Dermatology - Week 3 - Day 15-19

Day 15
June 15, 2008

First day of the Dermatology rotation. I am very excited about this because I have an extensive history in Derm as a patient. As a wrestler I experienced many skin problems, and have also been treated for psoriasis for 10 years.

In the morning all three of us sat in on Dr. Kuan’s clinic. He is an older physician, and has a resident type on the computer for him while he still uses the ‘old school’ paper. I was very eager to learn and asked a lot of questions.

The resident would take some time to explain some concepts to us.

At one point, Dr. Kuan said ‘In Taiwan you must have studied dermatology before being allowed in the clinic. I think I was being too aggressive with my questioning. So I held back with him after that. I decided it would be a good idea to purchase a dermatology hand book. This way I can also look at the computer screen, which is generally written in English.

In the afternoon, all three of us shadowed Dr. Hu. This woman had incredible energy. She came from Hong Kong. I wonder if it is her Hong Kong traits or her unique personality that exudes this feeling. She reminded me of a late teen in her youthful happy energy. She was very excited about showing us her Cosmetic center. She gave us her contact information and wanted to read our blog and take pictures with us. She said the best thing about being a dermatologist is using the treatment on herself! She was fun. She also was open to us asking questions. There was a stark contrast between this session and our morning session. Many of her patients came with cosmetic cases. I find myself enjoying the beauty of cosmetic medicine. I think my Mom is disappointed for me to say this. I think she feels that it would be shallow for me to go into cosmetic medicine. I believe that people can heal from the outside-in just as people can heal from the inside-out.

Day 16
June 16, 2008

Today I have been organizing plans for the present and future. Sometimes it is difficult to balance time with friends, family, and solitude. I am trying my best.

The Taiwan medical system is so efficient. The doctor stays in one room at the clinic while the patients come in one after another. In 3 hours the doctor saw more than 60 patients. There is less time for building of rapport as the patient just starts talking about the problem as soon as they walk in. The previous patient is still in the room with the next patient looming over their shoulder. I love it how each patient has a national insurance card where all their medical history is accessible as soon as it is inserted in the magical computer slot.

Due to this high volume of cases my dermatological learning has been thru repetition. Now that I have a handbook of dermatological disease I can read about the disease as the doctor is talking to the patient. This way I won’t have to bug the Doc with too many questions. I tend to ask a lot. Eczema, dermatitis, psoriasis, hair loss, scar reduction, hyperpigmintation, vitiligo. These are very common. The doctor I shadowed today specializes in hair transplantation and a procedure in which he forms a double eyelid. Many Asians want this feature. I asked if I could watch his operation tomorrow and he agreed .

Laundry time then dinner.

I am making some time every day for Board studying. I guess I am hard core. That is what Tammy said. I think it’s just that I love medicine.

Day 17
June 17, 2009

I was able to catch up on sleep today after having to be up at 5 am to go to Taipei for a morning pathological meeting the day before.

We went on rounds in the ward at 10 am. We were then sent to the treatment room. I saw a case of actinic keratosis and I also saw a biopsy taken with a differential of T cell lymphoma lesions or eczema.

I was granted permission to visit Dr. Huang and watch him perform the blepharoplasty (double eyelid surgery) in the afternoon. I feel that Dr. Huang is a gifted doctor and really cares for his patients. I am waiting for the surgery to begin while I wait in Taipei. While waiting I have been walking around Taipei, drinking tea and visiting Banks and business offices eavesdropping on conversations. There are a few English speaking Caucasians around. I am now less of a novelty.

Apparently plastic surgeons, dermatologists and opthamologists can do this cosmetic surgery in Taiwan. Interesting overlap.

I was able to see a second blepharoplasty of the lower eyelid to improve puffiness under the eye. The patient seems to experience pain. During these procedures only local anesthesia is administered. I believe this is probably a stark contrast from the United States.

I also witnessed a hair transplant. Dr. Huang specializes in this procedure. Hair from the posterior side of the scalp were removed follicle by follicle and inserted into the excisions made at the anterior scalp. A time consuming process, but the doctor explained that re-growth is about 90 percent.

