I saw more of the same as yesterday. However, the continual exposure is definitely helping me solidify a lot of things I learned yesterday. I immediately noticed that I did not need the doctors to point out aspects on the video feed every single time like yesterday. Today, I was able to reverse the scenario and point out abnormalities for confirmation by the doctors. I was not able to catch every single thing but the patient's today had some new problems I did not see yesterday.
Today, almost all the procedures were done under sedation. Their was an anesthesiologist present to provide injections of a hypnotic/amnesic agent called propofol. This drug seems to have similar effects as benzodiazepines in quickly inducing sedation and leaving short term memory loss. Other than this, the procedures were basically the same.
One of the most common abnormalities gastroenterologists face is ulcers. I would say out of all the patients I have seen in these last two days at least 80% had ulcers of some form. Whether they are in the stomach or intestines, ulcers have a specific staging system. They are divided into three categories, A (Active), H (Healing), and S (Scar). Each of these categories are subdivided into level 1 or 2. Active means there is penetration into the muscular layer and probably bleeding. Healing means the mucosal layers are starting to converge onto the ulcer to repair the damage. Scar means the ulcer is flattening out and the three stomach layers are intact. After learning about these different stages, I have been trying to visual stage them myself during each endoscopy. The idea is simple but looking at it and figuring it out was definitely much harder.
This is just the tip of the iceberg, but the gains from yesterday really make me feel like becoming a gastroenterologist is highly plausible.
Wednesday, July 2, 2014
Tuesday, July 1, 2014
Angela Shih Nephrology W4D1-2
For my last week at Taipei Hospital, I will be rotating with Director Chen in the Nephrology department. Dr. Chen is a extremely nice and soft-spoken person who took some time talking to us in order to understand our knowledge level in nephrology so far. He explained that nephrology is an extremely important department at the hospital because it encompasses so many factors and organ systems. Any damage/disease in the kidneys may result in a plethora of disorders such as hypertension, bone disorders, anemia, CHF, blindness...etc. He told us that there is a high prevalence in kidney disorders in Taiwan due to several reasons:
1) Poor Diet (easily accessible and cheap bad foods)
2) Taking herbal medicine that may be from unlicensed TCM doctors
3) Taking supplements from unregulated sources
4) Poor lifestyle choices (no exercise, sleeping late...)
As a result of these factors, a large population in Taiwan is currently suffering from chronic kidney diseases and all the additional complications that come with it.
In the morning on Day 1, we started out in the hemodialysis ward. Dr. Chen said Taiwan is in the top 3 country in the world for prevalence in dialysis. It is partly due to some of the factors mentioned above, but in addition to those, the high patient pool can be attributed to advances in medical care (less patients dying, new ones added constantly), changes in the health insurance (more affordable), and the fact that there are VERY few kidney donors. There is a very low transplant rate in Taiwan since in Asian culture, particularly Buddhist Taiwanese culture, people want to preserve the whole body after death. As a result, there are not enough donors to support the growing chronic kidney disease (CKD) patient pool and more and more promotions are being made to advocate for organ donations. We went over some of the basic components of dialysis with Dr. Chen. To my surprise, the ward was very large for such a smaller scaled hospital. There was easily 30-40 patients in the ward receiving hemodialysis (HD) at the same time. These patients receive HD every 2 days and each time lasts around 4 hours. Each day, the hospital can support up to hundreds of patients in the HD ward.
The two main components of HD are 1) volume control and 2) toxin removal rate. All the HD machines are automated, and the volume of dialysis fluid added and volume removed from each patient is calculated according to body weight. The removal of renal toxins is also calculated by observing the urea levels and the kidney's clearance rate levels. There are several patients in the ward who have been on dialysis for 10+ years. Many of them have received A-V fistulas and grafts in order to support the long term HD treatments as the repeated needle puncturing and treatments have ruined their veins and arteries. As part of the treatment process, the patients are also advised to monitor their diets and blood pressure to help slow down the progression of the disease.
On the second day in Nephrology, we observed the peritoneal outpatient department. As compared to hemodialysis, there are much fewer patients. In addition to observing the outpatient session, we observed the nurse clean the cathether and dress the wound. Although peritoneal dialysis allows for freedom of movement with the patients and they can receive treatment from home, there are still less people who opt for PD. I believe it's mostly because they view the abdominal placement of the catheter as more intrusive. During the OPD, we saw a 28 year old male patient who was on PD. We learned that he was recently given the opportunity to undergo a kidney transplant, which he agreed to. However, right before the procedure, he backed out. Upon questioning, he revealed that he passed up on the transplant because he had recently found a new job and didn't want to risk losing it. I thought it was a waste because kidney donations are so hard to come by in Taiwan, but I also didn't understand his background too well so it's unfair to judge purely on his visit. In the afternoon, we continued in the nephrology OPD and saw a total of around 20 patients. Dr. Chen spends a lot of time with each of his patients and really tries to explain things to them and also answer all their questions.
1) Poor Diet (easily accessible and cheap bad foods)
2) Taking herbal medicine that may be from unlicensed TCM doctors
3) Taking supplements from unregulated sources
4) Poor lifestyle choices (no exercise, sleeping late...)
As a result of these factors, a large population in Taiwan is currently suffering from chronic kidney diseases and all the additional complications that come with it.
