Megan Lung Pulmonology W3D4

Today marked my last day in pulmonology. Dr. Huang went over chest x-rays with us and showed us systematic ways to review CXRs so that we do not miss any possible lesions.

First, we have to evaluate the quality of the CXR.

• Make sure the CXR is big enough and that the peripheral parts are not cropped out, such as the neck or diaphragm.
• CXR should be done on inspiration. You can check by looking at what rib the diaphragm is located at. The diaphragm should be located at the end of anterior rib 6 and posterior rib 10. For obese patients this might be an inaccurate way to assess if the patient is inspiring.
• Make sure the position of the patient is not rotated or uneven. You can do this by looking at the spine processes to make sure they are straight and lined up.
• Exposure level: should be able to see the trachea and carina, should be able to see lung markings behind the heart and diaphragm. This is important because you can find lesions present there and if you are unable to locate these lung markings, you may miss the lesion. Lung markings should expand throughout the lung in a normal CXR, if not it may be under exposed.

There are many ways to look at a CXR. Some like to go from peripheral to to medial. Dr. Huang's systemic scan goes like this:

1. Check if left and right label, may be situs inversus! Check for the breasts if a female pt.

2. Airway, air, apex. For the airway there could be a foreign body, and endobronchial lesion, or cuff herniation. For abnormalities in air, there could be a pneumothorax or pneumomediastinum. In the apex there could be a pancoast tumor or an azygous fissure.

3. Bone, breast.  Check for any fractures. For the spine, check for bamboo spine, TB spine, at the thoracolumbar region for any protruding mass. For the breast, check for masectomy or augmentation.

4. Cardiac

5. Diaphragm

6. Extrapulmonary.  

ABCDE! 

Once a lesion is identified you will try to identify it through

• Hemodynamic, congenital
• Infection
• Inflammation, occupation, exposure, or through some systemic disease
• Neoplasm

In general, when looking at an X-Ray, it is mostly to look for signs and patterns to compare to the clinical symptoms. One cannot diagnose solely with an X-Ray, it is usually one consideration among lab tests and symptoms. I hope to get more practice reading X-rays in the upcoming year! 

     Dr. Ou said that the next couple days in surgery may not have much going on, but hopefully this is not true.  I would very much like to see a CABG before I leave.  Being back in the OR reminds me of my time at Tissue Banks International processing grafts, except now the tissue is of someone living not dead.  With this in mind, I am always awestruck by what modern surgery and anesthesiology is capable of doing.  Day 2 was comprised mainly of 3 surgeries and Day 3 was comprised of mostly outpatient.  I will elaborate exceptional cases from both days in the remainder of my blog entry. 

Throughout these days, I learned many things about the Taiwanese national health care system:

1.       All of the surgery residents are female (contrary to the states)

2.       All of the anesthesiologists are female (contrary to the states)

3.       The 5 least popular/most needed specialties are (in no order of importance and contrary to the states):

a.       OBGYN

b.       Surgery

c.        Internal Medicine

d.       Pediatrics

e.       Emergency Medicine

4.       Surgeons here have duties beyond just surgery:

a.       Handle all pre and post operation breast cancers that are not complicated

b.       Handle all pre operation GI cancers

c.        If cancer is complicated will refer to Heme-Onc dept.

d.       Some internal medicine complaints were brought to Dr. Ou in outpatient services

As for the Surgeries:

     The first notable surgery was a laparoscopic cholecystectomy.  First, air was pumped into the cavity to create space to work in as explained in my last blog.  Next, the Greater Ommentum was dissected to better expose the gall bladder.  Following, Dr. Ou drained the inflamed, pus filled gallbladder while suctioning out the fluid.  Though some residual pus remained inside the body cavity, we were told that a course of antibiotics would take care of the  empyema.  After stapling off and electrically cutting/cauterizing the celiac artery, Dr. Ou carefully dissected out the gallbladder making sure to cauterize all circulation that was bleeding.  Again, the specimen was placed in a bag before being taken out of the cavity, as to not risk exposing the incisions to the pus and bacteria of the infected gallbladder.  It was interesting to note the difference in level of skill between the residents and Dr. Ou, when handling the laparoscopic instruments.

