Gastroenterology W4D1 (w/ Dr. Wu)

I have been looking forward to this week for a long time. Ever since my undergraduate years I have been striving to become a gastroenterologist. Something about understanding and treating the digestive system really intrigues me. Maybe this stems from my love of food or possibly my father's problems with GERD. Either way, I want to learn more about exactly what being a gastroenterologist entails.

I began the day observing gastroscopies performed by Dr. Wu. I have observed such procedures before in the states and right away I noticed a lot of differences that really amazed me. First of all, no sedatives are used in Taiwan. Patients are completely alert and oriented when the endoscope is inserted into their bodies. The only drug they get is a xylocaine spray that acts as a local anesthetic to ease the initial insertion. Once the endoscope is approximately past the pharyngeal constrictor muscles, the majority of the discomfort is over for the patient. Interesting as it was to perform without sedatives, the craziest fact was how many gastroscopies he could perform in such a short period of time. I think each patient took approximately only 5-10 minutes. Although very quick, every patient seemed to have been thoroughly checked. He viewed the esophagus, stomach, and duodenum from multiple angles. Every time some aspect stood out, he took a quick picture. On top of all this, he also performed at least one biopsy on each patient to test for H. pylori infections. Any patient with ulcers had additional biopsies performed at the site of ulceration.

Later on, Dr. Wu had his colonoscopy patients. The basic idea is the same as the gastroscopy and once again, the patients are not sedated. They are given a local anesthetic, lidocaine hydrochloride, lubricated along the endoscope. As a side note, Dr. Wu explained that most patients can tolerate endoscopies without significant complications but those who cannot tolerate the procedure or wish to be sedated can have it done. The colonoscopies seemed to take about 5 more minutes than a gastroscopy. There was a lot more area to be covered and many instances required nurses to help straighten the intestinal tract (by pushing on the abdomen) for ease of endoscope movement. Like above, pictures were taken of areas that stood out and biopsies taken of abnormal findings like polyps (to determine if cancerous). Similar to recommendations in the states, patients over 50 are recommended to have a colonoscopy every 10 years. Those who have familial colon problems are encouraged to get checked as early as their 20s.

I ended the day by shadowing Dr. Wu in his outpatient clinic. If I was surprised by how fast other physicians saw outpatients, I wouldn't know how to describe Dr. Wu's speed. He probably saw at least 15 patients/hour. The most intriguing thing was how the patient queue worked for his room. He always had the next patient ready to be seen in the same room as the current patient. The patients were probably no more than 6 feet away from each other and could hear every detail being said by Dr. Wu. This greatly increases the speed but where did privacy go? Despite this, none of the patients seemed to mind. Dr. Wu probably would have seen even more patients if he did not continually converse with me and experience computer problems.

Even though I shadowed gastroenterologists in the past, I feel I observed and learned so much in just one day compared to the months I spent in US hospitals. That being said, today felt really repetitive. Everything seemed so routine that I got a bit bored. However, whatever interest I may have lost in the profession, I gained back in curiosity of more serious ailments. The only reason things seemed repetitive is because none of the patients had any rare or serious problems. Hopefully the rest of this week will provide some more insight into the range of ailments treated by gastroenterologists and help solidify or dissuade me from pursuing my current ambitions.

Anny Xiao Weekend in Guanshan Taitung, Rural Medicine

We arrived in Guanshan in Taitung county on Friday afternoon and were taken to a small Tzu Chi Buddhist hospital that had 32 beds. We met the hospital's director, an orthopedic surgeon who has worked in the hospital for many years, who handles simple orthopedic surgery cases but more complicated ones are referred to a bigger hospital in Hualien, a larger city north of Guanshan. The hospital has limited specialty departments, including cardiology, neurology outpatient clinic, orthopedics, radiology, obgyn, and pulmonology. They have no pediatrics or surgery department and their specialty departments are staffed by rotating specialists that come once per week or a couple days per month.