In the morning on Day 1, we started out in the hemodialysis ward. Dr. Chen said Taiwan is in the top 3 country in the world for prevalence in dialysis. It is partly due to some of the factors mentioned above, but in addition to those, the high patient pool can be attributed to advances in medical care (less patients dying, new ones added constantly), changes in the health insurance (more affordable), and the fact that there are VERY few kidney donors. There is a very low transplant rate in Taiwan since in Asian culture, particularly Buddhist Taiwanese culture, people want to preserve the whole body after death. As a result, there are not enough donors to support the growing chronic kidney disease (CKD) patient pool and more and more promotions are being made to advocate for organ donations. We went over some of the basic components of dialysis with Dr. Chen. To my surprise, the ward was very large for such a smaller scaled hospital. There was easily 30-40 patients in the ward receiving hemodialysis (HD) at the same time. These patients receive HD every 2 days and each time lasts around 4 hours. Each day, the hospital can support up to hundreds of patients in the HD ward.
The two main components of HD are 1) volume control and 2) toxin removal rate. All the HD machines are automated, and the volume of dialysis fluid added and volume removed from each patient is calculated according to body weight. The removal of renal toxins is also calculated by observing the urea levels and the kidney's clearance rate levels. There are several patients in the ward who have been on dialysis for 10+ years. Many of them have received A-V fistulas and grafts in order to support the long term HD treatments as the repeated needle puncturing and treatments have ruined their veins and arteries. As part of the treatment process, the patients are also advised to monitor their diets and blood pressure to help slow down the progression of the disease.
On the second day in Nephrology, we observed the peritoneal outpatient department. As compared to hemodialysis, there are much fewer patients. In addition to observing the outpatient session, we observed the nurse clean the cathether and dress the wound. Although peritoneal dialysis allows for freedom of movement with the patients and they can receive treatment from home, there are still less people who opt for PD. I believe it's mostly because they view the abdominal placement of the catheter as more intrusive. During the OPD, we saw a 28 year old male patient who was on PD. We learned that he was recently given the opportunity to undergo a kidney transplant, which he agreed to. However, right before the procedure, he backed out. Upon questioning, he revealed that he passed up on the transplant because he had recently found a new job and didn't want to risk losing it. I thought it was a waste because kidney donations are so hard to come by in Taiwan, but I also didn't understand his background too well so it's unfair to judge purely on his visit. In the afternoon, we continued in the nephrology OPD and saw a total of around 20 patients. Dr. Chen spends a lot of time with each of his patients and really tries to explain things to them and also answer all their questions.
Christine Le, Weekend: Rural Medicine in Guanshan
This weekend (Friday-Sunday), we went to Guanshan in Taitung county to observe the doctors from the Guanshan Tzu Chi General Hospital. This small Buddhist hospital (32 beds) has a few regular doctors, and most of its specialties are staffed by doctors who rotate from other areas. Due to the small size of this hospital, many of the more complicated cases are sent to larger hospitals in Hualien or Taitung (the city). Every Tuesday and Friday-Saturday, a team of healthcare providers (doctor, nurses, assistant) go to some of the aboriginal villages in the mountains to provide health care to the people. So, soon after we arrived at the hospital on Friday, we joined the healthcare team and drove up the mountains (about 1 hour trip) to visit 3 villages. At the first village, a small clinic was set up outside and in the second and third villages, the clinic was set up in a small building. Patients could come in any time during the clinic hours. The doctor, Dr. Shiao, also made house visits to bedridden patients who were unable to come to the clinic. Dr. Shiao explained to us that one way to pay for medical education in Taiwan is to serve in a rural area for 6 years after the doctor has completed his training. Rural medicine is not popular in Taiwan, so this program allows for people living in rural regions to gain access to medical care.
On Saturday afternoon we returned to the hospital and observed some of the doctors in the Emergency Department (ED), including Dr. Shiao. The ED was divided into 5 levels: Resuscitation (1), Emergent (2), Urgent (3), Less Urgent (4), and Not Urgent (5). We were told Levels 4 and 5 often see patients who are experiencing diarrhea, UTI, etc. It was in non-urgent side of the ED that we met Dr. Chang, an OB/GYN who also served as an ER doctor, since the ED doctors at this hospital were not specialists. He is also the doctor that goes up to the clinics in the mountains on Tuesdays. He gave us a tour of the hospital and we got to see the CT machine (which is unusual for a hospital of this size), the OR, the empty ICU (4 beds), and empty nursery (2 beds+ transport incubator). Because the hospital lacks the resources for ICU patients, they are often transferred to a larger hospital. Additionally, only about 6-10 babies are born at this hospital per year. Some pearls of wisdom that Dr. Chang bestowed upon us included:
1. The doctor-patient relationship is very important. Legal problems can stem from this relationship.
2. Never tell a patient that "the baby is normal" or that "there is an absolute cure"; you can say that "I have found no major abnormalities right now" because medicine is scientific and uses statistics; it is not absolute.
3. Observation is very important in medical training because it is a method of learning.
4. Always know the side effects of a treatment and why they occur.
5. You should object/question your teacher's opinion (in your mind). Do not blindly accept what they are saying; they may be right or they may be wrong. It is through questioning what you are taught, that you may surpass your teachers.
6. Check the patient's condition prior to looking at lab data, which is objective. If you think something is wrong, re-confirm the data.
During our (Angela, Arthur, and my) turn in the ED, we saw a case of the common cold, 2 cases in which the patient had gotten into a fight (2 friends that were beaten up by others; one had 5 broken ribs), a case of cut finger that needed stitches, and 1 case of a headache, most likely caused by drinking alcohol the day before.