The highlight of the day for me was to watch the upper eyelid blepharoplasty. This doctor does about 200 procedures a year, and he uses a technique he learned in Japan. Many Asians do not have a ligament attached to the orbicularis muscle of the eye. This will not allow a crease on the eyelid. Many Asians find the double eyelid more beautiful as it opens the eye. I find it fascinating how different cultures vary in their standards of beauty. Myself, aesthetically I prefer the look of an asian eye without the double eyelid. Many people want what they can’t have I guess. The procedure took 40 minutes and had a very noticeable effect. Only complications are swelling for a few days.

After the surgery I went by myself to the religious relic/herbal medicine area of Taipei. I was on a mission to find some herbs to try. I walked in and they asked me what was wrong. We stumbled through English with random Chinese words thrown in that I used to try to be a little less of an outsider. It would make them giggle. I told them nothing was wrong, but I wanted something to make me feel good. They ground up a mixture. I know there was Ginseng as part of the mixture. The woman that sold me the herbs flexed her muscle and pointed to her head indicating that the tincture would make me feel strong and smart. Later I asked a resident in acupuncture and he said the concoction would enhance my Qi and blood flow. Cool! It seems as if they don’t regulate who sells these herbs. No prescription needed. Interesting.

Day 18
June 18, 2009

This morning Tammy, Bill, and I were lucky enough to shadow a doctor who really spent a lot of time with us, explaining differential diagnoses and having us interact with patients.

I felt comfortable asking questions, and he would pull out books to show us images and concepts. He will be attending UC-Davis in the fall to study Law. I offered to show him around a bit. It will be a great opportunity to show him about Touro and Osteopathy! He seemed incredibly excited.

He walked around fast and had a big toothy grin. His excitement for teaching us showed me that he really loved to learn. I admire him for that. He is certified in Pediatrics and Dermatology! And now he will study law. When you love what you are learning you will be great to your patients I believe. From my brief interaction I feel he is one of the best doctors I have been around. He took us out to lunch and let his enthusiasm seep into us.

In the afternoon we shadowed Dr. Kuan, the same doctor from the first day. We were able to see many lasers as he treated patients for warts, pitting scars, nevi, dark circles under eyes, and hyperpigmentation. I did not realize how many various forms of laser are used.

When warts are removed we were told it is important to wear a tight mask to prevent wart growth in our trachea. That gave me a horrible scare!

Many people ask us to dinner here. Our dermatologist preceptor did. Regrettfully I had to say no because I wanted to take care of some personal chores and exercise. I am realizing I can’t say yes to everything in life.

Day 19
June 19, 2009

We shadowed a female dermatologist. She was cycling through patients very quickly, and it was difficult to ask her questions. Still, we were learning through repetition. I flip through my Dermatology handbook while she works with the patient and the computer screen written in English.

This doctor asked us questions at the beginning about our impression of the patient’s pathology. Generally, this was beyond my knowledge base, but I could reason. I think she assumed we had already completed our dermatology coursework.

Taidong - Jack's father's birthplace Day 19

Day 19

June 19, 2009

In the evening our group went to board a plane to Tai Dong. I probably butcher the spelling of these names. My phonetic intuition leads me to this spelling. Jack’s father is from this seashore town. We had a true local experience! We saw Mr. Tseng’s childhood house and sat around and ate Mangos. Probably the best mango I’ve ever had! We saw a beautiful local temple. His father took us to a Hot Spring. Hot Springs are resort areas here. Each pool of water has a different temperature so we can listen to our bodies wishes. After Jack and his father showed enough courage to immerse themselves in the nearly scalding water I along with Sean and Paul followed suit. After heat that extreme the cool water felt like heaven. My skin was beautiful for the next

while.

Visiting an old friend in Kaohsiung

Day 20

June 19, 2009

We woke up very early. I have a dear old friend in Taiwan ( I met him while we both lived in France) that I have been wanting to visit for years. This is one of the major reason I came here this summer. The rest of the group stayed to go to Green Island but I took a train to Kaohsiung to visit. He is a risk taker, after coming to Taiwan on a whim to teach english. He is still here after 5 years, speaks Mandarin and owns a business. When I am around him I tend to let go of my professionalism, which is quite nice.

It all came back, and we went out to PARTY! ………..

He is part of a foreigner scene. Local Taiwanese also like this scene and we met people that liked hangin’ round the foreigners.

