint presentation from Dr. Liao, outpatient clinic, and ultrasound:

·       After FNA, the patient should avoid hot food for 24 hours to avoid vessel rupture
o   Warm or cold food is okay

·       Foreign body sensation in neck is common with a goiter because it is impinging on the esophagus and/or trachea

·       If you suspect a thyroid nodule, tell the patient to swallow.  If it moves it may be a thyroid nodule, but if it does not move, it is likely a lymph node.

·       Metformin is 1st choice oral treatment for diabetes

·       If HBA1c is >7% can use up to 3 oral anti-diabetic medications; however, if still >7% than must start insulin

·       98% of diabetes patients seen at our hospital are DM2 patients

·       All diabetes patients are rated on a scale of 1-5 for insurance purposes.  All patients start at 1 and move up to 5 depending on the severity of cases.  Along with each level, comes more coverage for medications.

·       Diabetes patients should not wear slippers.  They should wear socks and close toed shoes to avoid damage to their feet.

·       Diabetes and thyroid problems can go hand in hand

·       HBA1C monitors glucose levels for the past 3 months and is a better indicator of prognosis than blood sugar because the patient cannot artificially alter it by dieting.  It correlates to mean plasma glucose levels:

·       Blurry vision can be caused by diabetes and patients are encouraged to not buy glasses until blood sugar is controlled.  This is because high blood sugar can cause swelling in the lens due to osmotic properties.  Note that this is not retinopathy, which takes years to develop.

·       People in Taiwan associate insulin with renal toxicity for some reason, so they always ask about renal function when starting insulin
o   A lot of time renal failure just so happens to occur after insulin regimen commencement because of longstanding hyperglycemia and kidney damage as well as certain TCM herbs exacerbating the kidney damage

·       Stabilize blood sugar before cataract operation

·       Diabetic ketoacidosis is treated in the ER with Potassium and an insulin pump

·       Because the government has many limitations on coverage and what is covered depending on severity of cases and control, not all thyroid function tests are ordered initially.  Dr. Tsai said that if he had to choose between T3,T4,the Ab tests, and TSH, he would pick TSH.

·       Ultrasound assisted FNA is superior because when you aspirate without it, you risk not aspirating from the nodule.
o   In addition, some tumors have a solid and a free portion and in some cases, the cancer cells are not in the middle free portion, but in the surrounding solid portion.  Thus it is better to aspirate from both, guided by ultrasound.

·       If a patient has nodules, they are usually euthyroid, not hyper or hypothyroid.

·       Take oral anti-diabetes medications before meals but if the patient forgets, the patient can take them after.  We just want to avoid hypoglycemia (by taking it in between meals).

·       Patient >70 years old, target blood sugar is <110 mg/dL.

·       We had a patient who noticed that ants would come in his bathroom around his urine that did not make it into the toilet bowl.  He came in thinking he might have diabetes.  He was correct.

     That finishes up my endocrinology experience; however, I had extra time one day so I talked to the cardiologists and they agreed to allow me into the cardiac catheterization room at the table.  It was a great experience.  I had to wear a lead vest, skirt, and neck protector.  I also had to wear glasses lined with lead to protect my eyes.  I was allowed to don a sterile gown so I can be at the table and observe the whole catheterization procedure along with a balloon angioplasty. 
     Local anesthetic was applied in the antecubital region of the patient, as we planned to access the coronary circulation through the brachial artery.  After this was accomplished, a guide wire was inserted and a diagnostic catheter.  Nitroglycerine was used to dilate the coronary system.  Following, contrast medium was used to identify the critical stenosis (as this patient presented earlier with unstable angina).  Because the critical stenosis was in the distal end of the LAD, a small balloon angioplasty without stenting was decided upon.  The guide wire was carefully positioned to where the stenotic lesion was located.  Following, the balloon wire was threaded over the guide wire until it was at the same position.  It was then inflated.  After the procedure, Dr. Wang allowed me to handle the catheters and thread them through each other as he re explained the procedure.  It was a great experience and further solidified my interest in cardiology.

     Lastly, Allan asked me to write an article summarizing some of my experiences for the TIHTC newsletter.  I will just include it here because it provides a nice summary/conclusion to the experience:

     To begin, here is just a little bit of background about us.  We are medical students from Touro College of Osteopathic Medicine from San Francisco, California and we just completed our first year of medical school.  We all rotated in different departments for one week each for a total of four weeks.  As our days here at Taipei Hospital draw to an end, I find it important to reflect on my experiences and what I have learned, as I have learned many things.  I came here with the objectives of gaining a better picture of national healthcare, of subspecialties, and of patient care.  I feel that I have accomplished all three.

     My first rotation was in cardiology where I had the opportunity to observe echocardiography, cardiac catheterization, and outpatient consultations.  At the end of the week, I can say that I can look at an echocardiogram and identify regurgitations, stenosis, and other dysfunctions of the heart.  In addition, my experience in the catheterization lab helped me with my 3D visualizations/understandings of the heart.  A difference between the US and Taiwan that I saw was regarding the use of anticoagulants.  In the US, anticoagulants are readily used to prevent thrombi and emboli; however, in Taiwan, anticoagulants are used more sparingly and only if clearly indicated.  For example, in the US, anticoagulation would have been prescribed for Atrial Fibrillation but in Taiwan it is not common practice to do so.

     My second rotation was in hematology/oncology.  This department further solidified my drive in pursuing medicine.  Here, we saw patients with good prognosis and patients who were on the verge of passing away.  Some patients still had a strong spirit, while others had already given up.  What was interesting to note in outpatient clinic was the importance of the family unit.  Outpatient visits in the United States usually only have the patient come into the office; however, here in Taiwan, we would often see 3 or 4 family members in the outpatient consultation with the patient.  Another difference in care that I learned of was the difference in the nursing home and care taker situation in Taiwan vs the US.  In the United States, families can hire caretakers without restriction and it is common practice to put the elderly in nursing homes.  In Taiwan, there are certain restrictions and guidelines that must be met for a patient to be eligible for hiring a caretaker.  In addition, I am told that because of the nursing home environment, many families try to avoid placing their loved ones in their care.

     My third rotation was in the General Surgery department, where I was able to observe a variety of different procedures, the most amazing of which being the open heart surgeries.  Because we are a smaller hospital, I am told that if anything goes wrong, we have no one to rely on, which often makes the job more stressful.  For example, our hospital only has one cardiovascular surgeon.   I can only imagine the pressure he is under when in surgery.

     To recap, I personally learned many things during my one month stay here at TIHTC.  I was able to see firsthand the pros and cons of the Taiwan National Healthcare and glimpses of what may potentially be the American healthcare system.  More importantly, the patient experiences solidified both my drive and my knowledge.  I would like to thank all those involved in making this experience possible.

Dr. Chen from Cardiology, Me, Anny Xiao

 Dr. Wang from Cardiology and Me

 Dr. Tsai from Endocrinology, Anny Xiao, and Me