For more pics click here! click here!
Sunday, June 28, 2009
Friday, June 19, 2009
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.
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.
Thursday, June 18, 2009
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.
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.
Wednesday, June 17, 2009
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.
Tuesday, June 16, 2009
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.
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.
Monday, June 15, 2009
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.
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.
Friday, June 12, 2009
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.
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.
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.
Thursday, June 11, 2009
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.
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
Wednesday, June 10, 2009
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)
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.
This is...
What we eat to get buff...
...like this...
...but then we eat this right after.
How we travel...
...to get to places like this...
...where Jack pops in like this.
Where amazing happens...
...like this AMAZING photo (taken by me).
The shortest and tallest members of our group.
The three stooges.
Superman joining forces with Ronald McDonald.
Tuesday, June 9, 2009
Day 2 of Cardiology - Sean
In the morning, I was scheduled to be in the "BVG room" with Dr. Chiang, one of the cardiology attendings. When I first got there, Dr. Chou was there to greet me and made sure everything was going well so far. He soon left me to observe Dr. Chiang, and later Dr. Wu (another attending), use Venous Ultrasound imaging to screen the lower extremeties of their patients for any instances of deep vein thrombi (DVT).
As he saw his patients, he took time to describe the basics of reading the images that appeared on the machine's screen. In simple terms, the ultrasound probe is best kept at around a 60 degree angle to the blood vessels for the best detection of blood velocity. The flow direction is also detected by the flow using Doppler effects. If the color showed RED, the flow direction was toward the probe; if it was BLUE, the flow was away from the probe. Using the velocity and direction, Dr. Chiang seemed to find his way around the lower vasculature towards the hidden clots that existed. I noticed while he moved the probe that there were areas where both colors were prominent in the lumen of the vessels. He told me that it was indicative of plaque buildup, which causes turbulence of the blood. Using these cues, he was able to make a rough guess of where a possible clot may reside. I was having trouble in the beginning just trying to orient myself between the vessels and its surroundings, so I was amazed at how he knew where exactly he was in the vasculature.
One technique of identifying the presence of DVT that I thought was interesting involved manually applying pressure to the distal portions of the veins to alter the blood flow. If there was a DVT, the flow would not be affected by the external occlusion. This technique, termed "augmentation", was used on all of the patients that came in that morning. The types of cases that came in included patients with varicose veins, intermittent claudication, pitting edema, and confirmed DVT in the femoral artery. In the patient with a confirmed DVT, it turned out that the major arterial vessels below one of her knees were not functional, but the venous vasculature was fine. The patient, fortunately, showed no signs of gangrene because of collateral vasculature and recanulization that was perfusing a sufficient supply of blood to the area. By lunch time I had seen enough patients to finally get the hang of what I was seeing on the imaging screen.
The afternoon schedule was again in the "BVG room" except this time the attending physician I followed was Dr. Hsu. The patients he examined next all had artificial blood vessels grafted into one of their upper extremities. Dr. Hsu performed follow-up exams on the condition of their grafts and also tried to figure out what was wrong if they experienced problems with the grafts. One of the patients, unfortunately, was experiencing more than 50% stenosis at the graft-venous junction. The placement of a graft involved creating a fistula between an artery and vein. In this case, the graft connected the basilica vein to the brachial artery. The stenosis was affecting the blood flow more than Dr. Hsu would have like, so he decided the patient should go in for an immediate angioplasty.
The angioplasty took place in the Catheterization Lab, where they used flouroscopy to guide the procedure. It was amazing watching them insert a guide wire through the radial artery, through the graft, all the way to the site of the stenosis. Then a catheter with a balloon at the end was inserted over the wire and inflated to expand the collapsed junction. After a few minutes of having the balloon in place, the catheter and wire were removed. I noticed a significant enlargement of the vessel after that. Just a side note, the patient was conscious the entire time! That was probably the most surprising thing because I had no idea that a procedure like that did not require patient sedation. The Cath Lab turned out to be an exciting part of Cardiology, and I am looking forward to spending more time there the rest of the week.
As he saw his patients, he took time to describe the basics of reading the images that appeared on the machine's screen. In simple terms, the ultrasound probe is best kept at around a 60 degree angle to the blood vessels for the best detection of blood velocity. The flow direction is also detected by the flow using Doppler effects. If the color showed RED, the flow direction was toward the probe; if it was BLUE, the flow was away from the probe. Using the velocity and direction, Dr. Chiang seemed to find his way around the lower vasculature towards the hidden clots that existed. I noticed while he moved the probe that there were areas where both colors were prominent in the lumen of the vessels. He told me that it was indicative of plaque buildup, which causes turbulence of the blood. Using these cues, he was able to make a rough guess of where a possible clot may reside. I was having trouble in the beginning just trying to orient myself between the vessels and its surroundings, so I was amazed at how he knew where exactly he was in the vasculature.
