Vincent Chou, Day 1, Nephrology with Director Chen

Each day I will discuss an interesting case I've seen:

A 25 year old asian female came with a chief complaint of fever x 1 week, R. flank pain x 2 days, and dysuria. Patient's PMH includes mental retardation. She was admitted 6/2/14 but we saw her for the first time 6/9/14.

Labs showed neutrophilia (87 cells/ml), hyperglycemia (315 mg/dl), increased creatinine (1.44 mg/dl),  pyuria (30-40 WBC/hpf), occult blood +++, proteinuria +, bacteruria ++, lymphocytopenia (5.5 cells/ml), SGPT 75 IU/L, CRP 34.5, HbA1c 6.4%.

Patient's general appearance was MN, MD, and acutely ill-looking. Patient states poor appetite and vomiting. 

Panamax was administered for fever and mosapride for GI symptoms. Ceftriaxone was started on 6/4/14 under suspicion of acute pyelonephritis. Culture showed candida albicans and gram positive bacilli. Ceftriaxone was continued despite culture results.

Renal sonography showed L. kidney with hydronephrosis and R. kidney with distorted central sinus with hyperechoic spots. 

Uncontrasted CT showed small calcifications, and contrasted CT was consistent with hydronephrosis. 

Dr. Chen's diagnosis was chronic pyelonephritis (CPN), and the patient was stabilized with ceftriaxone. She is scheduled to be discharged 6/10/14. Lab findings suggest acute pyelonephritis (APN), especially since patient's mother denies previous history of APN or UTI. Yet CT and renal echo provide evidence for a CPN. The unexpected finding of candida albicans on the culture and borderline diabetes mellitus further confound the diagnosis. 

Week 1 Day 2 Cardiology Rotation

This morning we shadowed Dr. Chen as he performed echocardiograms on 4 outpatients & 2 inpatients. Interestingly enough, we saw tricuspid regurgitation (TR) on every patient, although not with every heartbeat, and Dr. Chen explained that TR is extremely common in the population, usually considered physiologic, and is more often seen with a heartbeat during inspiration. One of the inpatients had cardiomegaly due to congestive heart failure and the other had atrial fibrillation, while the 4 outpatients were receiving echocardiograms as part of routine physical exams. This was surprising to say the least because echocardiography is much less accessible to patients in the US since it costs $1000-$2000 and even those with insurance have co-pays that can be as much as half the cost of the test. It would be interesting to see whether heart conditions are screened for and detected at higher rates in Taiwan due to the prevalence of echocardiography in the healthy population. As we observed Dr. Chen this morning, I could see that it was incredibly logical for echocardiography to be so accessible to all patients, since an echocardiogram can be performed quickly and efficiently (he saw 6 patients in 90 minutes), with no side effects for the patient or large cost to the hospital. If only it could be like this in the US...

I asked Dr. Chen if the patient with atrial fibrillation would be given warfarin, since most A-fib patients in the US are started on an anticoagulant to reduce the rate of stroke, but he said that patients in Taiwan are actually not prescribed any anticoagulants for A-fib, since their research studies have not supported the effectiveness of using anticoagulants in A-fib patients. He emphasized the importance of considering each patient on a case-by-case basis, rather than going by convention to prescribe warfarin for every A-fib case or digoxin for every CHF patient. He informed us that in clinical practice in Taiwan, they expect every patient to be different and anticipate treating them in an individualized way, taking into consideration their other risk factors and pathologies before prescribing a drug that may or may not be indicated, according to evidence based medicine.

Even though we've only been rotating for two days, I can definitely see that several physicians here are trained in providing patient-centered care that resonates with our osteopathic training. In thinking about how commonly certain drugs are prescribed for certain conditions in the US, I wondered if the corresponding clinical trials (often funded or led by drug companies) are part of the reason for the widespread practice of prescribing the same drug for different patients with the same condition. I really liked that he emphasized that each patient is different, regardless of whether they present with the same condition, and I will try to keep that in mind as I continue my training.