This weekend was a good lesson in rural medicine. Since so few doctors practice in rural areas, a rural physician needs to know a great deal outside his/her own specialty and must learn how to practice medicine with fewer resources. This experience has given me a better understanding about practicing medicine in underserved areas and my respect for rural physicians has grown greatly.
On Saturday afternoon we returned to the hospital and observed some of the doctors in the Emergency Department (ED), including Dr. Shiao. The ED was divided into 5 levels: Resuscitation (1), Emergent (2), Urgent (3), Less Urgent (4), and Not Urgent (5). We were told Levels 4 and 5 often see patients who are experiencing diarrhea, UTI, etc. It was in non-urgent side of the ED that we met Dr. Chang, an OB/GYN who also served as an ER doctor, since the ED doctors at this hospital were not specialists. He is also the doctor that goes up to the clinics in the mountains on Tuesdays. He gave us a tour of the hospital and we got to see the CT machine (which is unusual for a hospital of this size), the OR, the empty ICU (4 beds), and empty nursery (2 beds+ transport incubator). Because the hospital lacks the resources for ICU patients, they are often transferred to a larger hospital. Additionally, only about 6-10 babies are born at this hospital per year. Some pearls of wisdom that Dr. Chang bestowed upon us included:
1. The doctor-patient relationship is very important. Legal problems can stem from this relationship.
2. Never tell a patient that "the baby is normal" or that "there is an absolute cure"; you can say that "I have found no major abnormalities right now" because medicine is scientific and uses statistics; it is not absolute.
3. Observation is very important in medical training because it is a method of learning.
4. Always know the side effects of a treatment and why they occur.
5. You should object/question your teacher's opinion (in your mind). Do not blindly accept what they are saying; they may be right or they may be wrong. It is through questioning what you are taught, that you may surpass your teachers.
6. Check the patient's condition prior to looking at lab data, which is objective. If you think something is wrong, re-confirm the data.
During our (Angela, Arthur, and my) turn in the ED, we saw a case of the common cold, 2 cases in which the patient had gotten into a fight (2 friends that were beaten up by others; one had 5 broken ribs), a case of cut finger that needed stitches, and 1 case of a headache, most likely caused by drinking alcohol the day before.
This weekend was a good lesson in rural medicine. Since so few doctors practice in rural areas, a rural physician needs to know a great deal outside his/her own specialty and must learn how to practice medicine with fewer resources. This experience has given me a better understanding about practicing medicine in underserved areas and my respect for rural physicians has grown greatly.
Anny Xiao Week 4 Endocrinology Day 1 & 2
Yesterday
morning we met with the nutritionist who provides nutrition education in
the outpatient department and she gave us a general overview of the
information she teaches diabetes patients:
Limit daily calorie intake according to weight and BMI:
Normal weight BMI </=24: weight (kg) x 27 kcal
Overweight BMI >25: weight (kg) x 25 kcal
Limit carbohydrates to 4 portions per meal:
Each portion = 15g (same as what is taught in diabetes education classes in the US) but instead of emphasizing this, the nutritionist had many plates of plastic food to demonstrate portion sizes, which I thought was an effective way to help patients remember how many portions are in each type of food. For example, 1 bowl of rice = 4 portions of carbs, 1 bowl of noodles = 2 portions, 1 piece of toast = 2 portions. The nutritionist said that many Taiwanese patients eat too much rice and noodles, which causes high blood sugars.
Limit grains as well as rice:
Taiwanese people like to mix grains such as barley, oats, purple rice, brown rice and etc into their white rice to make mixed grain rice, and many think of these grains as healthy, so they tend to eat more of these, but the nutritionist advises them that these grains are also carbohydrates and should be included when considering the 4 portion limit of carbohydrates.
Limit fruits to 2 portions/day:
1 portion = 12 grapes, 1 small guava or mango,1 large kiwi, 1/2 banana. Many patients like eating fruit and eat lots of it without realizing its effect on their blood sugar, so the nutritionist has to teach patients about limiting sugar intake from fruit.
Limit milk to 1 cup per day
Commercially advertised milk meal supplement for diabetics is popular among diabetes patients in Taiwan. The milk contains sugar from lactose and maltodextrin but because of the high fat content, it does not cause a blood sugar spike after consumption. This is often used by elderly patients who can't chew as well as a meal replacement, but the nutritionist must teach them that 1 serving/can does not provide adequate calories for an entire meal (only provides 250kcal out of the recommended 500kcal/meal) so patients should eat rice or noodles with it if they are elderly and experience weight loss after using this as a meal replacement.
Encourage eating as many vegetables as they can, particularly steamed and boiled veggies. 2-3 portions/meal is recommended, with each portion being about the size of one's hand when laid flat on a plate.
Recommended protein intake = 1g protein for each kg of body weight. If the patient also has CKD, the recommended daily protein intake is 0.8g protein/kg body weight.
2-3 portions/meal is recommended, with each portion being about a 3 finger width piece of meat, fish or soybean product.
