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
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