In the cardiac catheterization lab this afternoon, we saw a case with a patient who had presented to the ER yesterday with severe chest pain. He had an MI several weeks ago and had been experiencing chest pain ever since he was discharged from the hospital, so he was admitted to the ICU with a diagnosis of post-MI unstable angina. During the coronary angiogram, Dr. Huang discovered a critical near total occlusion of the LCA due to an atheroma, which he informed us was a dangerous situation requiring emergency coronary artery bypass surgery, especially since the patient was symptomatic and at high risk for cardiovascular events (due to his recent MI and history of diabetes & hypertension). Dr. Huang brought the patient's family members into the catheter lab to explain the situation and presented them with 2 treatment options: prepare the patient for an emergent CABG or perform a PCI for the left main coronary artery lesion and then proceed with the CABG in a few weeks. The family eventually decided on the emergency CABG (scheduled to occur this evening) and the cardiologists performed preoperative insertion of a prophylactic intra-aortic balloon pump (IABP), which has been shown to reduce mortality and improve outcomes in high-risk patients undergoing CABG. For this procedure, he inserted the catheter via the femoral artery and positioned the balloon just inferior to the aortic arch, where it was set to inflate during diastole and deflate during systole. Dr. Huang explained that the IABP provides support for surgical recanalization by increasing coronary perfusion and blood pressure while decreasing afterload.

Although Taipei Hospital is a small community hospital with only 1 catheter lab and a small team of cardiologists, their ability to effectively manage patients (including emergencies) continues to be impressive!

Pulmonology, Week 1, Day 1

6/9/2014

Day 1 of our internship with the Taiwan International Healthcare Training Center at the Taipei Hospital!

This morning we did rounds with Dr. Chieng. Before seeing his patients, Dr. Chieng reviewed the chest x-rays and medications of the 17 patients with us. Then he said, "Let's test your memory!" and off we went rounding. Most of the patients were diagnosed with pneumonia, and some had tuberculosis or COPD. Some patients included:

- 85 year old male with acute exacerbation of COPD. This patient had chronic hypoxemia, some lung fibrosis, bronchiectasis, cor pulmonale, SpO2 89-90%, and oral candidiasis. He was given amoxicilllin-clavulanic acid+ clarithromycin.

-50 year old male with tuberculosis. The patient was a college teacher and contact tracing was done to determine that he was exposed to a student who had TB.

-50 year old female with pneumonia. This patient had bloody sputum, hemoptysis, and anxiety. She was given moxifloxacin. 

Something to note is that in Taiwan, trade name drugs are used, Ambicyn= amoxicillin-clavulanic acid, Uricin=clarithromycin, and Avelox=moxifloxacin. I wonder how it is possible to use non-generic drugs here?

Upon entering the patient rooms, I could see that family members were sleeping in the patients’ rooms as well, which made me think about the effect a family can have on the care of the patient. Families can advocate for their patients or they can hinder a patient’s care. Also, because there were so many patients, it was difficult for the doctor to spend more than a few minutes with each patient and it seemed as if some family members wanted to speak with the doctor a bit longer. Thus, the amount of time spent with each patient seems to be an issue here in this community hospital in Taiwan, as well as in the United States.

This afternoon we went into the ICU with Dr. Huang. We discussed the case of a 61 year old male who presented with fever and dyspnea of 2 days with a PMH of CVA and subdural hemorrhage. Dr. Huang showed us how to interpret a chest x-ray. He stressed that while we should find a method that works for us, it is very important to interpret in a step-by-step manner. The first 3 things to check are 1) Right and Left side, 2) quality of the chest x-ray, and 3) the position of the patient. Then, one way to read a chest x-ray is to check in order of ABCDEFG:

           

Airway

            Bone/Breast

            Cardiac

            Diaphragm

            Esophagus/Extrapulmonary

            Foreign body

            Gastric bubble

Also, it is important to check the regions that are easy to miss: apex of the lung, sub-diaphragm, and retrocardiac regions. We used the above patient’s chest x-ray to practice interpretation of chest x-rays. The diagnosis was pneumonia. Then we watched Dr. Huang perform an ultrasound on the patient to determine if there was any pleural effusion.