Also had fun riding on the back of his moped. Taiwanese love scooting around on these things.

Day 21
June 21, 2009

After adventure, we took it easy. Ate a casual lunch.

Caught in a rainstorm the tire went flat while we were riding a car with a guy named Chen. Tom was determined to take a risk. He wanted to change it. It started pouring down. We were soaked as we watched Tom fumble with the poor tools. Chen wanted to call professionals. Tom was about to lose hope. The jack almost was tilted and almost fell as Tom slaved. Danger lurked. He couldn’t get the jack high enough to get the spare on, the other tire was already off. The jack unstable, could fall any minute. Chen said he learned he couldn’t trust anything Tom said. Finally he got it. Relief. Adventure. Risk. The life of Tom. Chen was the voice of reason, Tom the crazy one, and I the giggler, amazed.

Still soaked we drove in our repaired car to the Mall to watch a movie. Packed, Taiwanese love to shop! We watched the American movie, “The Hangover” Nice to feel American. The movie was hilarious. Awesome!

Afterwards, Time to go home. Home is now Linkou, Taiwan. Truly feel comfortable there. I took the high speed rail. This rail will take you from southern to northern Taiwan in a couple of hours. Studied the USMLE first aid book on the ride, even though exhausted. I have been trying to study most days. I should practice more OMM, but these days are pretty packed it seems.

Ready to be back in Linkou and around medicine.

Metabolism and Endocrinology Wk 4

Day 22

June 22, 2009

Last week. Metabolism and Endocrinology . These cases prove to be complicated. Paul and I are partners. When we walked in the preceptor Dr. Chen seemed to be very pleased that we had come. He sat us down and knew a lot about us. Apparently he had studied our Curriculum Vitae. I felt like we needed to live up to our paper selves. We talked a bit about why we were interested in Taiwanese medicine and told him about Osteopathy.

There were two interns and a resident present as well. After an intern took a lengthy history from a patient, Dr. Chen asked me to do a physical exam. I took a deep breath and proceeded. Even though there was a language barrier with the patient I managed with the help of translating interns to cover most bases. I knew there was probably a problem with her thyroid or adrenal gland so I made sure to palpate her thyroid for thyromegaly just like Touro has taught us. I also completed an abdominal exam and musculo-skeletal and reflex exam. It turned out that these were important in discerning the disease process. It turns out that the complete general physical exam I learned at Touro has paid off as I was able to be efficient and thorough, surprising myself! This was my first physical exam I have performed on a real patient!

We only saw 3 patients the whole morning so we were able to ask lots of questions and dig deep into the knowledge bank of his mind. He asked us ‘pimp’ questions. We responded and analyzed. Americans are creative with their answers. Some people call it ‘creativity’ and some people call it ‘bs’ Or maybe we just talk more than our Taiwanese student counterparts.
During lunch we had a Doctor lecture about new diabetes management methods directly to us. This week it’s like we are enrolled directly in a course. Learning a lot.

In the afternoon we went to pathology conference. I asked a question at the round table to a bunch of senior doctors. Nerve racking, but good for me. I asked if Hashimotos Thyroiditis is connected to carcinoma. This question actually began a discussion amongst the doctors.
At the end of the day Dr. Chen gave us an introduction to thyroid issues, pathology, and diagnosis. This laid a nice base. He also gave us a tour of the research laboratory that he uses. We looked at some cell lines.
Catching up on sleep at night.

Day 23

June 23, 2009

At the hospital ward we joined a team of about 5 others for treatment of diabetic patients. Many patients have a ‘diabetic foot’ that needed amputation or other major procedures due to lack of blood flow. The attending physician on the team was kind enough to brief us about each case in English before going on rounds. We were given the opportunity to ask many questions. I think the Endrocrinology and Metabolism department looks at this as opportunity to help teach their staff and students English and the importance of international medicine. This department seems very excited about us being there and dedicated to teach us as much as possible. Also, they may hope to give their hospital a good name in the Americas. Regardless of the reason, it is a great learning experience.

In the afternoon, we went to the thyroid ultrasound examination room. When we first arrived the thyroid sonography appeared as a foreign language. After Paul and I examined each other’s thyroid with ultrasound and used the instrument on actual patients I know what a nodule and cyst look like on a thyroid ultrasound, and I can even maneuver the equipment. We also saw the doctor do many fine needle aspirations. He was a believer in hands-on training, but it’s probably a good thing we didn’t aspirate each other’s thyroid with big needles.

