Today marked my third day in the pulmonology department and I enjoyed it immensely. All the physicians in the pulmonology department are friendly, dedicated to their work, and are always eager to teach Vincent and I. On Tuesday, we shadowed Dr. Yu the entire day. Dr. Yu was an extremely patient person who took the time to go through each of his cases before we went on rounds. He, along with his nurse practitioner, sat us down and outlined each patient's CC, PMH, SH, TX...etc. We learned several interesting facts along the way, such as Mitral valve prolapse is the most common cause of chest pain in young people. It is very typical and the patient usually presents with intermittent chest pain that is not exertional, dyspnea, and anxiety. These symptoms caused by a MVP are most often triggered by stress, and the treatment will include non-selective B-Blockers (propranolol) and an anti-anxiety medication such as benzodiazepine (prazolam).
We saw several patients with TB, COPD, and pneumonia once again. There were only a total of around 10 patients, but it took us 5 hours to complete rounds since Dr. Yu explained each case in such detail. An interesting case we saw is outlined below.
Case 1
52 year old Male with TB pleurisity and gouty arthritis. Dr. Yu explained that the man was homeless and had been living in a shelter when he was diagnosed with TB. In addition to TB, he also had gout so the joints in his hands and feet were all deformed. We learned that because the shelter refused to take the man until he completes the TB treatment, the patient has been at the hospital for around 7 months already. As we know, the typical course of TB treatment lasts around only 6 months and includes the following drugs: Isoniazid, Rifampin, Ethambutol, and Pyrazinamide. However, since the patient has gout he cannot use Pyrazinamide as it is a drug that interrupts uric acid excretion, which can exacerbate his gout. As a result, his treatment has been prolonged to using the 3 other drugs over a 9 month course treatment.
After rounds, Dr. Yu took another 2 hours out of his schedule to show us interesting CXRs and CTs from cases he’s seen over the years. It was definitely fun trying to figure out what the patient has from the CXRs and CTs. For example, he had a patient who presented with chest pain, hemoptysis, and shortness of breath. The patient’s CXR revealed haziness in the left mediastinal/ULL region, which made him suspect a lung tumor initially. Because the patient has kidney issues, the radiologist chose not to use contrast when performing the CT. As a result, all they could see was a mass in that region. Dr. Yu then decided to do a biopsy of the mass as the next step. After the biopsy, the patient started bleeding continuously from the wound. Alarmed, Dr. Yu immediately ordered another CXR and CT to be done, but this time with contrast. The new films revealed a massive aortic aneurysm. If the biopsy had been performed any deeper, the patient would have bled out rapidly and expired. It was a close call but due to his quick thinking, Dr. Yu was able to save the patient’s life. I not only learned some important tricks to reading films, but I also got to witness the compassion of a physician who cares deeply about his patients. Dr. Yu not only spent the longest duration of time with patients I’ve seen thus far, but he also actively greets and truly attempts to understand the mental state and concerns of his patients.
Today (Wed), Vince and I shadowed a respiratory therapist named Eva. We learned the different methods and types of respiratory therapy and then went to observe her at work in the ICU and the respiratory care ward. We looked at the different types of respirators: both invasive and non-invasive ones, and also learned endotracheal tubes vs. tracheostomies. We got to auscultate a patient with pneumonia and was able to clearly hear crackles in person. In the RC ward, the care is supportive only. It was really difficult to see these patients laying helpless and possibly suffering with no way to communicate. They are likely never walking out of the hospital and there are several patients who have already been on respirators there for 10+ years.
Due to the health insurance system in Taiwan, the patient's stay in the RC ward is paid for by the government. However, the Gov. only pays a certain amount each month and any excess spent by the hospital to care for the patient will have to be taken care of by the hospital. Eva explained that even there is no hope for these patients, the families keep them on the respirators. This causes several dilemmas, one of them being these patients become financial burden for the hospital when they requires excess care that exceeds the budget. In addition, these patients don't have a good quality of life and their continual suffering not only affect themselves but also their family members. It is largely a cultural factor (respect for elders/life) that prompts the families to keep the patients on respiratory care; however, I had mixed feeling about the RC ward. On one hand, I do believe prolonging life in these patients is only inducing more suffering but on the other hand, I saw that it was able to keep patients alive and provide family members with much needed comfort and hope. There was an elderly women in the RC ward who was comatose and had been there for 10+ years. Her husband, an elderly man was there helping his wife with exercises to prevent muscular atrophy. Eva told us he has come to see her everyday for the past 10 years and even after suffering an MI while visiting her, he came to see her even as he was recovering in the hospital (the feels.....). The patient's physical presence is what has been providing this man with a purpose in life and if her life had been terminated in the name of relieving her suffering, it would be an act of cruelty against a person who is still alive and well. Ultimately, though our philosophies as physicians may clash with those of the patients or family members, it is up the to them to determine their own fate. It is not our job to agree or disagree with them, but rather to respect any decision they make about their own life.
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