Wk 3: Day 3: Pulmonology by Heidi Pang

This morning we got the opportunity to learn the clinical approach and role of a respiratory therapist here. They generally are rotated between ICU and RCW. We met with our preceptor, Eva Chang, and she started the day with giving us an introduction of the field and the scope of work that a RT is responsible for here in Taiwan. Respiratory Therapy is considered as a “young” field in Taiwan according to Ms Chang. Many RTs in Taiwan were nurses before switching their careers. Additionally, in Korean/Japan, RT’s responsibilities are mostly taken up by physicians or nurses instead. RTs have 2 main responsibilities: maintain oxygen level and ventilation. Their goal is to achieve early extubation.

1 RT in Taiwan on average has to take care of 23 patients, while in US each RT usually is responsible for 4-6 patients only. Although team work is highly emphasized here in Taipei, physicians remain to have the final say/most authority due to cultural reasons.

Taipei Hospital is considered as a community hospital/mid-tier hospital. Ms Chang explained that people who live around the city in Taiwan are those with lower economic status/elderly. Many of them have chronic diseases and are heavy smokers. Once they are sick they often develop complications such as sepsis.

After the discussion, Ms Chang took us to the ICU and RCW (respiratory care ward) to visit several patients and discuss on the cases. Our first patient at the ICU is a 91 y/o male who was admitted for hemoptysis for 3 days, poor appetite and overall weakness. His LVEF was only 38% and was finally dx with malignant tumor at his R main bronchus. Ms Chang had student Dr Megan Lung and I each performed a brief auscultation examination on the patient before briefing us on his physical findings. He had missing lung sound in his RML and minimal sound in his RLL, addition to signs of pleural effusion heard in his RUL. We found out afterwards that his RLL and RML are pretty much completely collapsed. Since the tumor is malignant and patient is relatively old, the family refused any treatment and patient is on end of life care at the ICU. General policy under the National Insurance is that patients are allowed to stay at the ICU for 21 days, then transfer to RCC, then to RCW by 42 days.

Patients at the RCW are not necessary under end of life care. In fact, many of the patients are relatively stable, but required ventilators. One patient has been at the RCW for 12 years! We could definitely experience the dynamics in family support at this ward. On one end, we can find a patient who has been at the hospital for 12 years w/o any family visit for at least a year, and on the other end we witnessed a husband coming into the RCW everyday, exercising for his wife who has ALS (Amyotropic Lateral Sclerosis).

In the afternoon, we met with Dr Huang once again and this time we discussed on the population and scope of care of patients at the RCW.

Clinical Pearls from Dr Huang:

-          2 types of tracheostomy:

1.       Tracheal button – difficult to change, sometimes fly out during cough

2.       Tracheal tube – can’t speak unless have valve (one way valve)

-          I asked Dr Huang on the chances of lung transplant for patients with terminal lung diseases. He stated that lung transplant is very rare in Taiwan since there have only been a few successful cases.

-          Be careful with using Quinolones (Tb 2^nd line Rx) to treat Tb. There are evidence that show appearance of resistance strain after being on quinolone for >7 days if patient did not have Tb in the first place

-          If suspecting Tb with + Acid fast test, treat as Tb first even if it may be other Mycobacterial species

-          Use Tb PCR to confirm Tb since Tb culture takes up to 2 months (Gold Standard)

-          Pleural lesion best use CT to confirm. After confirming lesion in CT, then can use sonography

-          Ultrasound for pneumothorax

-          PCT (procalcitonin) better indication than CRP for infection

-          五大皆空五大科: everyone tend to pursue the cosmetic field nowadays, or ENT since most of them are self-pay

It is interesting to note that no matter which department I have rotated in, or which physician/therapist/nurses I have talked to, they always seem to bring up their frustration with Taiwan’s healthcare system. Most agree that patients do benefit in a sense that they will always have access to healthcare. However, quality of care, physicians’ and healthcare worker quality of life, and supply of doctors are definitely being sacrificed.