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.
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