Today, I learned how important chest x-ray is in the diagnosis of pulmonary diseases. It can be used to guide which other tests need to be performed, and which therapies to initiate. Being able to read a chest x-ray is a skill that physicians must possess; and today’s lesson from Dr. Huang has inspired me to hone my ability to interpret chest x-ray.

Hematology-Oncology W1D1

Today was our first day at the Taipei Hospital and I started out with the Hematology-oncology rotation. Our preceptor for this rotation was Dr. Chen, who was the only physician in the hematology-oncology department. Dr. Chen welcomed us briefly and immediately took us on rounds with him along with another physician, Dr. Luo.

Dr. Chen mentioned that there are very few patients under his care currently so there might not be that many cases for us to observe. We saw a total of four cases today with patients that have breast cancer, colon cancer, gastric cancer, and multiple myeloma. The first patient was a middle aged female outpatient with breast cancer who was being treated with chemotherapy regimen that included drugs such as 5-Flourouracil. The meeting was very short as Dr. Chen simply instructed her to continue with her treatment and return a few days later for a check up.  The second patient we saw was an elderly female inpatient with colon cancer that had metastasized to the liver. She was unresponsive so Dr. Chen communicated with her caretaker. This particular patient has a mass that was too large to remove so she was only on supportive care with no future plans of further treatment.

After seeing the second patient, we went down to the fifth floor where Dr. Chen showed us a lateral radiograph of a skull and asked us to identify the abnormality. It was a skull X-ray of a patient in his 50s that showed punched out lesions that are characteristic of multiple myeloma.  Dr. Chen explained that this patient was referred from the nephrology department where he first went to due to renal insufficiencies. The patient was found to have high blood calcium levels and Ig light chain in his urine, which indicated his symptoms may be more associated with a hematologic origin rather than the originally suspected renal source. Dr. Chen explained to the patient’s nephew and daughter that his condition is incurable and his best option may be to undergo autologous stem cell transplant. Since the Taipei Hospital is not equipped to perform such procedures, Dr. Chen suggested that the patient go to a bigger hospital where he could get more thoroughly examined and possibly receive the transplant. The one thing that really stood out to me was how blunt Dr. Chen was when he was telling the patient’s family about the patient’s condition. He said repeatedly that his condition cannot be cured and it is up to him to choose what kind of treatment, if any at all, he wanted to receive. It was interesting to see the difference in how he deliver bad news as opposed to the way we were taught to deliver bad news. There was no initial set up at all to prepare the patient and his family of the grim prognosis and the time spent with the patient was very short.

The last case we saw of the day was an elderly female with gastric cancer who was on supportive care. This particular case was interesting because the patient had deferred her treatment plan to her six children who could not agree on one treatment to proceed with. As a result of her children’s inability to agree on a treatment option, the patient’s only option was to remain on supportive care. Dr. Chen showed some frustration in this case because the patient is not only not receiving the proper treatment she needs, her children are all directing their misguided anger at him. Dr. Chen spent a good amount of time speaking with some members of the family, suggesting them get together ASAP to come up with a plan in regards to their mother’s treatment.

Overall, it was a short but interesting day. It was definitely difficult to hear or understand some of the information Dr. Chen was telling us, but he was very patient in answering our questions. He explained that due to the high immigrant population in the area, the most prevalent cancers seen at the hospital are oropharyngeal cancer, liver cancer and esophageal cancer (likely due to lifestyle influences such as smoking and drinking). Dr. Chen mentioned the up to 50% of patients forgo treatment if told the cancer has likely metastasized because they believe the costs will not outweigh the benefits.