1 chicken drumstick = 2 servings
Encourage exercise 5 days/week: 30 min/day of walking for elderly patients, 1 hr/day running for younger patients
Encourage water intake 2L/day, limit alcohol and sweets as much as possible
Limit daily calorie intake according to weight and BMI:
Normal weight BMI </=24: weight (kg) x 27 kcal
Overweight BMI >25: weight (kg) x 25 kcal
Limit carbohydrates to 4 portions per meal:
Each portion = 15g (same as what is taught in diabetes education classes in the US) but instead of emphasizing this, the nutritionist had many plates of plastic food to demonstrate portion sizes, which I thought was an effective way to help patients remember how many portions are in each type of food. For example, 1 bowl of rice = 4 portions of carbs, 1 bowl of noodles = 2 portions, 1 piece of toast = 2 portions. The nutritionist said that many Taiwanese patients eat too much rice and noodles, which causes high blood sugars.
 |
| Plastic food displayed on plates to demonstrate portions |
Limit grains as well as rice:
Taiwanese people like to mix grains such as barley, oats, purple rice, brown rice and etc into their white rice to make mixed grain rice, and many think of these grains as healthy, so they tend to eat more of these, but the nutritionist advises them that these grains are also carbohydrates and should be included when considering the 4 portion limit of carbohydrates.
Limit fruits to 2 portions/day:
1 portion = 12 grapes, 1 small guava or mango,1 large kiwi, 1/2 banana. Many patients like eating fruit and eat lots of it without realizing its effect on their blood sugar, so the nutritionist has to teach patients about limiting sugar intake from fruit.
Limit milk to 1 cup per day
Commercially advertised milk meal supplement for diabetics is popular among diabetes patients in Taiwan. The milk contains sugar from lactose and maltodextrin but because of the high fat content, it does not cause a blood sugar spike after consumption. This is often used by elderly patients who can't chew as well as a meal replacement, but the nutritionist must teach them that 1 serving/can does not provide adequate calories for an entire meal (only provides 250kcal out of the recommended 500kcal/meal) so patients should eat rice or noodles with it if they are elderly and experience weight loss after using this as a meal replacement.
Encourage eating as many vegetables as they can, particularly steamed and boiled veggies. 2-3 portions/meal is recommended, with each portion being about the size of one's hand when laid flat on a plate.
Recommended protein intake = 1g protein for each kg of body weight. If the patient also has CKD, the recommended daily protein intake is 0.8g protein/kg body weight.
2-3 portions/meal is recommended, with each portion being about a 3 finger width piece of meat, fish or soybean product.
1 chicken drumstick = 2 servings
Encourage exercise 5 days/week: 30 min/day of walking for elderly patients, 1 hr/day running for younger patients
Encourage water intake 2L/day, limit alcohol and sweets as much as possible
In
general, the information provided to patients is very similar to what
is taught in diabetes education classes in the US, but tailored to the
dietary conventions & habits of Taiwanese patients.
Today,
we were with Director Liao as he examined patients using thyroid
ultrasound and performed fine needle aspiration (FNA) on thyroid
nodules. He explained that three things are looked at when evaluating
the thyroid: size (normal, enlarged or atrophied), nodules (none, single
or multiple) and function (euthyroid, hypothyroid or hyperthyroid). All the patients
we saw today were ones referred for some type of nodular goiter, with or
without abnormal thyroid lab results. When a patient presents with a
nodule on ultrasound, a FNA is usually indicated. Dr. Liao explained to us that at this hospital they rarely do ultrasound-guided FNA, which is more often done at a larger medical center. An US-guided biopsy is indicated when a normal FNA result is nondiagnostic
and malignant papillary thyroid cancer needs to be ruled out. I was
surprised to discover that local anesthetic is not used for the FNA,
which is done by palpating for the nodule, inserting the needle into the
nodule and rotating the needle several times before pulling up on the
syringe to extract enough cells. Performing the ultrasound and FNA
procedure was extremely quick and patients were efficiently scheduled for follow-up appointments in the outpatient department to discuss the FNA findings.
One
interesting patient we saw was a 49yo woman with a past history of
thyroidectomy at age 13 but because she was so young at the time, she
wasn't sure what her diagnosis was. Dr. Liao explained that it would be
difficult to find this information since it occurred 36 years ago. The
patient was referred for a recurrence of a nodule, which needed a FNA.
She had a visible goiter on her neck and when asked to swallow, movement
of the nodule could be seen. Dr. Liao told us that a thyroid nodule
will move when the patient swallows while an enlarged lymph node will not. He also informed us that prior to the time of her thyroidectomy, iodine had not yet been introduced into table salt so it is likely that she had iodine deficiency thyroiditis. Iodine was incorporated into salt about 30 years ago and iodine deficiency thyroiditis has since become very rare.
Megan Lung Heme/Onc W4D2
Today, Christine Le and I saw Dr. Chen's outpatients. They were a mix of patients with anemia and cancer looking to follow up.
Patient 1 had microcytic anemia, specifically iron deficient anemia. Hemoglobin decrease from 12 to 9 three weeks ago. Dr. Chen stated that if Hb is under 8 mg/dL, patient will be dizzy. Dr. Chen also suspects bleeding from GI. Iron deficiency anemia is determined by bone marrow aspiration and ferrum supplement was given 2 years ago.
Dr. Chen has been using recent evidence on combining Herceptin (trastazumab) with other chemotherapy agents has been very successful. Many of the treatment plans he uses comis combined with Herceptin.