One technique of identifying the presence of DVT that I thought was interesting involved manually applying pressure to the distal portions of the veins to alter the blood flow. If there was a DVT, the flow would not be affected by the external occlusion. This technique, termed "augmentation", was used on all of the patients that came in that morning. The types of cases that came in included patients with varicose veins, intermittent claudication, pitting edema, and confirmed DVT in the femoral artery. In the patient with a confirmed DVT, it turned out that the major arterial vessels below one of her knees were not functional, but the venous vasculature was fine. The patient, fortunately, showed no signs of gangrene because of collateral vasculature and recanulization that was perfusing a sufficient supply of blood to the area. By lunch time I had seen enough patients to finally get the hang of what I was seeing on the imaging screen.
The afternoon schedule was again in the "BVG room" except this time the attending physician I followed was Dr. Hsu. The patients he examined next all had artificial blood vessels grafted into one of their upper extremities. Dr. Hsu performed follow-up exams on the condition of their grafts and also tried to figure out what was wrong if they experienced problems with the grafts. One of the patients, unfortunately, was experiencing more than 50% stenosis at the graft-venous junction. The placement of a graft involved creating a fistula between an artery and vein. In this case, the graft connected the basilica vein to the brachial artery. The stenosis was affecting the blood flow more than Dr. Hsu would have like, so he decided the patient should go in for an immediate angioplasty.
The angioplasty took place in the Catheterization Lab, where they used flouroscopy to guide the procedure. It was amazing watching them insert a guide wire through the radial artery, through the graft, all the way to the site of the stenosis. Then a catheter with a balloon at the end was inserted over the wire and inflated to expand the collapsed junction. After a few minutes of having the balloon in place, the catheter and wire were removed. I noticed a significant enlargement of the vessel after that. Just a side note, the patient was conscious the entire time! That was probably the most surprising thing because I had no idea that a procedure like that did not require patient sedation. The Cath Lab turned out to be an exciting part of Cardiology, and I am looking forward to spending more time there the rest of the week.
Bill-Day 2 OBGYN
Teratoma cut open
Teratoma
Dr.Chiou rocking a polyp removal surgerySurgery day. Dr.Chiou’s first surgery was a polyp removal in the uterus, the surgery was very fast. The big surgery of the day was the teratoma removal. The surgery went quite smoothly. When the teratoma was removed, it was immediately sent to the lab to be analyzed. At that point the surgery was at a standstill. Dr. Chiou needed to know whether or not if it was malignant. After half an hour the lab calls and says that the specimen is an immature teratoma, which means Dr. Chiou needed to remove the rest of the ovary and fallopian tube on the patient’s right side.
Here is an article the relates to the case: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2430743
Monday, June 8, 2009
Day 1 of Cardiology - Sean
I didn't know what to expect starting the week in Cardiology. I was very excited though because of having finished the cardiovascular unit this past semester. I felt like this was my opportunity to see how much of that knowledge I could apply in the clinical setting. Of course, that's assuming I retained enough of it.
Area C of the 6th floor housed one of the Cardiology Wards, and that was where I met my preceptor, Dr. Chou. To my surprise, he was expecting me and actually had a printed schedule for the rest of the week. Dr. Chou was the chief Cardiology resident and based on his experiences, he felt I would benefit most from spending time with different attending physicians throughout the week. He brought me to the different areas of the hospital to meet the attendings I would be learning from. Each day was separated into morning and afternoon, and I was to shadow one of those attendings during those times while they performed some specific component of their specialty. For this first day, I was in the ward with my preceptor for rounds.
The first patient we saw was in line to go in for an electrophysiology study tomorrow. His heart rate was irregularly irregular, and I was actually able to palpate this by his radial pulse. There was a problem, however, because the nurses and junior residents could not seem to get a Foley catheter inserted. If you do not know what a Foley catheter is, wikipedia explains it here pretty nicely. So my preceptor went ahead and gave it a try. Since the patient did not have a history of benign prostatic hyperplasia, he felt like it shouldn't be a problem. After 3 long attempts (one including a technique that used a syringe full of lubricating jelly--use your imagination), Dr. Chou decided to stop. He suspected that one of the patient's drugs might have been an anticholinergic agent that caused the urinary sphincter to contract, making the opening to the bladder very small. Observing this from the sidelines was awkward, but it was interesting to see the various techniques used.