六月九号 - 中医部 TCM Day 1 Wk 1 by Heidi Pang

Today marks the 1st day of my one-week TCM internship at Taipei Hospital with the TIHTC training program. I was assigned with two different doctors during the day and in the afternoon. I arrived at the TCM department at 9am, where I found a group of patients already waiting in the general sitting area, while some of them are measuring vitals themselves (patient can measure their body temperature, BP and pulse themselves with a special machine and bring the print out results to the doctor). One unique technology that the Taiwanese healthcare system has adapted is that each patient carries their own personal "smartcard". The smartcard contains all of the patient's medical records. Each patient's chart consists of three main categories: Subjective, Objective, and Assessment. Patient will come in and hand the card to my morning proctor Dr Liao, then he will ask them general questions regarding their sleep, bowel movement, urination, general constitutional questions, and other specific questions according to their chief complaint. Some patients will be at the clinic for acupuncture treatment only, so Dr Liao may be seeing 5 patients at a time since the clinic rooms consists of 5-7 patient treatment beds as well. I realized that patient privacy is not really an important issue here at the TCM clinic. Dr Liao will be talking to one patient, and others can hear the conversations while receiving treatment since they are all in the same room. Patient can also knock and walk in to ask questions anytime. Because of these arrangements, however, Dr Liao was able to see 10+ patients within 1 hour. It was rather difficult to understand the conversation between Dr Liao and his patients as most of them were speaking Taiwanese instead of Mandarin. I was able to have a general idea of the situations, however, by reading the patient charts myself.

My second proctor in the afternoon was Dr Kuo who practices general TCM. Dr Kuo does not perform any treatment and he focuses on outpatient cases. In most cases, patients usually see Dr Kuo for upper/lower respiratory symptoms and insomnia. Post nasal dripping is also a rather common CC among patients who regular TCM clinics. Dr Kuo believes that there are 4 main causes for PND and acid reflux is only a minor cause (at most 10%). The 4 main causes for PND are allergic rhinitis, chronic nasosinusitis, influenza and past cold. We went through several patient cases with PND. It was interesting to note that a patient can develop chronic PND due to a common cold from 50 years ago. A generic formula that Dr Kuo follows for PND treatment usually consists of coptis root, American ginseng and Licorice, 1.5g BID. These specific herbs, however, are not covered by the universal healthcare system of Taiwan so patient will have to pay for them out of pocket. Patients who visit the TCM doctors often walk out with a bill of only <200NT, due to the universal healthcare system here in Taiwan. This is comparatively much cheaper than seeing a doctor for a regular visit in the States. Dr Kuo has also mentioned that getting a surgery done here at the hospital usually only costs ~10,000 NT including 1 month stay in the hospital.

When I think of traditional Chinese medicine, I often imagine throwing a lot of herbs in a pot and boiling it for hours to concentrate it down to 1 bowl worth of "soup". But the medications here at the hospital are made into powder form, so patients can first take the powder then drink 1 cup of warm water after to wash it down. This way of manufacturing the medicine allows for better shelve life and convenience. They do not offer capsule form at this hospital since it is too costly and time consuming to package them. There are definitely some similarities between the philosophy of TCM and osteopathic medicine. Both practices and emphasizes on the health of the entire body, and has strong emphasis on the overall flow of systems (blood, lymph, "Qi" for Chinese medicine). Acupuncturist also studies trigger points, like osteopathic physicians. While observing the treatment of a 60+ y/o female for LBP and neck pain, I realized that Dr Liao will be softening the tissue tension of the areas prior to the acupuncture treatment, also similar to our practice of soft tissue prior to any treatment modality.

