Day 4, Final Day of General Surgery - Sean

My last day of early morning rounds in the surgery ward was today. Again the usual routine of patient status updates took place. Today the magic number was 22 again...22 patients. It still amazes me to watch Dr. Yu and his residents put their brains on rapid fire and efficiently work through their patient queue. Once everything was finished, Dr. Yu thought it would be a good idea for me to join one of his colleagues, the former dean of the hospital and fellow surgeon, Dr. Chen on his clinic duty.

I was shocked after only the first hour! More than half of the patients were women diagnosed with breast carcinomas. Most of these women underwent surgeries to have either partial or complete mastectomies. I was completely lost most of the time, unsure of what to do while Dr. Chen and an intern performed follow-up physical exams on these patients. Luckily for me, the intern (actually a 7th year medical student in Taiwan, equivalent to a 4th year medical student in the U.S.) spoke English extremely well and so she explained a lot of what was going on to me. Dr. Chen was also very capable of explaining things in English, and did so when he thought appropriate.

All I can say is I'm thankful I wasn't the intern, because she was getting pimped left and right. It was impressive how she knew most of the answers, but wow was Dr. Chen aggressive. "What is the mechanism of cyclophosphamide...5-fluoro-uracil...methotrexate? Name their side effects." I was somewhat familiar with these drugs having learned about a few of them, but I was in no shape to answer such specific questions at the drop of a hat. You could tell his intentions were to teach and that he wanted you to learn, so it was not as scary as it may sound.

After 3 three hours in the clinic, there were a couple things that stood out to me. It was a bit difficult to witness a patient and her family receive bad news about her lab results. The report showed she had a breast carcinoma that would require a complete mastectomy. Talk about breaking bad news. It's entirely different than the TBL mock session we had at Touro. You could feel the sadness and confusion in the room. I admire the courage of the physician that broke the news to the family. It must not have been easy. The other thing that I remember clearly is seeing the sense of relief of a women that had come in because she found a lump in her breast. It turns out that she already had a mastectomy of one of her breasts, and had also recently completed her regime of chemotherapy. Once Dr. Chen examined the lump and told her it was nothing to worry about, I could almost feel the tension and worry disappear from her face.

In the afternoon, I saw a mastectomy and one last partial hepatectomy for the week. This time, the hepatectomy was part of a joint surgical procedure because the patient also had rectal cancer. The first surgical team removed the rectal cancer, and then Dr. Yu's team came to perform the hepatectomy. Before I left that final surgery, Dr. Yu welcomed me to come join him in the OR anytime I am free in the later weeks. I'm sure that my schedule will be busy in the other departments, but if I ever do find time, I think I would like to check out more surgeries. It's just a fascinating world--the world of surgery.

Again, I can't believe that my first week is over already. General Surgery is awesome. Although I had to wake up early most of the week, it was well worth the experiences. The opportunity to see what it takes to be a surgeon was definitely eye-opening. It is clearer to me now more than ever that choosing a specialty should based on something I have a passion for. Dr. Yu's hectic schedule is almost maddening, but it was obvious that he enjoys what he does from the way he interacts with patients. I have learned much from him, and hope that my ventures into other specialties will be as enlightening as it was in General Surgery.

Day 3 of General Surgery - Sean

Waking up early was a little harder today, but not so much. I was looking forward to see how many patients there would be during rounds this morning. As usual I arrived a little early. Once my preceptor and one of his residents arrived we all sat at the computer station and they reviewed the status updates of the patients to be seen. Dr. Yu told me that it was important to do the workup correctly and accurately prior to surgeries in order to assess the possible risks of different surgeries.

Today I would count 22 patients. That was a lot more than yesterday. Although it took slightly longer, it still consisted of brief interactions. I noticed that more of the patients today also seemed to have non-surgically related chief complaints. It was then that Dr. Yu enlightened me about the freedom of Taiwan's National Health Insurance Policy. If, for example, a patient required surgery and went to Dr. Yu to perform that surgery, often times that patient would build trust with him because the surgery went well. Because the health insurance policy allows people to see whomever they wish, the patient is allowed to see Dr. Yu (a surgeon) for any problem he/she may have no matter what it is (i.e. fever, headache, stomach problems). This was interesting to me because that means even though Dr. Yu is a surgeon, he must be well grounded in other respective fields so that he may have the knowledge to treat these patients' other ailments. Dr. Yu had confirmed that it was a lot tougher in that sense, and also that it kept him a lot busier because he was challenged to focus on more than his main surgical patients.