The preceptor was soft spoken but very patient, thorough, and organized with the method in which he taught us. He had a plan, and by the end I feel fairly confident with thyroid ultrasound diagnosis.

We went to Taipei to see a movie in the evening. Bonding time with the crew! I was in a giggly mood this night.

Last Day- Day 24 6/24/2009

Day 24

June 24, 2009

At the ward again we joined the diabetic foot team. These foot infections and deteriorations thru gangrene, cellulitis, and osteomyletis are visually disturbing as well as difficult to treat. The patients stay in the hospital for a long time in comparison to the U.S. because the insurance covers hospital stay. The doctor’s say this presents a problem and that many patients could care for the wound at home when they choose to stay. Overcrowding of hospitals. Learned a lot once again.

Came home and checked my email. A family friend sent an email advising me to call my family ASAP. Called and reached my mother. She told me that my dad had died this morning while they were riding on their tandem bicycle.

Intense shock followed by sadness.

My Dad is an incredible man. He died doing what he loves with the one he loves, my mother. They have the best relationship of any couple I’ve ever known. They love bicycles. They have ridden from coast to coast across America together. He lived for the love of life. A genuine, kind, and happy man. I am lucky to have had him as my father. He had a thirst for knowledge and loved to laugh. I will try my best to live up to his example.

It is time to go home to be with my family to mourn and celebrate life.

I had to leave 2 days early. I am on the plane now. I will arrive to Indiana in about 22 hours or so.

Day 1: 6/1/09 Traveling and Arrival to Taiwan

Day 1
Monday, June 1, 2009:
Traveling quite a long way makes a man in his mid 20’s a bit tired, but luckily I had a good travel companion in Tammy. I also got to watch 2.3 movies on the plane. I usually do not make time to watch movies so this was a special treat. Watching “Gran Torino” set the stage for observing how cultures can collide and even mesh. As I arrived, not speaking the language was difficult. Luckily, I thrive feeling lost in translation. One of my roommates is a senior resident in Plastic Surgery named Yi. He’s a quiet fellow with a gentle demeanor. My other roommate is a kind and overly excited gentleman from Canada. He has a girlfriend who is also doing rotations with him here in the ER.

The Modern Toilet (Restaurant)

For more pics click here! click here!

Day 5, Final Day of Emergency Medicine - Sean

For the last day in the Emergency Medicine Department, Dr. Lee arranged for us to accompany him to see the Hyperbaric Oxygen Center (HBO Center). I never would have imagined the facility would have looked like it did. It pretty much looked like a smaller-scale submarine.

A mini-lecture was presented to us by two Canadian students on the indications, contraindications, and other important information you would want to know about HBO. While in the facility, we were able to see patients already in the compartment receiving treatment, so we had little patient interaction that day. Dr. Lee let us take more pictures around the facility, and afterwards let us off for the rest of the day.
Rotating in the Emergency Department has taught me about the similarities and differences between the health insurance programs in the U.S. versus in Taiwan. In both, the patient's disposition (or chief complaint) is always the key factor that treatment focuses on. The major difference is the amount of power the patients have over their physicians in Taiwan. I found out that even though a physician may decide a the patient is healthy and should be discharged, if the patient believes they still are sick they can refuse to leave. Even if they are not sick and they just "want to be sure", they have the choice of staying.

In my opinion, this causes lots of problems, such as the obvious unnecessary overcrowding in the hospital. However, the insurance policy allows this, leaving physicians with no choice but to comply. Interestingly enough, the physicians I have followed all seem to have their own ways in circumventing this issue. It ranges from simply reasoning with the patient to even ordering "radiotherapy". (An example of "radiotherapy" is ordering a chest x-ray for a patient, even though symptoms and signs do not provide enough indication for it. However, it serves as proof to the patient that nothing is wrong.) It becomes a type of "psychological therapy" that persuades the patient he or she is fine, when they truly are.

The fast paced world of Emergency medicine definitely was exciting and had lots of variety. I can understand reasons for it being a popular field. But I also understand the requirement of a solid, broad, and thorough knowledge of medicine to be successful in the specialty. To be an ER doc, you definitely have to be on the top of your game, at all times.