Week 1 Cardiology Rotation Day 1

On our first day rotating in the Cardiology department, we saw two cases in the catheter lab with Dr. Huang. The first case was a 40 year old male patient with a past medical history of coronary artery disease due to familial hypercholesterolemia, who has had an LDL cholesterol of 400 and placement of 5 coronary artery stents despite his young age. Dr. Huang also mentioned that the patient's younger brother also has familial hypercholesterolemia and has triple vessel coronary artery disease (affecting the LAD, LCX and RCA) that necessitated 10 percutaneous coronary interventions and coronary artery bypass grafting (CABG).
The patient presented to the cardiologist after experiencing syncope, severe chest pain and cold sweats while riding his motorcycle. He then had a coronary angiogram that showed >90% critical stenosis in the left circumflex artery just distal to the bifurcation of the LCX & LAD, with restenosing of two of the previously stented arteries. Today's treatment plan was to place a stent in the LCX using balloon angioplasty to open the narrowed region of critical stenosis. However, after 4 attempts to inflate the balloon, the center of the stenotic region remained narrowed with no dilation whatsoever. Dr. Huang inflated the balloon to a maximum of 18 atm but there was no change in compliance of the artery due to severe calcification. He explained to us that inflating the balloon to a higher pressure was not an option due to risk of rupturing the artery, which could lead to cardiac tamponade and cardiac arrest, so he would be unable to place the stent and the patient would need surgery instead. The cardiac surgeon was consulted and they revised the treatment plan to include two options with similar long-term outcomes:
The first option was rotational atherectomy, an interventional coronary procedure that utilizes a high-speed rotational device that's coated with microscopic diamond particles. It rotates at high speed to break up blockages into tiny fragments that are small enough to be taken up by macrophages in the blood. However, this procedure has the risk of artery trauma (dissection, perforation, rupture or injury) and is not covered by national health insurance so the patient would have to pay $100,000 - $150,000 NT (~$5000 USD). The second option was Minimally Invasive CABG, which involves small incisions instead of a median sternotomy as with traditional open heart surgery and this procedure would be completely covered by NHI.

The second case we saw was another patient with coronary artery disease who had a 90% critical stenosis of the left circumflex artery. The treatment plan was to use balloon angioplasty to place a stent in the LCX via the brachial approach in the patient's right arm. However, after inserting the guide wire, Dr. Huang discovered that the patient had a tortuous axillary artery on the right side so he could not advance the wire any further due to risk of dissecting the artery, so he had to use the left brachial artery instead. Once the wire was in position, he inflated the balloon to 16 atm when it ruptured, indicating a hardened atherosclerotic lesion. A second attempt was made using the buddy wire technique, which involved adding a second coronary guide wire in the LCX to increase support for the balloon and provide stability for the guiding catheter, but the second balloon ruptured as well. A third attempt was made using the anchor technique and a smaller balloon, which involved inserting an additional guide wire into a non-target artery (the LAD in this case) to "anchor" it and provide support for crossing the guide wire into the LCX. Although this smaller balloon did not rupture, the stenotic region remained narrowed after the balloon was fully inflated.
After the procedure, Dr. Huang explained that a larger balloon could not be used due to risk of rupturing the artery and that the anchor technique was utilized because the patient had chronic total occlusion (CTO) of the LCX, which complicated the procedure. CTO is apparently encountered in 15-30% of coronary angiography patients and represents a 98-99% stenosis of the artery, which often prevents successful percutaneous coronary intervention. However, during the procedure they discovered that there was collateral circulation from the RCA supplying the occluded LCX, as a result of angiogenesis due to chronic myocardial ischemia.

Both of the cases today were rather complex and we learned that several things can get in the way of a successful PCI. I can definitely appreciate the patience and persistence needed for coronary angioplasty and the skill it takes to precisely maneuver the wires. It was interesting to watch the physicians troubleshooting and I can see the importance of having a few different methods to fall back on if the first attempt doesn't work in a complex case.
What surprised me was that for both of the cases, Dr. Huang brought the patient's relative into the viewing room and even into the catheter lab to show them the angiogram and discuss the patient's case with them, keeping them informed and making sure they understood the details of what was going on. He answered their questions thoroughly as he presented them with the treatment options, and I was impressed with his efforts to empower the patients and their families despite being behind schedule due to the complexity of each case.
After shadowing at hospitals in the US, it was a refreshing change to see the patients here benefit from the NHI, compared to watching American patients make difficult decisions about whether to get the treatments they need but can't possibly afford. I'm looking forward to seeing more of the positive impact of the NHI during the rest of our rotations here at TIHTC!