Many of the other patients in the ward, as one would expect, were sufferring from heart disease. I was surprised by how familiar I was with the cases I encountered. Distended jugular veins indicating increased JVP, pitting edema, EKGs with ST elevation indicating MIs, syncope, hypertension, right heart failure, unstable & stable angina -- I recognized all of these signs and was able to keep up with the attending and his residents. Although my understanding was not as in depth as theirs, I feel like I impressed them with what I already knew. And when I did not know what something was, I made sure to ask for clarifications and explanations. I was having a lot of fun doing rounds here. The pharmacology was easy to pick up on as well. Drugs like loop diuretics (furosemide, bumetanide), ACE inhibitors, ARBs, and carvedilol were some of the many drugs that I heard thrown into the air during patient presentations by the residents and intern. I've studied these enough times to know what each one was responsible for treating.
Another big moment for me during rounds occured when I was allowed to ausculate a patient suffering from myocarditis and pericarditis. My preceptor told me to listen and tell him what I heard. What I heard was a crumpling sound between heart sounds, and he told me that it was a pericardial friction rub. Apparently it is not something you hear too often in patients. I was very excited after hearing my very first "real" heart sound in a "real" patient. It turns out that tests and imaging scans showed the patient had tamponade and so pericardiocentesis was recommended for the patient.
It was a great feeling to realize that I had knew more than I thought I did. But, the conditions of some of these patients were really serious and made me feel disappointed that I didn't know more so I could help them. The attendings and residents had it covered, but I felt like I wanted to know what to do or what the patients needed. I guess we'll see how much I can learn in the days ahead.
Area C of the 6th floor housed one of the Cardiology Wards, and that was where I met my preceptor, Dr. Chou. To my surprise, he was expecting me and actually had a printed schedule for the rest of the week. Dr. Chou was the chief Cardiology resident and based on his experiences, he felt I would benefit most from spending time with different attending physicians throughout the week. He brought me to the different areas of the hospital to meet the attendings I would be learning from. Each day was separated into morning and afternoon, and I was to shadow one of those attendings during those times while they performed some specific component of their specialty. For this first day, I was in the ward with my preceptor for rounds.
The first patient we saw was in line to go in for an electrophysiology study tomorrow. His heart rate was irregularly irregular, and I was actually able to palpate this by his radial pulse. There was a problem, however, because the nurses and junior residents could not seem to get a Foley catheter inserted. If you do not know what a Foley catheter is, wikipedia explains it here pretty nicely. So my preceptor went ahead and gave it a try. Since the patient did not have a history of benign prostatic hyperplasia, he felt like it shouldn't be a problem. After 3 long attempts (one including a technique that used a syringe full of lubricating jelly--use your imagination), Dr. Chou decided to stop. He suspected that one of the patient's drugs might have been an anticholinergic agent that caused the urinary sphincter to contract, making the opening to the bladder very small. Observing this from the sidelines was awkward, but it was interesting to see the various techniques used.
Many of the other patients in the ward, as one would expect, were sufferring from heart disease. I was surprised by how familiar I was with the cases I encountered. Distended jugular veins indicating increased JVP, pitting edema, EKGs with ST elevation indicating MIs, syncope, hypertension, right heart failure, unstable & stable angina -- I recognized all of these signs and was able to keep up with the attending and his residents. Although my understanding was not as in depth as theirs, I feel like I impressed them with what I already knew. And when I did not know what something was, I made sure to ask for clarifications and explanations. I was having a lot of fun doing rounds here. The pharmacology was easy to pick up on as well. Drugs like loop diuretics (furosemide, bumetanide), ACE inhibitors, ARBs, and carvedilol were some of the many drugs that I heard thrown into the air during patient presentations by the residents and intern. I've studied these enough times to know what each one was responsible for treating.
Another big moment for me during rounds occured when I was allowed to ausculate a patient suffering from myocarditis and pericarditis. My preceptor told me to listen and tell him what I heard. What I heard was a crumpling sound between heart sounds, and he told me that it was a pericardial friction rub. Apparently it is not something you hear too often in patients. I was very excited after hearing my very first "real" heart sound in a "real" patient. It turns out that tests and imaging scans showed the patient had tamponade and so pericardiocentesis was recommended for the patient.
It was a great feeling to realize that I had knew more than I thought I did. But, the conditions of some of these patients were really serious and made me feel disappointed that I didn't know more so I could help them. The attendings and residents had it covered, but I felt like I wanted to know what to do or what the patients needed. I guess we'll see how much I can learn in the days ahead.
Bill-Day 1 OBGYN
Dr.Chiou; is a specialist in gynecologic oncology. Went on rounds with him and an intern and visited with 5 patients. Most did not want to go home yet, even though Dr. Chiou said they could be discharged today. In Taiwan, with its national health care, patients don’t have to pay for hospital stays, so they tend to want to stay longer and make sure their post surgery status is good. Dr. Chiou believes it’s good for patients but it also prevents new patients from getting a bed in the hospital. Chung Gung Linkou branch has 5,000 beds and they are all taken. The ER is overflowing with patients waiting for a bed, they even have beds in the hallways.
