July 10,
This morning
started off by using Echocardiography to evaluate 7 cases with Dr. Chen. One of the most interesting things that I
learned this morning was that Cardiac Echocardiography is routinely performed
as part of a general checkup here in Taiwan.
I can only imagine how early heart disease and its sequelae are
detected. Most of the cases we
visualized on echo were physiologic like minor mitral valve regurgitations or
tricuspid regurgitations. Another
interesting thing I learned was that here in Taiwan, anticoagulative therapy is
not routinely used. Atrial fibrillation is
prevalent at 25% in Asians greater than 60 years old here and Warfarin is not
routinely prescribed. Only when
anticoagulation is more clearly indicated is it prescribed. In addition, Dr. Chen noted that DVT is
relatively uncommon in the Asian population so when a patient is admitted to
the ICU and is bedridden, no anticoagulative therapy is usually used. The last thing we did this morning was go
through a few terminal patients. All of
the patients were of greater than eighty years old and some were greater than
ninety. He explained that their ejection
fractions are very low and that treatment is only supportive at this
point. I recall one ninety nine year old
female whose ejection fraction was only 3%.
Lastly, I learned of a few things going through the cases that I did not
previously know of. I learned of
Ebsteins congenital anomaly (where the septal leaflet of the tricuspid valve is
displaced towards the apex), how to use doppler to visualize regurgitations,
and how ultrasound can actually calculate ejection fraction, stroke volume,
volumes of different chambers, and ventricular wall thickness. Lastly I learned that the accuracy and
effectiveness of ultrasound is highly dependent upon physician skill.
In the afternoon
we were in the cardiac catheterization laboratory with Dr. Huang. Our first case was a 73 year old diabetic male
who suffered a Non ST Elevation myocardial infarction 1 week ago. 3 Vessels showed stenosis but none had
critical occlusions, so the family and physicians will deliberate for the next
3 weeks upon what to do. Our second
patient was not presented to us but he was a male who presented with chest
pain. He had a myocardial infarction
several weeks ago and was experiencing Post MI Angina, more specifically
unstable angina. He arrived in the ICU
and was sent for Angiography.
Angiography revealed triple occlusion disease with complete thrombotic
occlusion of the left main coronary artery.
Treatment options considered at this point were emergent CABG or PCI
then CABG. What was decided on was to
use an Intra-Aortic Balloon Pump (IABP) and then to have an emergent CABG
tonight. An intra-aortic balloon pump is
a balloon that is placed in the descending aorta, just beneath the aortic
arch. It inflates in diastole and
deflates in systole to increase perfusion and function of the heart and
decrease afterload.
At the end of the
day, we ran into Dr. Chen again and had a nice conversation about the universal
health care system here in Taiwan. He
explained that experienced doctors like himself are compensated exactly the
same as new doctors. A visit to see him (a cardiologist with
decades of experience) is only 200 NTD per visit. That is less money than I spent on dinner
yesterday. He explained that they only
practice clinical, evidence based medicine to benefit the patient. Experimental treatments are not used because
their effectiveness has not yet been proven and are also often expensive. The government chooses procedures and
techniques that are most efficacious and cost effective. Along the same lines, heart transplant is not
something really performed in Taiwan because the post-operative management is
extremely difficult and costly. Dr. Chen
also talked about how some of the population abuses the healthcare system. Often, after work hours, the ER will be
flooded with patients who complain of things as minor as GI upset and upper
respiratory tract discomfort. We learned
a lot from Dr. Chen today.
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