Patient 3 was a 62 yo female presenting with fever. She had left breast IDC grade 3, ER+ T2N2 Mx. After her 4th round of CTX, her platelets decreased and she does not feel well in general. She asked if she had to continue CTX after her recommended full course of 8 rounds. Dr. Chen said that there is always a possibility that she may have to do more rounds. He tells us that he always explains all the options and complications that may occur for patients if they choose to undergo chemotherapy. Many of the patients are conservative in their approach to treatment, often hesitating chemotherapy and surgical intervention. Unfortunately waiting a week, month, or a year can have dire consequences for cancer patients. Cancer can progress rapidly. This patient also presented with leukopenia (under 500) due to CTX. She was given prophylactic antibiotics.
Patient 6 presents with HER2/neu 3+ left breast cancer IDC, T2N0 with liver and bone metastases. She had a mastectomy 3 years ago and is on monthly zometa and weekly paclitaxel and herceptin regimen. Dr. Chen told us that she was not referred to him directly after her mastectomy and expresses that he would have begun adjuvant CTX if she had been referred directly. Unfortunately, due to some hospital error, she was not and her cancer has progressed.
Patient 7 was a 35 yo female with mental retardation, depression, and rapid deterioration of nasopharyngeal cancer with lung and bone metastases. She was supported by her sister walking in. Dr. Chen stated that she was able to walk fine when they last saw her a week ago. Dr. Chen suggested hospitalization but patient and patient's sister refused. Dr. Chen said that where they choose to let her pass away is up to them, and it may be more peaceful for her to be surrounded by loved ones in a familiar place than in the hospital.
Patient 9 was a 53 yo female with hepatosplenomegaly. She has had poor appetite with CTX treated with paclitaxel and herceptin. The CEA/CA 153 ratio was 67/663. This ratio is important in monitoring the treatment of cancer.
Patient 12 was a 65 yo female with ill defined mass in the central pelvis and sigmoid colon cancer with multiple liver metastases. She came to Dr. Chen for an opinion and he suggested palliative chemotherapy, taking his time to explain risks and benefits. He also warned them that they should take take action within 1-2 months as treatment options will decrease later on. Dr. Chen told them his opinion and the family still decided to go to a different hospital for a second opinion. Later he told us a little about his philosophy. He said that he only gets $100 per patient OPD and said that the patient seemed like they were not willing to listen to his opinion, therefore he cut short his explanations when it seemed like they stopped responding to him. For the sake of his time and money, he needs to make sure he is not putting too much time on a family and a patient who will disregard his plan anyway. I thought that was an interesting thought and one of the many concerns that a doctor who has to see 17 patients in outpatient clinic in the morning should address.
During rounds, we saw a patient with pending liver failure who had colon cancer and hospitalized for urosepsis and abdomen distension. Her ultrasound showed liver tumors. Dr. Chen suggested no chemotherapy and that she needed hospice treatment. He ordered vitamin K and a blood transfusion. Since she is on empiric antibiotic treatment, many bacteria in her gut will be killed. These bacteria make Vitamin K. Intrinsic clotting factors such as 2,5,7, and 9 need vitamin K as a coenzyme to effectively clot blood.
--
In the ED, student doctor Vincent Chou and I saw a 60 yo patient with prostate cancer come in with a subdural and subarachnoid hematoma due to a MVA. The neurosurgeon was called in for consultation on surgery. The neurosurgeon stated that he will probably not be conscious even if they stop the bleeding and decrease the intracranial pressure due to an elongated and damaged brainstem. There is bleeding on both sides of the brain, making surgery more complicated and less likely to have a good outcome if it was a unilateral hematoma. The number one priority for a brain hemorrhage is to keep the intracranial pressure low. Stopping blood flow is less important since there is only so much blood that can leak out into a compartmentalized space. There was also a herniation into the brain stem from the temporal lobe. The neurosurgeon suggested temporal lobe resection to relieve the pressure and stop the herniation into the brain stem. However this was not recommended since there is bleeding everywhere and it would exacerbate the hemorrhage.
Before it was mandated that motorcycle helmets be worn, Dr. Liu said that these kind of cases occurred all the time. He said he often got 3-4 of these cases per day as an intern 10 years ago. It was devastating to see the doctors tell the family what their options were, and that he would probably not come out of coma. Fortunately the doctor was very clear about the options and what surgery could offer them. Although they did not decide on anything (watch and wait or surgery), the patient will be kept on medication to sustain his vital signs while they discuss their options. The neurosurgeon suggested that the family decide on what to do if an emergency arises, and if they want to sign a DNR. He reassured them that signing a DNR does not mean that they will give up on the patient and 'do nothing'. He gave an example of a comatose patient whose family signed a DNR who eventually woke up and recovered fine. It is interesting to see the methods that doctors use to reassure patients or change a family's perspective based on anecdotal stories like these.
Patient 1 had microcytic anemia, specifically iron deficient anemia. Hemoglobin decrease from 12 to 9 three weeks ago. Dr. Chen stated that if Hb is under 8 mg/dL, patient will be dizzy. Dr. Chen also suspects bleeding from GI. Iron deficiency anemia is determined by bone marrow aspiration and ferrum supplement was given 2 years ago.
Dr. Chen has been using recent evidence on combining Herceptin (trastazumab) with other chemotherapy agents has been very successful. Many of the treatment plans he uses comis combined with Herceptin.