Shortly after we arrived, we began the hour long drive to the mountain villages for the weekly Friday IDS trip to provide healthcare to the aboriginal tribes. The hospital's IDS team consists of 1 nurse, 1 nurse practitioner, 1 pulmonologist and 1 assistant. They visit the tribes on Tuesdays, Fridays and Saturdays, usually visiting 2-3 different villages each day. The first clinic was a makeshift clinic in a mountainside village where we set up a table and 4 chairs. Notes were taken on paper and later entered into the computer at the next village clinic, which was a small building with 4 chairs in the waiting area and a small exam room.
One patient came in for knee pain and his knee appeared red, swollen and warm to touch. The doctor prescribed him an NSAID and colchicine and told him he may need to visit the orthopedics department if his knee did not improve.
At night we went to a third village where there was a similar small clinic building. Because people were off work by then, more patients showed up to see the doctor. In the morning, clinic was started again and patients began coming in at 6am. One female patient came in for gout and diarrhea and stated she had been taking medication for the past few days before she ran out. She was taking colchicine and the doctor informed her that the pain medicine could have caused the diarrhea.

The doctor informed us that most rural physicians are sent to these rural areas to provide healthcare to the underserved. They usually attend medical schools for free, provided that they will serve for 6 years after training in a rural area. Interestingly, the doctor told us that in Taiwan, private practice is more profitable so many family medicine physicians will open their own clinic after training in a hospital, so practicing at a rural hospital is undesirable to many physicians. This is different than in the US where it is more difficult to balance a business and a medical practice in private practice.

On Saturday afternoon, we returned to the Guanshan Tzu Chi hospital and shadowed the director as he saw patients in the ER. He was finishing up a 30 hour shift, which we learned was standard for him. I was surprised to hear that the hospital's director works so hard, along with the other doctors and nurses that are here full time. The first 2 patients we saw arrived after a bike crash. The first patient had abrasions on her leg, knee and elbow, and a fracture of her left humeral neck was found on X-ray. The doctor had the nurse make a sling out of a square piece of cloth to immobilize the patient's shoulder joint and told the patient that her shoulder would need to be in a sling for 4-6 weeks and that she would need to return to the orthopedic outpatient department for follow up. The other bike crash patient had head contusions and abrasions on her face and was diagnosed with a concussion.

Another elderly patient had a posterior hip dislocation, which was subsequently internally rotated and abducted. The director decided to treat this patient with a reduction procedure which involved having two people compress the patient's right and left ASIS while the director stood on the patient bed and pulled on the patient's femur anteriorly and medially. Prior to starting the procedure, the patient is given a parenteral injection of diprivan, which causes sedation for 10 minutes so they are not aware during the procedure. He had to use a lot of force to move the dislocated joint back into place but eventually we heard a sound and the director checked the hip range of motion by flexing it back and forth, and saw that it had returned to normal. He told us that after the patient awakens, you must check their neuromuscular status by asking them to move their leg and foot. Nerve damage and fracture is a possible risk of this procedure so he patients neuromuscular status before and after the procedure must be documented

Another elderly female patient was brought in after having a motorcycle accident. She had several large skin wounds where patches of skin had been peeled off the subcutaneous tissue but was still attached in at least 1 location. The director explained that since this skin was very thin, it could be sutured back on in a way that would allow it to fully heal. In contrast, if the skin that was peeled off was thicker or attached to subcutaneous tissue, the skin on top would become necrotic after suturing so some of the subcutaneous tissue would have to be debrided before suturing. He also showed us that skin and subcutaneous tissue that was not intact enough to be sutured would have to be debrided. However, the exception to this would be wounds on the face and on the palm, as debridement would cause a disfiguring scar and palm contracture decreasing hand functionality, respectively. The skin would have to be repaired without excising subcutaneous tissue and if necrosis occurred later, a skin graft would be needed. The patient also had a sternum fracture found on lateral CXR but the director told her that it would heal on its own in about 2 months and that she may feel pain there for that amount of time, but surgery was not indicated.
Despite the limited resources of this hospital, the ER team was still able to treat each patient's ailments efficiently. A piece of cloth was used as a shoulder sling and the director used a tool that was both a clamp and scissors so he could suture wounds without an assistant to cut the thread. The reduction procedure required no more than 2 sets of hands to apply compression while the director applied a pulling force. In many ways, I think practicing rural medicine can make you a better doctor because you must figure out how to do more with less, and I have much more respect for rural medicine physicians everywhere after our experience this weekend in Guanshan.