An ICU patient was referred to Dr.Chiou; she is 20yo and has been diagnosed with ovarian teratoma. She presented with irritability, restlessness and when she checked into the hospital was first said to have encephalopathy, but a smart doc suggested a full body scan and thus found a mass in her left ovary. She is scheduled to have surgery tomorrow. Dr. Chiou says that the teratoma caused an auto-immune disease that caused antibodies to attack her brain. He believes removing the teratoma will hopefully relieve and cure her encephalopathy.
The rest of the day was spent in the clinic. Dr.Chiou saw 53 patients in 4 hours. They have a fast and efficient way of taking histories. With their smart cards, patients medical history is a click away. Dr. Chiou performs follow-ups and routine pap smears, one right after the other.
An ICU patient was referred to Dr.Chiou; she is 20yo and has been diagnosed with ovarian teratoma. She presented with irritability, restlessness and when she checked into the hospital was first said to have encephalopathy, but a smart doc suggested a full body scan and thus found a mass in her left ovary. She is scheduled to have surgery tomorrow. Dr. Chiou says that the teratoma caused an auto-immune disease that caused antibodies to attack her brain. He believes removing the teratoma will hopefully relieve and cure her encephalopathy.
The rest of the day was spent in the clinic. Dr.Chiou saw 53 patients in 4 hours. They have a fast and efficient way of taking histories. With their smart cards, patients medical history is a click away. Dr. Chiou performs follow-ups and routine pap smears, one right after the other.
Sunday, June 7, 2009
Paul - Oncology Day 4
aaaaaaaMy last day in oncology was, at the very least, a huge culture shock. Dr. Chang and I scurried to his last patient of the day, a 23 year-old woman with a football sized abdominal mass and multiple liver metastases. He performs the “crease sign” test. He asks the patient to relax her palm in his hand as he passively extends her phalanges in order to observe her palmer creases for color contrast against the surrounding skin. Little contrast is noted, which signifies that the dose of EPO (erythropoietin) has probably failed to mitigate her anemic condition. He will confirm this with the blood labs later.
For now, he asks how the patient feels. She is speechless for a moment, but then begins to describe a dream in which her tumor resembled sharks swimming through her bloodstream, implanting their vicious snouts in various vulnerable visceral organs. With that, it’s time to face what he defines as the toughest part of his job: Delivering Bad News. We begin our 200-foot journey to a private room where his 23-year old patient’s family awaits his arrival. In
Dr. Chang sometimes feels powerless with Taiwanese patients and families for many reasons. In general, Taiwanese patients come to physicians much later than American patients do. This is well demonstrated in many epidemiological studies, one of which illuminates the stage of cancer in which oncological patients first enter the exam room. For Americans, it’s around Stage 1. Taiwanese patients, however, endure visible and tactile symptoms until Stage 3 or 4 before finally seeing a physician. Cultural differences such as the encouragement of pain tolerance and anti-pharmaceutical ideals might be two of several causes of this phenomenon.
I observed even more frustration in Dr. Chang’s expression when he described the convoluted process of delivering bad news. Taiwanese believe even less in exhibiting emotion than do Americans, and families are often outraged if they are not informed of their ill relative’s status before the patients themselves! This forces him to offer health status information to close family members first, who are universally unreliable in forwarding his vital news. It often takes several days to reach the patient, when they must begin the stages of grief and further delay their ability to make sound decisions based on Dr. Chang’s expertise. For this reason, the 8th floor’s most welcomed visitors are Psychiatrists (yay! That’s me in the future!!!! Hold up, oh no!! What am I getting myself into??).
With all of this swarming through my head, Dr. Chang and I entered the 80 square-foot room into which 12 family members were stuffed. On the room computer, he pulled up a CT image and MRI images of their 23-yr-old daughter’s abdomen and liver.
Upon explanation and informing them of her terminal status, the room is numb and a biting silence empties the room of hope. No tears are flowing, but even without understanding the entire explanation in Mandarin, I can’t help but absorb the unexpressed anguish. My cheeks and eyebrows begin to throb and I quickly disguise my face with my H1N1 mask. Dr. Chang breaks the cold silence to rationalize his inability to administer more EPO. EPO, although good for stimulating the production of RBC’s in anemic conditions, is dangerous in cancer patients. As a cousin of VEGF (Vascular-endothelial-growth-factor), EPO has the potential to feed the tumor even more, rushing the patient to an even earlier “time of passage.” The silence was short-lived this time, and the patient’s father burst into emotion. Following his tears was the rest of the family’s, as if they had finally received the permission they needed from him to cry.
I rode the elevator down from the 8th floor both reluctantly and thankfully. Dr. Chang has re-inspired me to be an extremely competent doctor and passionate educator. I am so thankful for this first week and have left it in a state of awe.
Subscribe to:
Posts (Atom)