Patient 3 was a 62 yo female presenting with fever. She had left breast IDC grade 3, ER+ T2N2 Mx. After her 4th round of CTX, her platelets decreased and she does not feel well in general. She asked if she had to continue CTX after her recommended full course of 8 rounds. Dr. Chen said that there is always a possibility that she may have to do more rounds. He tells us that he always explains all the options and complications that may occur for patients if they choose to undergo chemotherapy. Many of the patients are conservative in their approach to treatment, often hesitating chemotherapy and surgical intervention. Unfortunately waiting a week, month, or a year can have dire consequences for cancer patients. Cancer can progress rapidly. This patient also presented with leukopenia (under 500) due to CTX. She was given prophylactic antibiotics.
Patient 6 presents with HER2/neu 3+ left breast cancer IDC, T2N0 with liver and bone metastases. She had a mastectomy 3 years ago and is on monthly zometa and weekly paclitaxel and herceptin regimen. Dr. Chen told us that she was not referred to him directly after her mastectomy and expresses that he would have begun adjuvant CTX if she had been referred directly. Unfortunately, due to some hospital error, she was not and her cancer has progressed.
Patient 7 was a 35 yo female with mental retardation, depression, and rapid deterioration of nasopharyngeal cancer with lung and bone metastases. She was supported by her sister walking in. Dr. Chen stated that she was able to walk fine when they last saw her a week ago. Dr. Chen suggested hospitalization but patient and patient's sister refused. Dr. Chen said that where they choose to let her pass away is up to them, and it may be more peaceful for her to be surrounded by loved ones in a familiar place than in the hospital.
Patient 9 was a 53 yo female with hepatosplenomegaly. She has had poor appetite with CTX treated with paclitaxel and herceptin. The CEA/CA 153 ratio was 67/663. This ratio is important in monitoring the treatment of cancer.
Patient 12 was a 65 yo female with ill defined mass in the central pelvis and sigmoid colon cancer with multiple liver metastases. She came to Dr. Chen for an opinion and he suggested palliative chemotherapy, taking his time to explain risks and benefits. He also warned them that they should take take action within 1-2 months as treatment options will decrease later on. Dr. Chen told them his opinion and the family still decided to go to a different hospital for a second opinion. Later he told us a little about his philosophy. He said that he only gets $100 per patient OPD and said that the patient seemed like they were not willing to listen to his opinion, therefore he cut short his explanations when it seemed like they stopped responding to him. For the sake of his time and money, he needs to make sure he is not putting too much time on a family and a patient who will disregard his plan anyway. I thought that was an interesting thought and one of the many concerns that a doctor who has to see 17 patients in outpatient clinic in the morning should address.
During rounds, we saw a patient with pending liver failure who had colon cancer and hospitalized for urosepsis and abdomen distension. Her ultrasound showed liver tumors. Dr. Chen suggested no chemotherapy and that she needed hospice treatment. He ordered vitamin K and a blood transfusion. Since she is on empiric antibiotic treatment, many bacteria in her gut will be killed. These bacteria make Vitamin K. Intrinsic clotting factors such as 2,5,7, and 9 need vitamin K as a coenzyme to effectively clot blood.
--
In the ED, student doctor Vincent Chou and I saw a 60 yo patient with prostate cancer come in with a subdural and subarachnoid hematoma due to a MVA. The neurosurgeon was called in for consultation on surgery. The neurosurgeon stated that he will probably not be conscious even if they stop the bleeding and decrease the intracranial pressure due to an elongated and damaged brainstem. There is bleeding on both sides of the brain, making surgery more complicated and less likely to have a good outcome if it was a unilateral hematoma. The number one priority for a brain hemorrhage is to keep the intracranial pressure low. Stopping blood flow is less important since there is only so much blood that can leak out into a compartmentalized space. There was also a herniation into the brain stem from the temporal lobe. The neurosurgeon suggested temporal lobe resection to relieve the pressure and stop the herniation into the brain stem. However this was not recommended since there is bleeding everywhere and it would exacerbate the hemorrhage.
Before it was mandated that motorcycle helmets be worn, Dr. Liu said that these kind of cases occurred all the time. He said he often got 3-4 of these cases per day as an intern 10 years ago. It was devastating to see the doctors tell the family what their options were, and that he would probably not come out of coma. Fortunately the doctor was very clear about the options and what surgery could offer them. Although they did not decide on anything (watch and wait or surgery), the patient will be kept on medication to sustain his vital signs while they discuss their options. The neurosurgeon suggested that the family decide on what to do if an emergency arises, and if they want to sign a DNR. He reassured them that signing a DNR does not mean that they will give up on the patient and 'do nothing'. He gave an example of a comatose patient whose family signed a DNR who eventually woke up and recovered fine. It is interesting to see the methods that doctors use to reassure patients or change a family's perspective based on anecdotal stories like these.
Angela Shih OB-GYN W3D3-4
On the third day of our Ob-Gyn rotation, we got to see Dr. Tung perform a cone biopsy--also known as conization. The patient was a 44 year old female who had an abnormal pap smear result. The pap smear revealed high grade squamous intraepithelial lesions (HSIL) and Dr. Tung decided to do a biopsy as these lesions may indicate an increased risk of squamous cervical cancer. There are a few ways to perform a cone biopsy, but Dr. Tun focused on the 3 main methods:
1) Direct scalpel sample removal
2) CO2 laser
3) LEEP= loop electrosurgical excision procedure.