June 9, 2014 - Jonathan Go - Cardiology - Cardiac Catheterization Lab

June 9, 2014

     Today was our first day in the hospital here at the Taiwan International Health Training Center (TIHTC).  We arrived and were given our schedules.  This week my colleague, Student Doctor Anny Xiao, and I were placed in Cardiology rotations.  Our preceptor for today was Dr. Huang in the Cardiac Catheterization lab.   The healthcare system here in Taiwan is quite different from ours in the United States.  Taiwan employs a universal healthcare system that covers the medical costs of all Taiwanese citizens.  One of our patients today likely needs a CABG which would cost around the range of 50,000 USD in the United States.  Here it is free.   Furthermore, the doctors actually brought the family of the patients into the Catheterization lab and presented the cases to them using the radiological images.  We observed a total of 2 cases today.  The rest of this entry is a summary of those cases.

     Our first patient was a 40 year old male who presented with chest pain, severe cold sweats, and syncope.  He has a PMH of Familial hypercholesterolemia, 5 stents already placed in his coronary circulation, re-stenosing of a number of those stents, and LDL readings in the range of greater than 400.  He has a FH of a brother with Familial Hypercholesterolemia who has undergone a triple bypass and 10 PCIs.  The main stenosis is at the bifurcation of the Left Anterior Descending and Left Circumflex artery.  The worst of these is the Circumflex vessel which was stenosed at 99%.  The initial treatment plan was to place a stent in the Left Circumflex and handle the other less severe stenosis with thrombolytic therapy.  Unfortunately, the balloon angioplasty was attempted four times and was unsuccessful four times. There was no opening of the stenotic vessel at all so Dr. Huang stopped the procedure.  He was also worried of risk of rupture and cardiac tapenade.  If this would have happened we would have seen a decrease in blood pressure and cardiac arrest within 5 minutes.  The revised treatment plan involved two options.  The first option was the use of a Rotablator.  This device spins at 6000RPM within the vessel to ablate the atherosclerotic plaque.  We asked if there was possibility of emboli but Dr. Huang said that plaques are broken up into pieces so small that macrophages will just digest them.  Also thrombolytics would be used concurrently.  The Rotablator option was less popular with Dr. Huang because of risk of rupture of the already damaged and weak vessel.  In addition, the Taiwan Universal health system does not cover the procedure.  It would have cost 150,000 NTD or about 5000 USD.  Option 2 was a mini Coronary Artery Bypass Graft.  In 80-90% of cases there are no recurrences of the stenosing within 10 years.  They planned to do the operation without opening up the sternum and without stopping the heart (Beating Heart Method).  This option is fully covered by the national healthcare.

     Our second patient’s history was not presented to us but we noticed PVCs on the EKG as well as a high BP.  We came to find out that he had a Chronic Total Occlusion of the left Circumflex Artery leading to collateral circulation from the Right Coronary Artery to the Left Circumflex (due to angiogenesis from chronic myocardial ischemia and small anterograde flow).  A PICC line was attempted on the patient’s right side but his arteries were too tortuous around the axillary artery.  The procedure was halted for worry of possibility of dissection and rupture.  Following, a PICC line was attempted on the patient’s left side.  The insertion was successful; however, further complications were encountered.  The first 2 balloons inflated in hopes of opening the stenosed vessel both ruptured without opening the lesion.  A 3^rd, smaller, balloon did not rupture but the stenotic lesion did not remain fully open.  Again, the further use of another larger balloon was avoided for worry of rupture of the vessel.  Two Methods were used in trying to open the stenotic lesion.  The first method was the Buddy Wire Method, where a second wire is inserted along with the wire used to advance the balloon and stent.  The second wire helps to support and stabilize the stent and balloon.  Because the Buddy Wire Method was unsuccessful, the Anchor method was employed.  In this method, a balloon was inflated in the proximal portion of the Left Anterior Descending artery to help stabilize and support the wire guiding the balloon and stent into the Left Circumflex Artery.  This too was met with no success.

     Seeing the cases in person has definitely helped solidify some of the concepts behind Angiography and Interventional Catheterization techniques.  What was surprising to me was that both of the cases we saw were both complicated.  Things did not go to plan.  I am excited to see what tomorrow’s experiences bring.