Week 3: Day 5: Pulmonology by Heidi Pang

Today is my last day rotating at the pulmonology department.  Dr Chien began the day by going through all the patient cases with me before patient rounds. I told him that my weakest skill was to interpret pulmonary function test results. He looked up a couple of past patient cases and went through some key points for interpreting the results: ideal test should be done with patient exhaling for at least 6 seconds. Most important parameter is FEV1. If <1L, can predict that patient may have dyspnea; 2^nd thing is to look at the FEV1/FVC ratio, if <70% = obstructive lung disease. Normal FEV1 should be 100%. I will just summarize a couple of things that I have learnt today from patient rounds:

1.       Sometimes vein gas values are collected for measuring metabolic acidosis since we usually have access already for drawing CBC at ER. It can be used to estimate ABG values

2.       Expiratory stridor (low pitch wheezing over neck) is a sign of possible dynamic upper airway collapse

3.       It is often difficult to recommend NG tube for patients with Parkinson’s disease as they would often pull out the tube themselves. In order to prevent risk for aspiration pneumonia, patients are often asked to buy this special food supplement called “kwai lin bao”. It’s texture is somewhere between solids and liquids.

4.       Sepsis guideline: blood transfusion at around Hb <7; if with active bleeding Hb <10 for blood transfusion. Usually Dr Chien will target at Hb 8.

5.       Steroids are considered as 美国仙丹, aka American’s Magic Pill!

The highlight of my day was the opportunity to participate in a Tb management conference with the whole pulmonology team!!! Taipei Hospital has a TB specialist team, meaning that if the community/department of public health tracks any Tb cases, they will be referred to our hospital. The team will go through all the Tb patient cases monthly (some nurses and three main pulmonologists – Dr Huang, Dr Chien and Dr Yao). Patient list is separated by month, beginning phase cases, cases that are reaching end of treatment, and those that have completed treatment. Each patient has an individual form that the NP filled in as a summary with personal info, Rx list, Lab studies that are performed, side effects for Rx, Phase1+2+3 and examinations done during the 3 phases. Dr Chien said that although there is an international guideline for Tb management, they mostly use Taiwan’s guideline instead. Main things that I have learnt during the meeting were:

-          Rifampin: dosage is weight related

-          EMB: if patient has significant optic neuritis/side effect of the eyes, order VEP with the opthamologist.

-          PZA: very toxic, often cause hepatitis within 2-3 days of use. Calculate dosage by multiplying weight x2

-          Lab studies include: sputum, antibiotic sensitivity, gram stain, CXR. Lab studies are routinely done every 1-2 months to monitor the effectiveness of the medications

1.       If sputum is tested + after 1^st round, patient has to be on Rx for 9 months

2.       If culture still + after 2 months, patient has to be on Rx for at least 9 months

3.       Even if initial exposure test is negative, should recheck one year later

-          THERE ARE A LOT OF VARIATIONS WITH TB TREATMENT DEPENDING ON AGE, SIDE EFFECTS, LAB STUDY RESULTS

Dr Chien mentioned that last year they had 100 cases of Tb in this hospital, and they have already treated 60 patients so far this year. A “center” probably will have ~300 patients each year. Tb specialist teams are set up as they are eligible to receive incentives from the government. According to Dr Chien, they can get up to 8000NTD incentive for each Tb patient.

We ended the day with a discussion on Taiwan’s physician working mentality. He mentioned that physicians in general have 2 main worries: stress level and reimbursement. Interestingly, if patient is expired, medical malpractice is considered as a criminal case under Taiwan’s legal system. Many families therefore do not care about the cause of death and often will just sue their physician no matter what since it’s free. Although physicians often end up winning, cases usually last for at least 1-2 years and add on a lot of stress for them. Dr Chien said that, however, the legal system is starting to change, and many hospitals are trying to negotiate with the patient’s family before the family takes any action. The government is also trying to encourage younger residents to enter the 5 main departments （ex: IM, OB/GYN, Surgery）since there is a lack of physicians in those field due to stress and the lack of reimbursement.  They do so by giving them extra incentive starting at resident level. 

And of course, cannot end the week without a picture with the doctors!