During the biopsy procedure, Dr. Tung removed 3 samples, one from the cervix, one from the endocervix region, and one from the endometrial layer. The patient started to regain consciousness during the procedure and had to be put under again because the procedure was taking too long. Dr. Tung explained that as she was cutting with the loop, she realized the cervix was not thick enough for the sample she originally planned to take so she had to switch to scalpel excision which required extra careful maneuvering.
Another interesting case we saw today was that of a 23 year old female who presented with a chief complaint of dysmenorrhea. It wasn't the clinical part of the case that was interesting, but rather the interactions of this case that caught my attention. This 23 year old female came in to the office with her parents. Her father was a doctor in the hospital also, so I suspect there were special arrangements made for her to move up the extremely long list of patients. Dr. Tung also spent 40 minutes with this patient alone trying to cover all her bases and explaining everything multiple times. This patient, though she was an adult already and recently married, sat in the seat and barely said anything. Her mother spoke on her behalf, claiming her daughter did not speak Chinese well. However, it was apparent she both understood and spoke Chinese. It was really strange for me to see her mother answer questions such as "are you sexually active?" and "how long have you been sexually active?" for her daughter. I feel this may cause difficulty in helping the doctor diagnose the patient since all the information she is receiving may or may not be true. Over the 4 days I shadowed in the OB-Gyn department, I saw several mother daughter duos, so I believe it could be a cultural thing for mothers to come with their adult daughters to the doctor and answering questions for them. In the US, it is common practice for the doctors to ask the family members or significant others to leave the room when asking such intimate questions. Here, on the other hand, the doctors often allow family members to stay while taking history and would allow the family to answer and speak for the patient even if the patient was capable of answering herself.
In the afternoon, we shadowed Dr. Cao in OPD. We saw a 45 year old woman who came in complaining of a mass in her vagina. Upon examination, Dr. Cao found a large cervical polyp that was visible even before inserting the vaginal dilator. Dr. Cao asked the patient if she wanted it removed, and when she said yes, he immediately scheduled for a same day removal. An hour later, we were in the surgery room watching Dr. Cao perform a polypectomy. He proceeded to excise the polyp without using any anesthesia. He explained it was because there are few nerve endings in the cervix so she would not feel much pain. A few simple zaps with the electrocauterizing device and a few twists with a forceps later, the polyp was out. It took less than 20 minutes and the patient was able to go home polyp free. The polyp was sent to pathology to determine its cytology. Though they are mostly benign, it was still sent as a precaution.
On the 4th and last day of my rotation, we once again went to outpatient. We shadowed Dr. Cao in the morning and saw several pap smears and cases of amenorrhea. Dr. Cao discusses a little about what it's like to be an Ob-Gyn in Taiwan with us during a short break. He had very unfavorable opinions about the profession in Taiwan. He explained that in the past, OB-Gyn was a highly esteemed specialty and only the top students were able to compete for the residencies. However, with changes in the health insurance system and declines in the economy, there are less and less children being born and the salaries of the Ob-gyn physicians are decreasing steadily. In addition, there is a high lawsuit rate in the profession and it often costs the physician at least 2-3 years of salary if he were to lose a malpractice suit. Also, Ob-Gyns do everything from pap smears, outpatient visits, ultrasound, X-ray procedures, delivering babies to surgical procedures. Overall, it is risky and tiring profession for these physicians in Taiwan. In the US, Ob-Gyn is also a specialty that is becoming more and more unpopular due to the unpredictable hours and demanding nature of the profession. I believe Ob-Gyns are crucial and easily one of the most important physicians in medicine. If the trends continue in Taiwan with which few to none of the students want to go into this specialty, Taiwan may face an extreme shortage of Ob-Gyn doctors and more patients would suffer the consequences of the shortage.
1) Direct scalpel sample removal
2) CO2 laser
3) LEEP= loop electrosurgical excision procedure.
During the biopsy procedure, Dr. Tung removed 3 samples, one from the cervix, one from the endocervix region, and one from the endometrial layer. The patient started to regain consciousness during the procedure and had to be put under again because the procedure was taking too long. Dr. Tung explained that as she was cutting with the loop, she realized the cervix was not thick enough for the sample she originally planned to take so she had to switch to scalpel excision which required extra careful maneuvering.
Another interesting case we saw today was that of a 23 year old female who presented with a chief complaint of dysmenorrhea. It wasn't the clinical part of the case that was interesting, but rather the interactions of this case that caught my attention. This 23 year old female came in to the office with her parents. Her father was a doctor in the hospital also, so I suspect there were special arrangements made for her to move up the extremely long list of patients. Dr. Tung also spent 40 minutes with this patient alone trying to cover all her bases and explaining everything multiple times. This patient, though she was an adult already and recently married, sat in the seat and barely said anything. Her mother spoke on her behalf, claiming her daughter did not speak Chinese well. However, it was apparent she both understood and spoke Chinese. It was really strange for me to see her mother answer questions such as "are you sexually active?" and "how long have you been sexually active?" for her daughter. I feel this may cause difficulty in helping the doctor diagnose the patient since all the information she is receiving may or may not be true. Over the 4 days I shadowed in the OB-Gyn department, I saw several mother daughter duos, so I believe it could be a cultural thing for mothers to come with their adult daughters to the doctor and answering questions for them. In the US, it is common practice for the doctors to ask the family members or significant others to leave the room when asking such intimate questions. Here, on the other hand, the doctors often allow family members to stay while taking history and would allow the family to answer and speak for the patient even if the patient was capable of answering herself.