     Following, we observed the excision of a lipoma inside the inferior aspect of the right arm of a patient.  I originally thought the patient was under general anesthesia but the patient was actually just put to sleep.  Local anesthetic was used on the surgical area.  After excising the approximately three inch diameter lipoma, Dr. Ou had to cut off extra skin before sutchering, for cosmetic purposes.

     The last surgery of the day was the most involved and was the one I learned the most from.  This patient was suffering from chronic peptic ulcers that lead to an obstruction at the stomach-duodenal junction.  There were a few of questions that needed to be answered.  The first was are the lesions benign or malignant.  The second was whether to bypass the stomach completely or do a partial gastrectomy (which is more physiological).  The third was whether to do the procedure laprascopically or through traditional open cavity method.  Regarding the later question, from the morning presentation of Day 3, I know that the laparoscopic method provides similar 5 year outcomes with a decreased time before being discharged and a decreased time before resuming ingestion, with only a ten minute longer procedure on average.  Nonetheless, this patient was very skinny and malnourished, so Dr. Ou decided to do the traditional open cavity gastrectomy. 

     After the opening of the cavity and dissection towards the stomach, Dr. Ou explained that we try to preserve as much of the Ommentum as possible because a lot of lymph tissue is located inside of it.  After finally having access to the lesion, Dr. Ou examined it for malignancy.  Although the outside looked like cancer, the inside of the lesion looked benign.  He explained that it was most likely due to chronic fibrosis, scarring, and build up.  Regardless, to err on the safe side he decided to resect it; however, since he thought it was likely not cancer, he did not decide to remove lymph nodes and he also preserved half of the stomach.  Thus, he tied off and stapled all of the vessels supplying the right side of the stomach, which was the side to be excised.  After excising part the stomach, the question was now whether to do a Bilroth I or Bilroth II anastomoses of the stomach to the intestinal system.   

The following is a figure explaining the differences: http://streamlyner.com/wp-content/uploads/2014/06/billroth-1stomaco-normale-stomaco-operato-e-gastropatie-ys112tcw.gif

Bilroth I anastomoses connects the partially resected stomach to the duodenum.  This is the more physiologic approach and will lead to a better appetite and better experience for the patient post operation; however, it also runs a higher risk of rupturing and leaking.  Because cancer was not completely out of the question, Billroth I route was not favored.  The Billroth II route takes a piece of the jejunum and connects the partially resected stomach to the jejunum itself.  The duodenum is kept but sealed with a GIA staple.  In this way, the pancreas can still excrete bile into the intestines.  This was the route that was chosen.  This is a safer route, though will lead to less appetite and more discomfort for the patient post operation.  We were unable to see the rest of the surgery, but when we left, the surgeons were in the process of excising parts of the jejunum.

      Today, we were not able to spend too much time in the outpatient clinic; however, what was most notable to me was a case of a 53 year old Male who had a history of a goiter.  He had a right thyroid lobectomy for cosmetic purposes; however upon pathological inspection, he had a follicular adenoma.  What was interesting about this case was that it was a well differentiated tumor, but it had invasive behavior.  Dr. Ou explained that the two options would either be to remove the left thyroid lobe as well (but this would mean lifetime hormone supplementation) or to leave it and observe.  Dr. Ou favored the later option.

Christine Le, Week 3: OB/GYN, Day 3

This morning we got to observe Dr. Tung perform a conization (cone biopsy), which is an extensive form of a cervical biopsy in the operating room. A cone-shaped wedge of tissue is removed from the cervix, which includes the transformation zone and all or a part of the endocervical canal. There are 3 methods to perform this procedure:
1) scalpel (cold knife conization)
2) laser
3) electrosurgical loop (Loop Electrosurgical Excision Procedure, LEEP)

At first, Dr. Tung tried to use the LEEP method, but the tissue was too thin, so she had to switch to the cold knife method. The whole procedure took about 20 minutes.

