Today we met with Eva, a respiratory therapist in the ICU.
She discussed the intricacies of her job—all the vital signs she is responsible
for monitoring (often for over 30 patients at a time), changing settings on respirators
depending on their vital signs, etc. She says, however, her most important job is
not listed in her job description. Over the years, she understood that establishing
human connection with patients and their families is something that should be
strived for everyday. To learn to communicate with patients and their families,
to tell them good or bad news, to keep their hopes and dreams up, is something
that will go a long way in not only providing service and comfort to those
around you, but also in helping yourself maintain optimism and purpose. Especially
in a system where efficiency is the first priority, and with certain patients
who’ve been admitted for 10+ years (in the respiratory center), qualities such
as patience, kindness, and hopefulness is a breath of fresh air. We are lucky
to be introduced these ideas often in Touro and often take them for granted
(when they seem to interfere with didactic studying). Yet only after being in
this hospital for 2 weeks, a refresher course in humanity via Eva is much
needed.
Afterwards, we had a discussion with Dr. Huang about a few
interesting cases in the ICU:
An elderly patient has dyspnea and pleural effusion was
found from CXR. A thoracocentesis is performed and the pleural fluid is
analyzed for types of cells present. If an abundance of lymphocytes, this
suggests TB or malignant cancer. If an abundance of neutrophils, this suggests
a typical infection. Next, the biochemical aspect of pleural fluid is checked.
If transudative, this suggests systemic issues such as heart failure, liver
ascities, or kidney problems. If exudative, this suggests local issues such as
infection or tumor.
Other lab values may also be checked, such as CEA or SAAG,
which may also point us in a direction of the etiology of pleural effusion.
CT showed subcarina tumor with central necrosis, compressing
the L. bronchi. Due to the complicated location of the tumor, a biopsy would be
risky of puncturing blood vessels or airways. The patient’s family declined
biopsy and opted for supportive care only.
The following day, we had a discussion with Dr. Huang in the
respiratory center. We had just been there yesterday with Eva and saw many of
the long-term patients (10+ years). The setting sparked a unique discussion:
the failures of Taiwan healthcare and its universal insurance system. Because
of this insurance, hospital stays are extremely cheap. Patients’ families take
advantage of the system and often leave the patients there for extended
periods. Meanwhile, patients may “shop” around for hospitals and doctors, often
receiving medications from many pharmacies but never completing the dose. There
is cavalier overuse of the ED, and the
doctors are so understaffed that they start using internal medicine physicians
in EM shifts. A newfound attitude that healthcare is a right instead of a
privilege is increasing cost of health care to the government, which in turn
puts stricter rules and mandates on hospitals for spending. A stiff penalty is
given for every test deemed “unnecessary,” which may at times be as
ludicrous/unfair as a CT with a negative finding. The government cuts corners
by purchasing from drug companies certain generic brands that may only have
70-80% efficacy compared to the original version. Taking a hint from America,
many patients have less Confucian respect for physicians and find any possible
route to file malpractice, especially against emergency and OB/GYN physicians.
This leads to a severe shortage of EM docs (which further increases load in
EDs) and OB/GYN physicians (while there are roughly 200 IM physicans produced
per year, there are only around 5 OB/GYN’s).
It was shocking to hear from a physician’s point of view the
realities and possibly unsustainable future of Taiwan’s healthcare system. Only
a few weeks ago did we present how great Taiwan is with their smart card and inexpensive healthcare.
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