General Surgery W2D5 (w/ Dr. Ou)

Dr. Ou invited his friend to give a presentation about what I thought was going to be esophageal cancer surgeries. I might have heard incorrectly or maybe the presentation just ended up being something different. Dr. Ou's friend presented more about surgery trends, standards, and doctors. I felt the presentation was more of an inspirational speech than a lecture. This may be partly attributed to the fact that I was sleep deprived and didn't understand a decent amount of what was being said, but the powerpoint slides had English. The presenter talked about the necessary characteristics of a surgeon such as hand-eye coordination, vision depth, tactile feedback, and more. He also gave a more poetic depiction of surgeons as having eagle's eye, lion's heart, girl's fingers, scholar's investigation, and teamwork. From my understanding of the presentation, I believe the lecturer was trying to say how talented surgeons are and how difficult it must be to have all these different characteristics. However, like medicine, surgery is constantly evolving and changing for the better. Surgeons must continue to stay up-to-date with methods and techniques to better serve their patients. The lecturer mentioned that new methods always seem radical at first but become "obvious" or common sense in the future. Thus, surgeons must keep an open mind towards innovation.

After the mornings lecture, I was able to observe a laproscopic surgery for a patient who had an abscess around the large intestine + ileum junction. This abscess has caused great discomfort to the patient and led to physical wasting of their body. The pain is localized to the right lower quadrant but the appendix was removed years ago. Thus, the pain is assumed to be something else. The CTs show a mass filled with fluid near the cecum. The surgery was initially performed using 3 holes, 1 for the laproscope and 2 for surgical tools. During the procedure, the physicians ran across many peritoneal adhesions because of prior surgeries and illnesses. This made it difficult to access and excise the afflicted area. The abscess was in a very delicate area, surrounded by adhesions, and simply split open during the operation. Consequently, the surgeons created a larger incision into the abdomen to get a better general view of the area and to take out a larger portion of the colon. In the end, they cut out part of the large and small intestine and attached the remaining ends of the GI tract to one another.

After a week of observing surgery, I feel like a new spark of interest has been lit in my medical ambitions. I have considered surgery in the past, but that's all it was, a consideration. The performance under pressure is something I have always appreciated, but the level of skill needed with mind and body make being a doctor much more respectable. Now, I feel like surgery may be a desirable path for me in the future as well.

Anny Xiao Week 3 General Surgery Day 4

Today began with a surgery & emergency medicine combined morning meeting about a patient who was brought to the ER last month after being stabbed in the chest. The patient was a victim of a multiple homicide that occurred at a subway station in Taipei, which was a significant event for the hospital because homicides are so rare in Taiwan. After arriving in the ER, the patient had a 6cm chest wound, had no pulse and was intubated and given CPR. He was given a total of 10 units of PRBC but his BP was undetectable for some time and the surgery team was called to the ER to help. A CXR was obtained and diffuse pleural effusion was seen, so a chest tube was inserted. A CT showed a broken trachea and internal bleeding and an emergency thoracotomy was done.The controversial thing that occurred was that the patients wounds were sutured shut without further investigation or treatment of internal bleeding and the patient died of hypovolemic shock likely combined with cardiac a tamponade. The presentation was not finished because the doctors spent most of the hour having a heated discussion about what could have been done differently to save the patient's life. Although they had to reschedule the remainder of the presentation for next week, I appreciated being able to watch them discuss and seeing their passion for their jobs and the hospital's medical practice.

After the morning meeting, we went to the OR to prepare for a triple vessel CABG. The patient had a heavily calcified LAD & LCX both with 90% stenosis and a heavily calcified RCA with 70% stenosis. As the chief resident began to work on the patient's left leg to dissect the great saphenous vein, the cardiac surgeon began working on the lima artery. The great saphenous vein was used to bypass the LCX & RCA, while the lima artery was used to bypass the LAD (since it is closest to the lima). A heart lung machine was used so the heart could be stopped during anastamosing of the vessels and a cardioplegic drug solution was given intravenously to stop the heart. After attachment of the coronary side of the 3 vessels, the cardioplegic infusion was stopped and the doctors began preparing and waiting for the heart to begin beating again. Defibrillator paddles were used and I began to feel nervous when the heart didn't start beating on its own after 15 minutes as expected, but the surgeon looked calm as he continued to tap and massage the heart to stimulate small contractions. Another 5 minutes later, the heart began to beat on its own at 31 bpm, slowly increasing to 75 bpm in the next few minutes. The rest of the anastamoses were finished successfully and at the end of the surgery, all the surgeons helped clean the patient and wrap up his sutured wounds and I was impressed to see them working together with the nurses to accomplish this task.