After the conization, we returned to the OPD where Dr. Tung saw many patients. Most patients came in for Pap smears and others needed an ultrasound (aka transabdominal sonography). One patient that stood out to me was a 23 year old who came in with a chief complaint of dysmenorrhea. She has had dysmenorrhea since menarche, which was at 11 years of age. Additionally, she has been on hormone treatment with lower dose oral hormone contraceptive since the age of 13 and for the past 3 years has been taking Norethindrone/Ethinyl estradiol (oral contraceptive with iron supplement). This patient came in with her mother and father (who may have been a physician at this hospital). It seemed as if the patient's primary language was English, as she conversed with her mother in a mixture of Mandarin and English. However, what struck me was that during the majority of the visit (which lasted about 30-40 minutes, much longer than other visits, which were 5-10 minutes), the mother spoke for the patient. The mother told the doctor that the patient was recently married and wanted continuous oral contraceptive for menstrual cycle control. The mother spoke for the patient and even answered questions regarding sexual activity and sexual activity prior to marriage. When another person answers for the patient, there is always the possibility of pertinent information not being disclosed and affecting the care of the patient. If the patient is capable, then who would know the history and health status of a patient better than herself? Also, I feel that in the US, the mother and father would have been asked to leave the exam room, unless the patient requested that they be present. Then, after the patient was given an ultrasound and Pap smear, the mother sat on the stool intended for patients, and discussed contraceptive options with the doctor, while the patient herself stood close by and listened to the discussion, but did not really participate. This struck me as quite odd. This interaction between the doctor, the parents, and the adult patient made it seem as if the patient was not in control of her own health care and was unable to advocate for herself. And this was not the first time I have witnessed mothers answering all the doctor's questions in the OB/GYN outpatient clinic for their adult daughters (all in their 20's). I believe that the age of majority in Taiwan is 18 years of age. (Age of majority is the threshold of adulthood as it is recognized by law), so why do these mothers play such a large role in their adult children's health care, particularly gynecological care? At what point in their lives do these adult children get to talk to the doctor on their own? Is this an aspect of Taiwanese culture that is difficult to understand based on our ideas of adulthood, patient confidentiality and privacy, and gynecological care in the United States?

Then, in the afternoon, we observed Dr. Cao in the OPD. One interesting case was a 45 year old patient who reported having a palpable mass in the vulvar region. The doctor's examination revealed a large cervical polyp that protruded into the vagina (it was about the size of my thumb). Dr. Cao called the operating room and scheduled a polypectomy. After about 20 minutes we headed into the operating room to watch Dr. Cao perform the procedure. He explained to us that twisting the polyp would be enough to remove it and sure enough, it did not take very long to remove the polyp via the twisting method.

In only 3 days with the OB/GYN department, we have seen several interesting cases and procedures as well as many common gynecological diseases . And although it is unlikely that I will want to pursue an OB/GYN specialty, I have enjoyed learning from Dr. Cao and Dr. Tung and look forward to continuing this week with them.

Megan Lung Pulmonology W3D3

Today we shadowed a respiratory therapist named Eva. She gave a brief summary of what she does in the ICU unit and the Respiratory Care Ward. Eva also gave us an excellent historical, economical, and social perspective to Taiwanese healthcare.

First she began with a powerpoint that explained the basic concepts of mechanical ventilation. While the US has 60 years of respiratory therapy history, the field is exceptionally young in Taiwan; only 25 years old. In Korea and Japan, about 50% of the doctors also do the job of respiratory therapists. Respiratory therapists manage patients who depend on BiPAP, tracheostomies, or intubation. They also try to get the patient better and "wean" them off of respiratory machines by going through exercises to strengthen their diaphragm and chest wall.

Eva then gave us more information about the majority of patients who come to Taipei hospitals. Patients that come to this hospital are often elderly, poor, and have many comorbidities. These three identifiers affect each other and cause a vicious cycle of poverty that leads to many complications and illnesses. Many patients present with pneumonia and COPD and often spiral into sepsis and multi-organ failure. Furthermore, many of the patients are either uneducated about healthy choices, or cannot afford healthy food. Xin Zhuang, the place that the hospital is located, is considered a small part of "New Taipei" (all the colored areas). New Taipei is poorer than Taipei city. Unlike the U.S., the rich and educated live in Taipei while the poor live on the outskirts. However with the metro, transportation has made traveling to better hospitals easier for those living far away from Taipei. I thought that this was an interesting aspect that has a huge influence on healthcare. Still inequalities exist between northern and souther Taiwan, as well as those who live farther away from Taipei. Hopefully with the ever expanding metro, quality health care access will cease to be an issue.