Days 1 through 4 of Emergency Medicine - Sean

Emergency medicine is interesting because you never know what you might come across. I knew this going into this week's rotation, and so I was hoping to gain experience dealing with many different types of cases. What follows is a summation of the main events of each day.

Day 1
This entire week, Mariko, Viet, Jack, and I were scheduled to be in the Emergency Department under the same preceptor, Dr. Lee. It turns out he had organized a curriculum for us to follow throughout the week working with different attending physicians in different areas of the Emergency Department. The first morning we received an orientation from one of the medical residents, Dr. Shih, who gave us a quick rundown of what we would do, where we should go, and who we would work with. We were dismissed after that until the afternoon where we reported to Dr. Lee (a different one) in the 2nd and 7th observation areas.
We were able to see several patient with various chief complaints that afternoon. GI pain, cellulitis in a patient's face, dizziness in a stroke patient, abdominal pain, and vomiting were some of them. At one point, Dr. Lee had to leave for a few moments, but left us to figure out the diagnosis of one of his patients based on the history and symptoms. Using our "resources", Mariko, Jack, Viet, and I deduced that the patient had acute bronchiolitis. We were somewhat correct, but since the patient was an adult, it was more likely that it was bronchiectasis.

Day 2
It was the four of us again, except this time we were told to come in early for a joint department conference between the Emergency Department and Internal Medicine Departments. They did a case presentation of the same patient, except specific to the time that patient spent in each department. The meeting was in Mandarin, so I was not able to get that much information from the meeting, unfortunately.
In the afternoon, we were in the 8th observation following Dr. Tsen. Again we saw several patients here, but this time they were new patients arriving in the ER. Some of the cases included: thrombocytopenia, abdominal pain and lack of bowel movement for 3 days, dizziness and headache for 1 week, and cellulitis of the foot. The patient that was experiencing dizziness and headache for a week was actually a young Vietnamese women. Since she was more comfortable conversing in Vietnamese, our one and only Viet Tran volunteered to obtain a history of the patient's present illness. Dr. Tsen would sometimes have an extra question or two to ask, and so Viet translated to her and back. Towards the end of the day, we were able to witness a trauma patient that was brought in by the EMTs. From what I could take fro mthe situation, an elderly lady was working in the street when a truck ran over the lower part of her right leg. The situation was very intense because I could see that the woman's skin was partially ripped from the leg, exposing her calf muscle and many of the blood vessels in the region. Amazingly, there was not as much bleeding as one would expect. The physicians feared that she may have internal bleeding in the abdomen from falling and were waiting for an echogram to screen her. An orthopedic surgeon and plastic surgeon were summoned for a consult to assess for any broken bones and to plan for reconstruction of the skin.

Day 3
There was another early morning meeting today. This meeting was specific to the Emergency Department and involved another case presentation. Breakfast was provided, so that was pretty nice :). After the meeting we were dismissed until the afternoon.
We returned to the ER to meet Dr. Chen and followed him to see his patients in the 1st and 12th observation areas. Some of the cases in these areas were more complex than the previous areas. They ranged from CHF to acute pancreatitis to malignant neoplasm of connective/soft tissues to skin infections to cerebral artery infarcts. Most of the patients in these areas were at the hospital for at least 1 or 2 days already, so they were receiving extended care. I learned that because of the health insurance in Taiwan, patients can stay in the ER for as long as 2 weeks and pay only 750 NT (~$25) no matter the type of care they receive. Pretty ridiculous, especially for the cases that did not seem as serious. Yet the patients have the right to stay. Suddenly it became clear why the ER was so crowded and why there are so many observation areas.