Part of the great saphenous vein to be used for bypassing the LCX

The heart lung machine: the temporary lung on the top right, heart on the bottom right

Top L: Keeping track of how much gauze is used; Top R: the surgeon tapping the heart to stimulate contraction; Bottom L: surgical steel used to close the sternum; Bottom R: the finished product

Week 3: Day 5: Pulmonology by Heidi Pang

Today is my last day rotating at the pulmonology department.  Dr Chien began the day by going through all the patient cases with me before patient rounds. I told him that my weakest skill was to interpret pulmonary function test results. He looked up a couple of past patient cases and went through some key points for interpreting the results: ideal test should be done with patient exhaling for at least 6 seconds. Most important parameter is FEV1. If <1L, can predict that patient may have dyspnea; 2^nd thing is to look at the FEV1/FVC ratio, if <70% = obstructive lung disease. Normal FEV1 should be 100%. I will just summarize a couple of things that I have learnt today from patient rounds:

1.       Sometimes vein gas values are collected for measuring metabolic acidosis since we usually have access already for drawing CBC at ER. It can be used to estimate ABG values

2.       Expiratory stridor (low pitch wheezing over neck) is a sign of possible dynamic upper airway collapse

3.       It is often difficult to recommend NG tube for patients with Parkinson’s disease as they would often pull out the tube themselves. In order to prevent risk for aspiration pneumonia, patients are often asked to buy this special food supplement called “kwai lin bao”. It’s texture is somewhere between solids and liquids.

4.       Sepsis guideline: blood transfusion at around Hb <7; if with active bleeding Hb <10 for blood transfusion. Usually Dr Chien will target at Hb 8.

5.       Steroids are considered as 美国仙丹, aka American’s Magic Pill!

The highlight of my day was the opportunity to participate in a Tb management conference with the whole pulmonology team!!! Taipei Hospital has a TB specialist team, meaning that if the community/department of public health tracks any Tb cases, they will be referred to our hospital. The team will go through all the Tb patient cases monthly (some nurses and three main pulmonologists – Dr Huang, Dr Chien and Dr Yao). Patient list is separated by month, beginning phase cases, cases that are reaching end of treatment, and those that have completed treatment. Each patient has an individual form that the NP filled in as a summary with personal info, Rx list, Lab studies that are performed, side effects for Rx, Phase1+2+3 and examinations done during the 3 phases. Dr Chien said that although there is an international guideline for Tb management, they mostly use Taiwan’s guideline instead. Main things that I have learnt during the meeting were:

-          Rifampin: dosage is weight related

-          EMB: if patient has significant optic neuritis/side effect of the eyes, order VEP with the opthamologist.

-          PZA: very toxic, often cause hepatitis within 2-3 days of use. Calculate dosage by multiplying weight x2

-          Lab studies include: sputum, antibiotic sensitivity, gram stain, CXR. Lab studies are routinely done every 1-2 months to monitor the effectiveness of the medications

1.       If sputum is tested + after 1^st round, patient has to be on Rx for 9 months

2.       If culture still + after 2 months, patient has to be on Rx for at least 9 months

3.       Even if initial exposure test is negative, should recheck one year later

-          THERE ARE A LOT OF VARIATIONS WITH TB TREATMENT DEPENDING ON AGE, SIDE EFFECTS, LAB STUDY RESULTS

Dr Chien mentioned that last year they had 100 cases of Tb in this hospital, and they have already treated 60 patients so far this year. A “center” probably will have ~300 patients each year. Tb specialist teams are set up as they are eligible to receive incentives from the government. According to Dr Chien, they can get up to 8000NTD incentive for each Tb patient.