In the afternoon, we shadowed Dr. Cao in OPD. We saw a 45 year old woman who came in complaining of a mass in her vagina. Upon examination, Dr. Cao found a large cervical polyp that was visible even before inserting the vaginal dilator. Dr. Cao asked the patient if she wanted it removed, and when she said yes, he immediately scheduled for a same day removal. An hour later, we were in the surgery room watching Dr. Cao perform a polypectomy. He proceeded to excise the polyp without using any anesthesia. He explained it was because there are few nerve endings in the cervix so she would not feel much pain. A few simple zaps with the electrocauterizing device and a few twists with a forceps later, the polyp was out. It took less than 20 minutes and the patient was able to go home polyp free. The polyp was sent to pathology to determine its cytology. Though they are mostly benign, it was still sent as a precaution.
On the 4th and last day of my rotation, we once again went to outpatient. We shadowed Dr. Cao in the morning and saw several pap smears and cases of amenorrhea. Dr. Cao discusses a little about what it's like to be an Ob-Gyn in Taiwan with us during a short break. He had very unfavorable opinions about the profession in Taiwan. He explained that in the past, OB-Gyn was a highly esteemed specialty and only the top students were able to compete for the residencies. However, with changes in the health insurance system and declines in the economy, there are less and less children being born and the salaries of the Ob-gyn physicians are decreasing steadily. In addition, there is a high lawsuit rate in the profession and it often costs the physician at least 2-3 years of salary if he were to lose a malpractice suit. Also, Ob-Gyns do everything from pap smears, outpatient visits, ultrasound, X-ray procedures, delivering babies to surgical procedures. Overall, it is risky and tiring profession for these physicians in Taiwan. In the US, Ob-Gyn is also a specialty that is becoming more and more unpopular due to the unpredictable hours and demanding nature of the profession. I believe Ob-Gyns are crucial and easily one of the most important physicians in medicine. If the trends continue in Taiwan with which few to none of the students want to go into this specialty, Taiwan may face an extreme shortage of Ob-Gyn doctors and more patients would suffer the consequences of the shortage.
Christine Le, Week 3: OB/GYN, Day 4
Today is my last
day in OB/GYN because tomorrow we will be leaving for Guanshan in Taitung
county to spend Friday-Sunday at the Tzu Chi Hospital. In the morning, we
observed Dr. Cao in the OPD. As usual, there were over 20 patient visits and
over half were for Pap smears or follow-up visits for previously done Pap
smears. Other cases included irregular menstrual cycles, both excessive and
infrequent. One case that stood out to me was a 43 year old female with
developmental disability who came in with her mother. The patient had had no
menstrual cycle (amenorrhea) for years and this may have been due to the psychiatric
drug she was prescribed. However, she had been experiencing vaginal bleeding in
recent months probably due to her stopping the use of the drug. The ultrasound
showed a right ovarian mass about 3.7 cm. During the discussion with the
doctor, the patient’s mother asked if it was possible to get a hysterectomy for
her daughter because it was tiring to care for the patient every time she got a
menstrual cycle. Dr. Cao immediately told the mother no, because there were no
criteria for performing the procedure. Beyond the fact that there were no
indications for doing the procedure, the mother’s question prompted me to think
about sterilization. According to the Human Rights Watch (http://www.hrw.org/news/2011/11/10/sterilization-women-and-girls-disabilities):
Forced sterilization occurs when a person is
sterilized after expressly refusing the procedure, without her knowledge or is
not given an opportunity to provide consent…Women with disabilities are
particularly vulnerable to forced sterilizations performed under the auspices
of legitimate medical care or the consent of others in their name…Across the globe,
forced sterilization is performed on young girls and women with disabilities
for various purposes, including eugenics-based practices of population control,
menstrual management and personal care, and pregnancy prevention (including
pregnancy that results from sexual abuse)… The difficulty some women
with disabilities may have in understanding or communicating what was done to
them increases their vulnerability to forced sterilization. A further
aggravating factor is the widespread practice of legal guardians or others
making life-altering decisions for persons with disabilities, including
consenting to sterilization on their behalf.
In many countries, the practice of forced
sterilization continues to be debated and justified by governments, legal, medical
and other professionals, and family members and carers as being in the “best
interests” of women and girls with disabilities. However, arguments for their
“best interests” often have little to do with the rights of women and girls
with disabilities and more to do with social factors, such as avoiding
inconvenience to caregivers, the lack of adequate measures to protect against
the sexual abuse and exploitation of women and girls with disabilities, and the
lack of adequate and appropriate services to support women with disabilities in
their decision to become parents.
The mother’s
inquiry about hysterectomy took me by surprise, and it led me to consider a few
things:
1.
How
are the developmentally disabled viewed/treated in Taiwanese society?
2.
How
are the developmentally disabled cared for and what are their treatment goals
in Taiwan?
3.
What
education/training is available for families/caretakers who care for
developmentally disabled children and adults?
This week in the
OB/GYN department has been a great learning experience. During the week, we
were able to see many common gynecological disorders, as well as surgical and
imaging procedures. In addition, I have become more familiar with interpreting
abdominal ultrasounds and have gained more knowledge regarding clinical
practice of obstetrics and gynecology. I would like to thank Dr. Cao and Dr.
Tung for taking the time to teach us by explaining about gynecological diseases
and procedures (especially since we have not learned much about the subject), discussing
each patient case with us, and explaining their thoughts about the field of OB/GYN
in Taiwan.
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