Some of the interesting cases I saw today:

• A patient presented with Post-Transplant Lymphoproliferative Disorder (PTLD) following a liver transplant. This condition describes when B-cell lymphomas occur as a result of infection with the Epstein-Barr Virus while immunosuppressed. It is fairly rare occuring in 0.2% of patients within one year of transplant. The original plan had been to take the patient off of immunosuppressive drugs to allow the immune system to rebalance. Dr. Yu palpated the patients lymph nodes and stated that compared to 1 week ago, they decreased in size.
• Many patients that underwent surgery the days before had been examined for follow-up, including: latharoscopic cholecystitis patient (entry point stitches), herniorrhaphy patient (examined stitches for appropriate healing), another partial hepatectomy patient.

I was pimped during rounds as Dr. Yu asked me about the blood supply for the different segmets of the GI tract. However, since I told him I had not had the anatomy yet for that system, he sort of rescinded the pimpage and actually explained it to me. The foregut receives arterial supply from the celiac trunk, and includes the structures from the distal third of the esophagus to the duodenum. The midgut has arterial supply coming from the superior mesentery artery, and includes the structures from the duodenum to the proximal two-thirds of the colon. The hindgut has arterial supply from the inferior mesentery artery, and includes the distal one-third of the colong to the upper part of the anal canal.

Dr. Yu gave me an important lesson about surgeons following that experience. "A surgeon must always be aware of blood supply and anatomy." Mastering these is what distinguishes a remarkable surgeon. Afterwards it was off to the OR. There were quite a few surgeries going on at the same time, so I was able to float around among them. As many of the surgeons were Dr. Yu's colleagues and residents, I became a familiar face and they began explaining more about the prep

Here is a brief list of the surgeries that I was able to observe:

• Modified radical mastectomy --> involves complete surgical removal of the breast, while sparing the pectoralis muscle
  
• Radical proximal gastrectomy --> the first half of the stomach was removed to treat cancer findings; then the esophagus was anastomosed to the distal half of the stomach.
  
• Hepatectomy of segment 6 and partially of 4/5 --> repeat
  
• Latharoscopic cholecystitis --> repeat

Here is an image of liver anatomy to get a sense of the location of these segments:

Overall a good day with lots of variety in clinical rounds and the operating room. Unfortunately, tomorrow will be my last day. It has been wonderful so far, and I hope I get to see as much as I can to make it worthwhile.

Day 2 of General Surgery - Sean

So Dr. Yu felt it would be a good idea if I experienced the schedule of a general surgeon, so I was to report to the Surgery Ward at 6:30am to go on rounds with him. Since I was worried about being late I woke up at 5:30am, which wasn't too bad actually. Perhaps the jet lag was working in my favor. I was there before my preceptor, trying to prepare myself for my first opportunity to see what "going on rounds" was like.

Dr. Yu arrived and immediately went to access the patient database to gather status updates and information on his patients. One of his junior residents, Dr. Shing, also accompanied him. Although in Chinese, I was able to take notice of how detailed the patient records were. The organization system was impressive as Dr. Yu easily pulled up old labs, new labs, old scans, new scans, and vital updates. At times, it was a little bit difficult to keep up with his rapid clicking through all of the menus. Once he noted all the information he needed, it was off to see his patients.

Within the duration of the next 45 minutes, we ended up seeing 14 patients! I was surprised by how little time was spent interacting with each patient. That works out to just about 3 minutes a patient. Although some patients were there to be observed after their surgeries so not much was required for them, 3 minutes is still a short amount of time. It was also surprising to observe how much the patients liked Dr. Yu. I could tell that his patients trusted him a lot. He would often pat his patients on the shoulder, arm, or hand, and give them a smile. It was simply an example of amazing bedside manner.

Among the 14 patients, just a few of the interesting cases:

• The patient that received the Laparoscopic Cholecystectomy yesterday was there for follow up. Dr. Yu palpated the stitches to make sure it was everything would heal nicely. I found out that patients are usually kept for at least 2 days in the ward following that type of surgery.
• A patient who had a previous partial Hepatectomy was suffering from cirrhosis as well. This comorbidity had lead to ascites accumulation due to a leak. Another surgery would have to be performed to repair the source of the leak.
• The rest included a hernia patient to have surgery later today, another liver tumor patient who will require a hepatectomy, and a patient with gout, just to name a few.
  