We ended the day with a discussion on Taiwan’s physician working mentality. He mentioned that physicians in general have 2 main worries: stress level and reimbursement. Interestingly, if patient is expired, medical malpractice is considered as a criminal case under Taiwan’s legal system. Many families therefore do not care about the cause of death and often will just sue their physician no matter what since it’s free. Although physicians often end up winning, cases usually last for at least 1-2 years and add on a lot of stress for them. Dr Chien said that, however, the legal system is starting to change, and many hospitals are trying to negotiate with the patient’s family before the family takes any action. The government is also trying to encourage younger residents to enter the 5 main departments （ex: IM, OB/GYN, Surgery）since there is a lack of physicians in those field due to stress and the lack of reimbursement.  They do so by giving them extra incentive starting at resident level. 

And of course, cannot end the week without a picture with the doctors!

Jonathan Go Week 3 Day 4 and 5 General Surgery

     Day 4 started off with a morning meeting that was prematurely cut off.  Regardless, the topic was very interesting.  You may have read about the Taiwan MRT train station stabbings that occurred a couple months ago.  The victim with the most serious injury was brought to our hospital.  The presentation was about his case and emergency care.  The victim was a young male adult who suffered a stab wound to the heart; however, from what I am told, the emergency room doctor basically just sutured the wound without performing ultrasound or any studies to figure out the etiology of his bleeding to try to stop it.  The patient eventually expired of shock, most likely hypovolemic.  The rest of the presentation was supposed to be about emergency care, but like I said, it was sidetracked and halted prematurely.  I asked Dr. Chen to send me her powerpoint presentation because I am interested in the subject.

     On day 3, Dr. Ou told us that the next couple of days would be rather uneventful; however, this turned out to not be the case.  During the final days of general surgery, I saw a lot of hemmorhoidectomies; however, one of these was performed as a stapled hemmeohoidopexy.  First off, to lay a background, the chief resident explained to me that we needed to preserve the muscle in the anal canal and only excise the external part of the hemorrhoid.  So, Dr. Ou began by suturing a purse string suture to separate a ring of what we wanted to excise from what we did not want to excise.  Next, the device shown below was inserted and clamped down around what was sutured.  Following, the ring separated by the purse string suture was excised and stapled at once using the device.  This prevents excessive scarring in the anal region and allows less post operation recovery time.  Dr. Ou told me that the hemmorhoidectomy patients usually report a lot of pain for the first 3 weeks after the procedure and that this device was supposed to lead to almost no post operative pain; however, this is not what most patients report.

     The other surgery that I learned a lot from was that of an elderly male patient who has a history of 2 CABG and 1 Mitral Valve replacement 5 years ago.  Now, he has massive regurgitation and stenosis of the implanted prosthetic valve, which is most likely attributable to endocarditis.  They also were contemplating another CABG if time permitted.  Because his chest wall had been opened up so many times, there was a lot of fibrosis and more importantly, adhesions between the heart and the chest wall.  Because of this, the surgeon had to spend many hours simply opening the chest cavity without rupturing the heart or the vessels of the heart.  At one point, a vessel was ruptured and blood squirted all over the surgeon’s face and he had to leave the room to clean it off.  Because this was a high risk procedure, access to the femoral vessels was preliminarily acquired because if too many vessels in the heart were damaged, the heart/lung machine would have been inserted through the femoral vessels and up a catheter to the heart to maintain a circulation while the surgeon fixed the damage to the heart.

     After the surgeon fully opened the chest wall and exposed the heart (which took 5 hours within itself), the heart/lung machine was started and Plegisol (cardioplegic solution) was administered to stop the heart.  The machine basically replaces and bypasses the pulmonary circulation by taking blood from the right atrium, oxygenating it, and pumping that oxygenated blood back into the aorta distal to a clamp on the aorta.  The patient is also administered heparin to stop coagulation.  The machine can only be continuously used for up to 4 hours because the coronary circulation is bypassed, and any longer would lead to permanent ischemic damage to the heart.  The surgeon then continued with the actual mitral valve replacement.  He removed the old prosthetic valve, which had one leaflet immobilized.  After inserting the new mechanical valve, one of the leaflets was not moving very well.  After half an hour of problem solving, we finally figured out that it was because one of the valve leaflets was getting stuck on a pledget used to secure the old valve in place.  After the valve was fully in place, the patient had already been on the heart/lung machine for more than 3 hours, so it was determined that it was time to take the patient off of the machine.  The machine was stopped at 3.5 hours.  We took the clamp off of the aorta, allowing the cardioplegic substance to be evacuated from the heart, which allowed the heart to beat again; however, the blood pressure was very low.  At one point it was 36/30.  In addition, blood was still being suctioned from the heart, continuously.  I asked for the etiology of the bleeding and if there was a vessel that was nicked or that needed to be sutured.  The perfusionist told me that it was “oozing” due to the heparinization of the blood. We give protamine sulfate to reverse the effects of heparin, but it needs time to counteract the heparin and counteract the oozing.  Despite waiting for 45 minutes, the blood pressure was still very low, so an IABP was on standby in case we needed it (explained in a blog from week 1).  After thirty more minutes, the patient stabilized and I went home because by this time it was already past 8 o’clock.