Eva also showed us the Respiratory Care Ward. Most of these patients have chronic lung problems and are in there for long term care. Some have loss of consciousness and two patients we saw had ALS, which made them unable to move any part of their body except their eyes. It was truly a sad experience to see so many RCW patients who have been there for so long, some for multiple years. Eva told us that she often visits these patients to cheer them up and wishes there was better palliative care for these folks. She suggested music, art, or even some spiritual guidance. This kind of thinking is pretty common in the states already and it is a pity to see that Taiwan is still lacking in end of life care. Traditional Chinese philosophy here is to avoid any invasive procedure yet at the same time to keep their family member alive at the expense of quality of life. Here "face" is very important. How much you care about your parents is linked to how aggressive you try to keep them alive; letting them go peacefully can be a sign of disrespect and lack of filial piety. Interestingly, invasive procedures such as a tracheostomy are adamantly opposed because there is a background of Daoism that is a big part of Chinese culture that promotes 'naturalness' and 'wholeness'. There is still a clash between culture and modern medicine and it leads to patients who are in the RCW for years on end.

Eva gave us some perspectives to consider when we begin to practice medicine. She told us that she was aggressive with her treatment when she first began as a RT. Gradually she became 'soft' and said that when you push treatments on patients you have to ask yourself why. Is it for the patient or is it to prove that you are smart and capable? We have to constantly ask ourselves these questions and put aside our egos to be good health care practitioners.

Dr. Huang also gave me and Heidi his perspective of healthcare in Taiwan. Due to universal healthcare, patients often go "hospital shopping". Not every hospital has standardized their medications, so a doctor in this hospital cannot see the information from another hospital that the patient may have gone to earlier. This allows for a lot of medication waste. Patients go from hospital to hospital and amass medication. There are no limitations to how many times you see the doctor, and doctors are often overloaded with patients. Furthermore they are afraid to order extra tests because if they are audited and found to have ordered superfluous tests not directly related to treatment, they will be severely fined. It seems like the doctors here are over burdened and trapped between patients and the insurance company. Eva suggested that perhaps a limit to how many times someone could see a doctor could help the problem. But due to the large waste that the system allows, insurance companies cut down on other areas of the hospital that are sorely needed.

I feel like the intricacies of healthcare expand beyond the interaction between doctor and patient. Location, history, culture, and economics are all important factors that determine the course of a patient's illness. I hope to gain more perspective in the days to come.

Anny Xiao Week 3 General Surgery Day 3

This morning we attended the surgery morning meeting (like surgery ground rounds)), which consisted of a presentation on gastric cancer and its prevalence, diagnosis, grading and treatment, followed by a discussion amongst the surgeons & residents. It was coincidentally very relevant to the partial gastrectomy surgery we saw the yesterday so it was fortunate that we caught this presentation. I learned that laparoscopic surgeries and traditional open surgery have similar morbidity and mortality outcomes but laparoscopic surgeries have a shorter time to initiation of an oral diet and earlier discharge from the hospital. Additionally, chemotherapy for gastric cancer actually provides little benefit, although of the chemotherapeutic agents herceptin has been shown to promote a better survival rate and overall response rate.

After the meeting, we went to the outpatient department to see Dr. Ou's outpatients. He had many patients scheduled and spent a total of over 5 hours in the outpatient department today. Many were past surgical patients of his that came for routine follow-up appointments. The first patient was a 64yo female patient with a PMH of breast carcinoma S/P right modified radical mastectomy (MRM) 5 years ago. Dr. Ou explained that a MRM is removal of the breast & subcutaneous tissue with removal of most of the axillary lymph nodes, but it tries to preserve healthy tissue and skin by modifiying the pectoralis major muscle to keep it intact. After the MRM, the patient elected to receive herceptin chemotherapy although the surgery was successful. She spent $70-80,000 NT (~$2300-2600 USD) to receive this elective treatment because she wanted to do everything possible to prevent a recurrence. I think that if targeted chemotherapy treatment cost that much in the US, many more patients would be able to afford their cancer treatment. The patient had just completed 5 years of chemotherapy and recent labs and imaging studies were normal so Dr. Ou scheduled her for removal of her Port-A catheter and instructed her to return for a follow-up visit in 6 months. Interestingly, patients with straightforward cancer cases are managed by the surgeons, who see many patients for follow-up after surgical treatment of cancer. Dr. Ou explained that the more complicated cancer cases are handled by the hospital's hematologist/oncologist (there's only 1 in this hospital), while the surgeons handle the simpler cases.