Day 4
Dr. Luo was the physician to follow in the 1st treatment area this morning. Overall, these patients had the more critical or life threatening conditions. Patients that came in with symptoms of shortness of breath, chest pains, or a known morbid disease were placed in this area of the ER. IV bags were hanging all over the room, and nurses were constantly administering meds and other means of care. Dr. Luo showed us several of the patients' radiological images as he tried to explain the diseases at hand. The residents in the ER also tried to help orient our confusion over different disease presentations and treatments, like for SLE. This area was definitely more fast-paced than the observation areas.
The 2nd treatment area was where patients that arrived in the ER with less critical conditions were sent. This, of course, meant that most of the traffic in the hospital came through here. We finally were able to meet the organizer of our curriculum for the week, Dr. Lee. Since the area was so busy, we were split amongst different physicians. Lucky for me, I was able to follow Dr. Lee first hand. I was totally amazed by the speed of how he dealt with patients, both effectively and compassionately. I could sense the tension he faced in getting through the constantly growing list of patients, but at the same time I experienced his genuineness when I listened in on his conversation with patients. My major impressions of Emergency Medicine comes from observing Dr. Lee. He told me it was a specialty full of tension and excitement, and that I should expect to be constantly challenged with a varying symptoms for every type of case.

Cardiology Procedures - Viet

Here's a video of some of the procedures I saw on my cardiology rotation. In the video you will see balloon angioplasty, stenting, catheterization, and many other cool things!

Cardiologyon Vimeo.

Bill-Day 2 Dermatology

The 3 of us went to the 7:30 am morning meeting in Taipei. The meeting was about 2 current cases that the doctors could not quite figure out. The residents reported the cases and then it was open for discussion among the attendings and senior doctors. It was cool to see, but it would have been better if it was in English.
After the meeting, we got back on the bus and headed back to Linkou. Today, Jonathan and I sat in on Dr.Chang’s clinic hours and Tammy went to the treatment ward. Jon and I got to see a range of derm cases. Most of the people came in with Tinea Pedis. Due to the heat and humidity, fungal infections are quite common and frequent. We also saw cases of herpes zoster and simplex, and a case of syphilis and had progressed to Secondary Syphilis.
In the afternoon, I went to the treatment ward. The residents there saw patient after patient and did procedures from cryotherpy for warts to skin biopsies.

Bill-Day 1 Dermatology

Went to Taipei to meet up with Dr.Yang. This week, luckily, Tammy and Jonathan also have derm. When we got to The Taipei branch of the hospital, Dr.Yang, the Chief Resident told us that we would be rotating with different doctor’s everyday and every shift as well.
In the morning, the 3 of us sat in on Dr.Gau’s clinic hours. He is the oldest dermatologist at the hospital and thus has a lot of knowledge and insight to the world of derm.
In the afternoon, we met up with Dr.Hu, from Hong Kong. She was very nice and enthusiastic about meeting us and teaching us for the afternoon. She took the time and showed us the cosmetic center and the different lasers they use: DYE laser, Ruby laser, CO2 laser. She even let us try the LPG machine, it is a machine that helps shape the body, a machine that helps you work out, without you actually having to work out. The 3 of us took turns using it; it was quite relaxing and fun.

Day 5, Final Day of Cardiology - Sean

I woke up this morning hoping that I could leave the Cardiology department with a good understanding and perspective on the specialty, and hopefully narrow down what I found appealing about it. I started things off in the Cardiology ICU unit following Dr. Wu as he checked on the patients on the floor. Just by looking at the patients through the windows into their separate rooms, I could already feel the severity of their conditions. So many tubes, wires, IV bags, and machinery surrounded these patients that it was obvious of their struggle to overcome their conditions. Most patients were unconscious, and on a few of them I could really see the fight to improve in their faces.

The beauty of the specialty, and of medicine in general, came to me when I found out one of the patients had originally arrived without a heart rate. She was resuscitated, but unfortunately she remained in a comatose state. Not much was else was available for her except for transferring her into the Ward for care until further improvement. Still, imagining that a person who has basically given their last breath with an arrested heart can be given life again is intense.

Something interesting about the Chinese culture was revealed to me by Dr. Wu when explaining the history of a patient that had acute MI and acute pulmonary edema. Apparently the patient had herpes zoster and in his immunocompromised state, the disease flared up presenting as rashes all around the midsection accordingly along specific dermatomes. Many Chinese refer to this sign as a "skin snake" and believe it is a sign of death. Dr. Wu assured me that this had no truth in it, but it was interesting to hear about such an extreme view of a disease.