After rounds, I was sent to a conference room where a lecture was given about the Tokyo Guidelines for diagnosing and treating acute cholangitis and cholecystitis. Did you know that a definite diagnosis for acute cholangitis is the presence of Charcot's Triad (fever and/or chills + jaundice + abdominal pain)? Me neither! The lecture was entirely in Mandarin, but luckily the powerpoint slides were in English, so I wasn't completely lost.

I then went to the OR afterwards. I was able to see 2 more hepatectomies today. Here's a picture of what the liver looks like inside an anesthetized patient after being skillfully exposed by the surgeon:

I was also able to observe a herniorrhaphy. It was pretty interesting to say the least that at the end of the surgery, the surgeon applied traction to the patient's testes. I later found out that because part of the repair requires suturing material to the inguinal ligament and other structures, it can sometimes cause the testes to be pulled upwards. Applying traction will prevent the slight chance of the testes ascending all the way into the abdominal cavity.

That was it for Day 2. I found out that the early start time was NOT just for today. I will be going in for rounds once again at 6:30am. I wonder if it will be harder to wake up? I guess we'll see...

Day 1 - Sean

OK! Let me introduce you into the wonderful world of General Surgery...

After getting breakfast with Team Taiwan (that's all of us, by the way), we all dispersed in groups to our respective departments. Being the only person who signed up for General Surgery, I decided to tag along with the group whose preceptors' offices were closer to mine. As they left to go meet their preceptors, I waited for my later scheduled meet time. At this point I was really anxious to see what I would be doing for the first day, and was wondering how soon it would be before I could see some surgeries. Well it turns out that my preceptor was already in the operating room when I got to his office and he had sent one of his foreign fellows to get me. Luckily, he grew up in Australia, so he spoke perfect English and was able to explain a lot of things about the hospital and the department to me.

After walking through what seemed like a maze to get to my preceptor, I found myself changing into surgery scrubs (cap, mask, and shoe covers included!). I even received my own locker to store my clothes and whatnot. I then learned that the changing room was above the OR and that I would have to take this weird spiral stairway to get below.

It has kind of a creepy but cool feel.

I finally got to meet my preceptor, Dr. Yu, and immediately was able to sit in on the removal of a mass in a patient's right breast. In the connecting OR next door was a cyst removal in the popliteal region of another patient's right leg. It was then that I learned it was normal for one attending surgeon to oversee around three surgeries at once. From what I could tell, Dr. Yu relies heavily on the skills of the residents training under him. In the surgeries he participated in, I could sense his seriousness in training his residents. This was definitely more obvious in the more complicated surgeries.

I spent the rest of the day in the different ORs and got to see two more major surgeries. The first was a partial hepatectomy. Seriously, this was an amazing procedure. Overall it took around 4.5 hours, but it was an awesome experience. The technique used to control the bleeding when resecting a chunk of liver was something that I never would have imagined. The surgeon uses a clamping forceps type tool to crush a small line of tissue. Although this loosens up the liver tissue for suctioning, it leaves behind the bile ducts and blood vessels that are intertwined in the mesh of the entire liver. If the diameter of these structures is less than 3mm, an electrical cautery rod is used to basically burn through them sealing them in the process. If, however, they are larger than 3mm, the structures require suturing.

The second major surgery was a Laparoscopic Cholecystectomy. I was told that this procedure is the "bread and butter" of being a General Surgeon here in Taiwan. I guess it's because a lot of skill and technique is required to maneuver the view scope, to suction, and to remove the gallbladder itself. Just a couple of noteworthy things about the surgery: 1) surgical staples were used to staple off the gallbladder from blood supply, etc. 2) a sterile glove is insterted into the abdominal cavity once the gallbladder has snipped off --> loose gallbladder is dropped into the glove, and the glove is pulled out through one of the 3 Laparaoscopic entry points.

That's pretty much it for my first day in the surgery ORs. At the end of the day, I just could not believe that I was able to see so many things. Stay tuned for Days 2 and 3 and some random pics of the trip so far.