Another interesting patient had a large thyroid goiter of his right thyroid gland that was surgically removed recently for cosmetic purposes. However, Dr. Ou discovered in the pathology report today that the mass was actually follicular carcinoma, which was surprising since the previous diagnosis in the patient's chart was "nontoxic nodular goiter". The patient explained that this type of cancer is not seen on fine needle aspirations of the thyroid, since the cells appear benign. However, this cancer is invasive and can metastasize. Dr. Ou then ordered a liver ultrasound and other imaging studies to check for metastases, informing the patient that one option is to remove his left thyroid gland as well although it would require a lifetime of thyroid hormone replacement medication. However, if they chose not to remove it, there would be a risk of follicular cancer cell growth in the left thyroid gland, so Dr. Ou assured the patient that he would consult the rest of the surgical team and give him time to think it over in order to find a balance between the quality of life and long-term outcomes for the patient.

General Surgery W2D4 (w/ Dr. Ou)

Today is the day I have been looking forward to all week. Dr. Ou has been hyping up today's events because an open heart surgery is scheduled. The patient is set to have a coronary artery bypass graft (CABG). The patient has critical stenosis of the left anterior descending artery (LAD) and is set to have a bypass using the left internal mammillary artery (LIMA). LIMA was chosen instead of a vein (i.e. great saphenous vein) because of its ability to handle arterial pressures.

The doctors began by prepping the patient's body, sterilizing the entire chest. They made an incision around the parasternal border in the 5th or 6th intercostal space (not entirely sure). After cutting through all the layers and finding the pericardial sac, they used some sort of mechanical apparatus to ply apart the ribs and create a larger opening to perform the surgery.

For ease of surgery, the physicians performed many small tasks to facilitate the bypass. The left lung was intentionally deflated to prevent compression and obstruction of the heart. Once the LIMA was located, they cauterized all surrounding branches and tied a red traction band to the artery. This traction band allows easier tracing of the artery and facilitates its resection. When the time came to cut into the pericardial sac, the surgeons opened the sac carefully and sewed the membrane to the chest wall. This prevents the pericardial membrane from falling behind the heart and also keeps a wide view angle of the problematic area. Afterwards to further position the heart, the surgeons stuffed sterile gauze behind the heart to push it forward as well as rotate it for a better view of the LAD.

The intense part came afterward when they had to stabilize a beating heart to sew the LIMA onto the LAD. They used some horseshoe shaped tool that had suction cups along the "U" shape to stabilize the heart. However, when they tried to hook up the two arteries, they realized the LIMA wasn't long enough to attach to the LAD. To resolve this issue, they removed part of the great saphenous vein in the right thigh to connect to the LAD and LIMA.

At Touro, we learned that there is a debate about whether these procedures should be performed on a stopped or beating heart, but one of the physicians there explained some criteria to choose beating/stopped heart procedures. Operations for a stopped heart are usually because of the number of vessels involved, right coronary artery, and patient condition/status.

Of all the surgeries I have witnessed, I think I learned the most from this one and also, solidified a lot of prior information learned in class.

To top off this awesome day, I was allowed to scrub up and wear a sterile gown/gloves for a different surgery. One of the doctors there taught me how to sterilize my arms and "suit up" for surgery. I was at the table as a laproscopic check up was done on a stab wound patient. The atmosphere of being right next to the patient and just being a far away observer was extremely different. The view was amazing and I felt really alive, for lack of a better word. Before as an observer, I was always a few feet away and honestly, got tired and bored once in awhile. However, while I was AT the table, I don't think I have been more focused and awake in a long time. Everything was a new experience and I was just really grateful to get this chance.

This entire day really opened my eyes to surgery and I am definitely a lot more interested in pursuing it in the future.

Christine Le, Week 3: OB/GYN, Day 1-2

Day 1

First day of my OB/GYN rotation! Even though we have not yet covered the reproductive system in our pre-clinical education, I wanted to gain some clinical exposure. There are only 2 OB/GYN doctors in this hospital, so they each see a large number of patients per day.