After spending the morning in the ICU, I decided to head to the Ward one last time to go on rounds with my original preceptor Dr. Chou. I saw several patients, some who were the same patients from before. After brushing up on my pharmacology earlier in the week, more of the drugs the patients were taking and the physicians were listing made sense to me. (One thing is for sure, diuretics are important!) One of the patients had a coronary artery bypass graft, and I learned the importance of statins in secondary prevention in these cases. One of the attending physicians, Dr. Kuo, gave me his take on the evolution of statin use in the future. Apparently, statins will basically become like daily vitamins, in his opinion. It makes sense considering the current health trends in our lives. But that is an entirely different discussion.

I was able to go to the ECHO room one last time as well. In the ultrasound images, I had the opportunity to see a ruptured chordae tendinae that was flapping around whenever the mitral valve opened and closed. Dr. Wang, the attending there, surprised me a with a little quiz question:
Dr. Wang -- "What would this cause?"
Me -- "Incomplete valve closure...so...regurgitation."
He didn't say anything after that, so I assumed I was right.

All in all, the week spent in Cardiology has been eye-opening. The specialty ranges from an internal medicine setting to a surgical/procedural setting, so in a sense you get a little of both worlds. It definitely has many complexities to it, so there is a high demand for logic and physiologic understanding. Basically, Cardiology = Lots of Studying! I had a lot of fun in the Cardiology department, and I was able to solidify a good amount of what I learned in the CV portion of our CVRR curriculum. Hopefully, Emergency Medicine next week will do the same.

Bill-Day 5 OBGYN

Surgery day again. Dr. Chiou performed a total hysterectomy on a 67 year old patient. She had a uterine prolapsed, and due to her age, it was decided that she have a hysterectomy. The surgery lasted for about 3 hours. Several other Attendings came into the OR to observe the surgery.
In the afternoon, Dr. Chiou had outpatient clinic student teaching sessions. This was an opportunity for medical students to have more patient interaction. Dr. Chiou first explained the cases and reviewed patient histories, he then gave the student a few minutes to review the patients chart. Dr. Chiou sat behind the patient and let the student take control. Most of the patients were coming in for follow ups, find out their results. Dr. Chiou asked if I wanted to try, but I respectfully declined because I don’t think the patient would have wanted to hear their medical info in broken mandarin, and then translated again by Dr. Chiou. I wanted to save the patient their time and patience.

Day 4 of Cardiology - Sean

The morning began in the Catheterization Lab once again. A patient suffering from angina pectoris was found to have stenosis in the Left Anterior Descending Artery of the heart. I was able to watch the cardiologists place a drug eluting stent into the collapsed lesion. The technique used the inflation of an angioplasty balloon to secure the stent into place by hooking into the blood vessel's walls. I learned that even though a stent was put into place, there is still a 5% chance that re-stenosis may occur due to the body's physiological repair mechanisms. Although, drug eluting stents try to prevent this from occuring through the slow release of specific drugs.

In the afternoon, I was able to head to the Cardiology Ward again for rounds. I was looking forward to this because of how much I felt I learned from my first experience. My preceptor joined me as I followed along with attending physician Dr. Chang who lead a group of residents and interns to see patients. It was pretty much the same routine as it was on Monday. They presented the patient (in English for my sake) and discussed the reasons for their choices of treatment. The types of cases I saw were: CHF, mitral valve replacement with a mechanical valve, myocarditis, pericarditis, pericardial effusion, acute myocardial infarction, and chronic DVT.

My preceptor let me auscultate the patient with the mechanical replacement valve and I could clearly hear the obvious clicking sound it made. Interestingly enough, Dr. Chou said that the patient can often hear it when they sleep or when they are somewhere quiet. In some cases, the sound may even annoy the patient, but Dr. Chou said that it's something they just have to deal with.

An interesting case was a 21 year old patient with chronic chest pain, but the etiology of the pain was unknown. My preceptor told me that there is a list of common diseases they usually rule out first before exploring other causes for chest pain. The 6 possible common disease were:
1) acute myocardial infarction (assessed by EKG, CXR, cardiac enzymes)
2) aortic dissection
3) pulmonary embolism
4) tension pneumothorax
5) esophageal rupture
6) perforitic peptic ulcer.

I really enjoyed the ward again. It's just a lot more fun when you know what's going on. Unfortunately, there's only one more day of Cardiology left. I hope tomorrow is another good day because Cardiology has been great so far.