     All in all, the surgery took over twelve hours.  The surgeon, the nurses, and the perfusionist did not eat or drink a single bite or a single drop within this time.  I was, am, and will be forever amazed at the hard work and sacrifice.  

Stuff I learned apart from what was already explained:

·       I noticed that every now and then, the patient would become tachycardic and then go back to being bradycardic

o   Apparently, when using the electric cutting tool, the electrical current can cause the tachycardia

·       I noticed that every now and then the heart that was supposed to be stopped would beat.  I was told that this was not supposed to happen, but since everyone is different, sometimes it just happens.

·       Monthly national healthcare insurance fee for each Taiwanese citizen is only 600 – 700 NTD per month (20 USD).  Although already cheap, the government covers those who cannot pay or who say that they are too poor to pay.  Because of this, less and less people every year are paying for their insurance.  In addition, those who do pay seem to expect more from their doctor and expect better service.  

·       Because our hospital is a government hospital, the doctors are not paid by cases.  Because of this, some doctors see considerably more patients than other doctors.  Patients don’t understand this and will often complain when a busier doctor cannot spend as much time with them.

Week 3: Day 4: Pulmonology by Heidi Pang

During today’s morning meeting, we had an IM resident presented on pancreatitis. He focused on the evaluation of acute pancreatitis since it’s a medical emergency.  I will try to summarize the main points of the presentation:

-          Use CT scan to diagnose, also use w/ contrast

-          Important to know if there’s necrosis (may lead to peritonitis). Use endoscopy to visualize CBD

-          2 main causes of acute pancreatitis: 1 and 2 covered 70% of the cases

1.      Mechanical: for example Gallstone (most important to look for ones caused by ERCP)

2.       Toxicity: Alcohol

3.       Less common – Metabolism: ↑TG (700+)

-          Signs and symptoms:

1.       Epigastric pain radiating to the back!!!!!

2.       Fever usually only occur to those have pancreatitis due to mechanical cause

3.       HIGH MORTALITY rate if patient has PERITONITIS

-          COMMONLY PANCREATITIS ISN’T THE PRIMARY DISESASE!!

1.       DDx: *biliary disease, intestinal obstruction, mesenteric ischemic, *inferior MI, AAA, *distal aortic dissection, PUD

-          Evaluation:

1.       Lipase ↑ (more specific and sensitive than amylase)

2.       Amylase

3.       ALT – 3x normal = gallstone obstruction

4.       Ranson’s Criteria (Check during admission and one after 48 hours)

-          For Chronic pancreatitis: CT scan may show more stones

We did not get to rotate with the thoracic surgeon in the afternoon as he is still on leave for another week. Instead, I had the opportunity to spend the afternoon at the OB/GYN outpatient clinic with 董医师for a couple of hours. She mentioned that Taiwan, patient often refuse often treatment at around menopause, even when the government has been promoting it and emphasize that treatment is free. She estimated that ~50% of patients still refuse such treatment. PAP smear and mammogram are mostly free but examination rate remains at around 30-40%. If patient chooses to accept oral contraceptive, rarely will anyone choose to stay on Rx for over 1 year (mostly 1-3 mo at a time). By the way, did I mention that PAP smear only costs NTD300 for self-pay patients?

I had the opportunity to observe a HSG procedure (hysterosalpingography). Patient was a 31 y/o female with infrequent MC. HSG is usually performed during follicular phase of MC. Radioactive contrast medium is injected into the uterine cavity through the vagina and cervix. We did run into some difficulty during the HSG procedure, as the radiologist were not able to get a good picture of one side of the patient’s fallopian tube and ovary (I believe that they have tried different views at least 5 times). Dr Dong explained that it might indicate that the patient has a true obstruction at the beginning of the tube so the dye was not able to penetrate through. I also had the chance to watch a couple of ultrasound examination, PAP and palpated a 9cm cyst!!!! Today was a very unique experience for sure. 

