Angela Shih Pulmonology W2D1

Today was my first day in pulmonology. The day began with a morning meeting in the internal medicine department and continued on with rounds with Dr. Jian. Dr. Jian was kind enough to provide us with a list of patients before we went on rounds so we could have an idea of what each patient was afflicted with. It made it much easier to follow his rapid explanations of each patient's condition. We saw several cases of TB, pneumonia, and COPD. Most of the pneumonia cases were either community acquired pneumonia (contracted from nursing homes) or nosocomial infections.

One of the cases that stood out to me was the case of a 78 yo. male with terminal COPD. He has been bedridden for a period of time already and is in chronic respiratory failure with BIPAP use.  He has been treated with Cefulin for COPD related infections and also insulin for his Diabetes Mellitus. In addition, he is immunocompromised due to chronic steroid treatments for his COPD induced dyspnea. As a result of his conditions, this patient has attempted suicide on 6/10/2014. He is now under the careful observation of caretakers. I did not see his family during rounds and to my understanding, his family has authorized a DNR. Similar to this case, I’ve seen many other terminally ill patients who are all on supportive care only. Dr. Chen from Heme-Onc and Dr. Jian both expressed thoughts that these terminally ill patients are only prolonging their suffering by remaining on supportive care. As difficult as it is to admit there is nothing more that can be done for a patient, I understand that there comes a point when a physician has to try and convince the family to let the patient go before he/she deteriorates any further.

Another thing I observed in the hospital was the great amount of native and foreign caretakers in the hospital. Nearly each of the patients we saw today had a personal caretaker—several of them being foreign workers who spoke little to no Chinese. It was at times difficult for the doctor ask about the patient’s condition when the caretaker couldn’t even understand the questions. Since the hospital is already short staffed, many times the doctors depend on these caretakers to observe and report the conditions of the patients. I believe the quality of patient care at this hospital can be greatly influenced by the capabilities of these caretakers. It would be interesting to see if implementing a teaching program at the hospital about basic patient care or medical Chinese lingos would help these caretakers become more efficient at their jobs and thus, improving patient health.

In the afternoon, Vincent and I went to the ICU to shadow Dr. Huang. Dr. Huang was super friendly and sat us down to teach us how to read CXRs. We learned that 3 most important factors in reading films—quality of the film (ie: exposure), patient position, and the size of the film. Each of these factors determine whether a film is usable or not. A simple way to remember how to read a CXR efficiently is by using the ABCDE mnemonic.

A-    Airway, apex

B-     Bone, breast

C-    Cardiac

D-    Diaphragm

E-     Extra-pulmonary 

In addition, there are 6 blind spots in CXRs. Those being soft tissue, large airways, bone, apex, retrocardia, and sub-diaphragm regions. Abnormalities in these regions are easy to overlook and miss, so it is often important to observe these areas carefully and obtain additional films from different angles if necessary. For instance, if an apical lesion is suspected, a lordotic view film may be needed to obtain a better view so the clavicles aren’t blocking the region. Dr. Huang was really helpful and eager to answer our questions. I learned a lot from him today and I look forward to shadowing him again on Wednesday.