Joining in on the fun (Traditional Chinese Medicine)

Got mint?

sensing my harmonious pulse

Hmm... cold and no pulse (jk :D)

doctor to doctor consultation

(check out what the resident is wearing. TCM docs are cool!)










checking on a pt. undergoing acupuncture treatment

Bill-Day 4 OBGYN

Food poisoning, did not go on rotation

Day 3 of Cardiology - Sean

This morning in the Cath Lab, there was a patient that required Cardiac Resynchronization Therapy (CRT). According to Dr. Hsu, this was one of the more complex procedures in the Cardiology specialty. The patient currently had a pacemaker implanted but the rate of contraction it was programmed for before no longer was effective in orchestrating a synchronized contraction for efficient blood output. 0.08 seconds was the interval that the patient's current pacemaker was off. Thus, the CRT would serve as an upgrade replacement for the current pacemaker.

The heart beating with the patients old pacemaker, under flouroscopy.

During the procedure when the old pacemaker was removed, an external pacemaker was used while the new electrodes were put into place. The cardiologists decided it was better to leave the old electrodes in place since they were so embedded into the heart's tissue. It would do more harm than good to surgically remove them.

The new pacemaker required the placement of 3 new electrodes: one that leads into the right atrium, one that leads to the lateral wall of the left ventricle through the coronary sinus, and one that leads to the right ventricle near the interventricular septum. Each target was carefully selected by the cardiologists for maximal desired effect.













Here the 3 new electrodes are visible; the 2 old electrodes are present as well.














The new pacemaker by Medtronic; it was implanted in the left subclavicular region.

An interesting thing I learned was that whenever a pacemaker procedure is performed, the manufacturing company of the pacemaker sends representatives to bring the device to the operation and also assist during. I was told that Medtronic is the largest pacemaker company, so their representatives were in the flouroscopy room during the entire procedure. One good thing about this was that after the 5 hour procedure, the representatives treated us all out for lunch.

In the afternoon, I went to the echocardiography room where Dr. Wang explained all the tricks about reading the ultrasound images. The premise is similar to venous ultrasound, except you're looking at the heart. Doppler is again useful here to detect blood flow, so anytime you see both colors crossing at the valve regions, that is indication of regurgitation. The velocity of the blood flow could also indicate stenosis if it was higher than normal. I was surprised when Dr. Wang performed transesophageal echocariography because I did not realize that the probe would be so long. Lidocaine spray was used to numb the gag reflex somewhat, and it looked very uncomfortable for the patient, but the back view of the heart seemed very useful for locating any problems in that region.

I was sort of pimped once today, but I guessed right:
Dr. Wang -- "Is this a thrombus?"
Me -- "Where?"
Dr. Wang -- "Right here." (points at screen).
Me -- "Oh. That looks like its the left auricle."
Dr. Wang -- "Good. So what do you think?"
Me -- "Umm...it doesn't look like a thrombus to me, but I've never really seen a thrombus before."
Dr. Wang -- "Sometimes you need to have some guts and confidence in your answer."
Me -- "Hmm. No, that is NOT a thrombus."
Dr. Wang -- "Very nice!" (chuckles a bit)

Bill-Day 3 OBGYN

Morning article discussion on screening for ovarian cancer using CA 125 and transvaginalsonography(TVU). The presentation and discussion was in English. After that went on rounds again. Today there was an 84 year old grandmother, who complained of abdominal pain. Further evaluation led to finding a mass. CT scan showed there were masses in her lungs as well. She was quite up beat and optimistic. She told Dr. Chiou that she didn’t want to know what was wrong, just do what he could, if there is anything serious, just tell her children.

In the afternoon, Dr. Chiou allowed me to go down to the delivery room and see some deliveries. In 2 hours I saw 4 births, 2 vaginal and 2 c-section. The vaginal ones were very fast. The women were not sent to the delivery room until the moment they were going to give birth. Before that, they would be in the labor room…. “patiently waiting”. The c-sections took longer, I found it a bit brutal they way it was done. When the doctor cut through the uterus, and cut through the amniotic sac, the resident began to push on the belly, at an angle toward the feet, trying to help position the babies head. Once the head was at the opening, the doctor grabs the baby by the head and pulls her/him out. He quickly hands her off to the nurse and begins work on the placenta. After removing the placenta, the doc works on closing everything back up.