Wk 3: Day 3: Pulmonology by Heidi Pang

This morning we got the opportunity to learn the clinical approach and role of a respiratory therapist here. They generally are rotated between ICU and RCW. We met with our preceptor, Eva Chang, and she started the day with giving us an introduction of the field and the scope of work that a RT is responsible for here in Taiwan. Respiratory Therapy is considered as a “young” field in Taiwan according to Ms Chang. Many RTs in Taiwan were nurses before switching their careers. Additionally, in Korean/Japan, RT’s responsibilities are mostly taken up by physicians or nurses instead. RTs have 2 main responsibilities: maintain oxygen level and ventilation. Their goal is to achieve early extubation.

1 RT in Taiwan on average has to take care of 23 patients, while in US each RT usually is responsible for 4-6 patients only. Although team work is highly emphasized here in Taipei, physicians remain to have the final say/most authority due to cultural reasons.

Taipei Hospital is considered as a community hospital/mid-tier hospital. Ms Chang explained that people who live around the city in Taiwan are those with lower economic status/elderly. Many of them have chronic diseases and are heavy smokers. Once they are sick they often develop complications such as sepsis.

After the discussion, Ms Chang took us to the ICU and RCW (respiratory care ward) to visit several patients and discuss on the cases. Our first patient at the ICU is a 91 y/o male who was admitted for hemoptysis for 3 days, poor appetite and overall weakness. His LVEF was only 38% and was finally dx with malignant tumor at his R main bronchus. Ms Chang had student Dr Megan Lung and I each performed a brief auscultation examination on the patient before briefing us on his physical findings. He had missing lung sound in his RML and minimal sound in his RLL, addition to signs of pleural effusion heard in his RUL. We found out afterwards that his RLL and RML are pretty much completely collapsed. Since the tumor is malignant and patient is relatively old, the family refused any treatment and patient is on end of life care at the ICU. General policy under the National Insurance is that patients are allowed to stay at the ICU for 21 days, then transfer to RCC, then to RCW by 42 days.

Patients at the RCW are not necessary under end of life care. In fact, many of the patients are relatively stable, but required ventilators. One patient has been at the RCW for 12 years! We could definitely experience the dynamics in family support at this ward. On one end, we can find a patient who has been at the hospital for 12 years w/o any family visit for at least a year, and on the other end we witnessed a husband coming into the RCW everyday, exercising for his wife who has ALS (Amyotropic Lateral Sclerosis).

In the afternoon, we met with Dr Huang once again and this time we discussed on the population and scope of care of patients at the RCW.

Clinical Pearls from Dr Huang:

-          2 types of tracheostomy:

1.       Tracheal button – difficult to change, sometimes fly out during cough

2.       Tracheal tube – can’t speak unless have valve (one way valve)

-          I asked Dr Huang on the chances of lung transplant for patients with terminal lung diseases. He stated that lung transplant is very rare in Taiwan since there have only been a few successful cases.

-          Be careful with using Quinolones (Tb 2^nd line Rx) to treat Tb. There are evidence that show appearance of resistance strain after being on quinolone for >7 days if patient did not have Tb in the first place

-          If suspecting Tb with + Acid fast test, treat as Tb first even if it may be other Mycobacterial species

-          Use Tb PCR to confirm Tb since Tb culture takes up to 2 months (Gold Standard)

-          Pleural lesion best use CT to confirm. After confirming lesion in CT, then can use sonography

-          Ultrasound for pneumothorax

-          PCT (procalcitonin) better indication than CRP for infection

-          五大皆空五大科: everyone tend to pursue the cosmetic field nowadays, or ENT since most of them are self-pay

It is interesting to note that no matter which department I have rotated in, or which physician/therapist/nurses I have talked to, they always seem to bring up their frustration with Taiwan’s healthcare system. Most agree that patients do benefit in a sense that they will always have access to healthcare. However, quality of care, physicians’ and healthcare worker quality of life, and supply of doctors are definitely being sacrificed.