Student doctor Heidi
Pang and I are rotating in hematology and oncology this week with Dr.
Chen. Dr. Chen's work is generally divided between outpatient
consultation and inpatient hematology and oncology patients. On Monday, we
rounded on the inpatients and today we checked on the inpatients again as well
as consulted with outpatients. So far, this rotation has provided much
insight into this specialty as well as Taiwanese Healthcare.
Over the course of the
last couple of days, there have been many patients; however, I will do my best
to only talk about exceptional cases and the ones I learned the most from. The
first case is about a 70 year old female with myelodisplastic syndrome,
pancytopenia, and a systemic infection of unknown etiology. Initial
treatment was met with no success and now the patient refuses other
chemotherapeutic agents. Dr. Chen says that with time there is almost a
100% chance she will convert to AML. Because of her refusal, the main
focus right now is to treat the anemia and the infection. This patient’s
son wants to acquire a caretaker to take care of her mother because she has
urinary frequency and sometimes falls at night on her way to the bathroom. Unfortunately, she is not yet 80 and by law
she cannot officially have a caretaker, nor can a doctor condone it, as will be
explained later.
Another interesting case was that of a 57 year old female with left
breast cancer (for some reason all of the breast cancer patients we saw today
had left breast cancer, but Dr. Chen says that it is just because of a small
sample size only). Her brain atrophied
over the last two years leading to mental retardation due to an unknown
etiology. Against Dr. Chen’s
recommendation, the family wants aggressive chemotherapy. This brings me to a topic that I have been
thinking about lately. Even if this
patient survives the chemotherapy and is cancer free, what would her quality of
life be like? What would her quality of
life be like during therapy? What would
her family’s quality of life be like? As
bad as it sounds, how many resources will be put into this patient, when the
government is already scrambling for money to spend on all of the other
citizens of Taiwan. This topic is
starting to be addressed by Taiwan in the official DNR legal document, but even
then, sometimes it is broken, as I have heard.
Our final case of the day was somewhat of an
emotional one. This was a middle age to
old male presenting with aspiration pneumonia and jaundice. On physical examination, cervical
lymphadenopathy was found. After all of
the imaging studies were performed, it was determined that he had a SCC that
was in his esophagus, in his mediastinum, and in his whole right lower lobe. We did not know if the cancer started in the
esophagus and metastasized deep into the lung or if the two tumors were
unrelated. Nonetheless, when we entered
the room we were met by a frail man who could barely talk due to the tumor in
his esophagus. His first words were
words pleading for him to be released from the hospital because he believed his
case was hopeless (the attending had told him this). Dr. Chen told him that if he left he would be
in a lot of pain and would cough up blood and would not be able to
swallow. Nonetheless, the patient still
refused treatment and wanted to be discharged.
After telling him more facts, Dr. Chen finally said that if he really
wanted to go, someone had to be there to witness that he is refusing
treatment. It was very sad to witness.
Dr. Chen talks a lot about his
views and philosophies about medicine. He told us that it is important to
tell patients the facts and not to sugarcoat things. He believes that a
lot of the population does not appreciate the services provided for them.
When faced with the decision of possible overtreating vs undertreating, he
usually undertreats. He also talked about how our hospital lacks a lot of
medications and supplies that would normally be used first line, like certain
chemotherapeutic agents. Another topic we discussed was about physician
compensation. He is only compensated 100 NTD per outpatient visit.
That is 3.33 USD! Lastly, we talked about the care of old, geriatric
patients. He explained that the nursing homes in Taiwan are much
different than the nursing homes in the United States. The nursing homes
in Taiwan are very small, cramped, and lonely. Because of this, some
families try to hire caregivers for their ill family members; however, the
government has certain restrictions on who can hire a caregiver (like being
greater than 80 years old). Before, when doctors would try to acquire
caregivers for patients, the doctors would be punished legally, so now all
doctors err on the side of caution and just don't involve themselves in
procuring caregivers if the law prohibits it, no matter how much the patients
need it.
Other cases we saw included GI cancer, Breast
Cancer, Multiple Myeloma, CLL, and a lot of anemias. Some things that I learned from these cases:
·
PCV symptoms start occurring when the Hb>18.
o
Two routes can be chosen for treatment:
§
Phlebotomy
§
Chemotherapy
o
Chemo is more expensive
·
CLL markers are CD5 and CD23
·
CCRT: Concurrent Chemotherapy and Radiation
Therapy is very aggressive but very hard on the patient
·
Got to palpate hepatomegaly: Was surprising how
hard the liver felt
·
Telling the difference between consolidation and
cancer in CXR
o
If there are no air bronchograms it suggests
cancer rather than consolidation.
No comments:
Post a Comment