In the morning, Angela and I joined Dr. Cao in the outpatient department (OPD). He showed us what to look for when doing ultrasound

            -black indicates water or fluid density (bladder)

            -white indicates bone density

            -in between black and white indicates soft tissue density (uterus)

Some patients were given a pelvic ultrasound in order to examine the uterus. The ultrasound revealed some patients as having myomas, which are benign tumors or nodules that develop within the muscle tissue of the uterus, but many of the ultrasounds revealed no particular findings.

Over one-third of the patients came to receive a Pap smear and several came to receive the results of their Pap smear. The hospital recommends women over the age of 30 to get Pap smears and since it is free of charge to the patient, many patients do come see the doctors for their Pap smears.  Dr. Cao explained to us that providing free Pap smears allows for earlier detection of cervical cancer, thus cutting down future treatment costs and increasing prognosis. This service, covered by the National Health Insurance (NHI) is a great example of the saying by Benjamin Franklin: An ounce of prevention is worth a pound of cure, since cervical cancer is the easiest gynecological cancer to prevent. In contrast, Pap smears are not free in the United States. According to the CDC, only those with low income or no health insurance may be eligible for free or low-cost Pap smears through the National Breast and Cervical Cancer Early Detection Program. Also, screening guidelines in the US recommend that women over the age of 21 get regular Pap tests. http://www.cdc.gov/cancer/cervical/basic_info/screening.htm  Since Pap smears are not covered by insurance in Taiwan until a woman is 30 years of  age, isn’t it possible that a subpopulation of women (ages 21-29) are not being screened for cervical cancer due to the fact that they will have to pay out of pocket for the test?

Other cases we observed included: vaginal yeast infections –Candidiasis, Trichomoniasis (sexually transmitted infection caused by the parasite Trichamonas vaginalis, suspected polycystic ovary syndrome (PCOS), bleeding after taking emergency contraceptive, bleeding after taking RU 486 (medication that causes abortion), condylomas (anogenital warts), and ovarian cyst. We saw 32 patients in about 3 hours.

In the afternoon, Dr. Cao used a Powerpoint presentation to explain common diseases seen in OB/GYN and their treatments. This crash course in clinical medicine pertaining to the female reproductive system will help set the foundation for all that I hope to learn this week and will hopefully prepare me for the reproduction block in 2^nd year.

Day 2

We started off the morning with Dr. Cao in the OPD. One interesting case was a 58 year old patient with a PSH of abdominal total hysterectomy due to myoma who presented with a chief complaint of difficulty passing stool. She said something was physically getting in the way of her stool passage. Upon examination, the doctor found that the patient had a rectocele, which occurs when weakening of the fascia that separates the rectum from the vagina causes the front wall of the rectum to bulge into the back wall of the vagina. After the exam, she told the doctor that when she went to another clinic, all they gave her was a stool softener. Why didn’t the other clinic do a physical exam? It took very little time for Dr. Cao to determine her diagnosis upon examining the patient. Then we went into the operating room to observe Dr. Cao perform electrocauterization on the condylomas that a patient had yesterday. Then we returned to the OPD to continue seeing patients. Interesting cases included a 22 year old patient who was pregnant, but did not receive regular pre-natal care, a 35 year old developmentally challenged patient who came in with her mother to change her IUD (intrauterine device), a 22 year old patient who possibly had a herpes infection and a yeast infection, a 36 year old patient with a carbuncle (skin infection that often involves a group of hair follicles) that involved pus. We also observed many Pap smears. We saw 26 patient in the morning session

In the afternoon, we observed Dr. Tung (the first female doctor I have encountered in the hospital) in the OPD. One patient, 33 years old, had been trying to get pregnant and asked the doctor for a HSG (hysterosalpingogram) test, which is an X-ray test that uses dye to visualize the area of the uterus and fallopian tubes. Soon after Dr. Tung called the radiography department, she was able to perform the procedure. It was interesting to find out that a radiologist was not needed to do this imaging procedure and that the OB/GYN doctor performed it. The results showed that the dye did not enter the fallopian tubes, suggesting an obstruction. Other cases included other patients who wanted to get pregnant, amenorrhea, bleeding after taking RU 486, and adnexa cystic lesion. And of course many Pap smears. The continuous stream of patients provideed me the opportunity to learn about many diseases and conditions involving the female reproductive system and I hope I can remember all of what I have learned and apply it to the material we will learn in the upcoming academic year.