Up here on the 8th floor of the Pathology Department of Chang Gung Memorial Hospital rest many uneasy patients, both with curable conditions and terminal illnesses. In the United States, staying in the hospital with a terminal illness is highly discouraged, as insurance companies will only cover hospice care under these conditions.
The Taiwanese health care system not only enables patients to stay in the hospital for as long as they are symptomatic, but inadvertently encourages them to stay as well. Dr. Chang reports that insurance companies pay better for most medications if the patient is occupying a bed in hospital. It is also difficult to send patients home when pamphlets for very specific oncologic conditions don’t exist in Mandarin. How are these patients supposed to understand every nuance of their very specific conditions and medications if written information doesn’t exist? Dr. Chang sure doesn’t have time to tell them all of this information. If a patient keeps him for five minutes, that’s already pushing it!
Sunday, June 7, 2009
Paul - Oncology Day 1 and 2
aaaaaa We walked toward the pathology building anticipatorily, Viet, Tammy and I, through the 1st floor hallways of
We are the first formal American foreign exchange students at CGMH, and for this, we are truly fortunate. After our culture shock walk, we stopped. Up the elevator our trio rides, feeling butterflies inside, ready to be stripped of much of our pride. And we waited.
Viet and Tammy were quickly stolen away as I wait for my preceptor, whose Fellow approached me with some news.
“Dr. Chang is very busy this morning. He has OPD clinic, so he must see 60 patients from now until twelve-thirty, when we can all have lunch,” he informs me.
Waaaaaaaiiiiitttt a minute, back up!!! It’s currently nine o’clock and…..
”How many patients did you say?” I ask confusedly. His thick accent, though good English diction, lead me to believe that, by “60”, he meant “16” maybe?
“60 patients,” he repeated confidently. “For now, I can show you CT’s, X-rays, and profiles of Dr. Chang’s current patients so you are briefed on the cases you will see this afternoon.”
Three and a half minutes per patient????? Not to mention how hard it must be for a physician to stay focused for that long! This was my introduction to the Taiwanese healthcare system, and it made me realize how much easier it would be for us as future physicians in the
From there on, it was constant pimping. I was allowed access to the patient database and would have to read about each of the oncology patients Dr. Chang would see that afternoon. Here is one of the twelve patients under Dr. Chang’s continuous care:
Patient #1:
59 yr old female farm worker
Dx: Metastatic Melanoma with primary lesion on the feet between toes
Melanoma has little to do with sun exposure in
Most common among female farm workers
Suspected Etiology: Exposure to carcinogenic pesticides and chemicals
Dr. Chang takes me through his thought process for a metastatic melanoma case:
1) Surgery – not affective for Melanoma
2) Radiotherapy – usually not effective for melanoma
a. Some palliative properties, like surgery.
b. New research says it might be effective if intermittent big doses are given (400-600 centigrade 1x/wk) rather than regular small ones (150 centigrade 3x/week)
3) Chemotherapy (including immunotherapy and hormone therapy)
a. Immunotherapy could be an effective option:
High Dose IL-2 – Extremely effective but in 70% of patients, it causes severe capillary leaking à loss of orientation, severe nephropathy, severe memory loss (Dr. Chang has seen patients forget that their loved ones have been in the hospital to see them every day during their illness), and many skin lesions. This can only be used for people in perfect health otherwise.
GP100 – Effective because it is a cell-based (as opposed to 2ndary messenger-based) immunotherapy that activates NK cells to target the tumor cells. This is his choice for treatment.
4)
a. In many cases, doctors in
Dr. Chang also decided to do a test for occult blood and PET scan to rule out or confirm gastric metastasis.
Friday, June 5, 2009
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.
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.
Oncology Day Two, Three, and Four! - Viet
Day 2,3,and 4 was much like day 1. At 9:30am Dr. Hsu would go through the charts of all of his patients and check on their status. He would explain to me what disease the patient had, background about the disease, and treatment the patient was receiving. While he did this, he also asked me some tough questions...
Pimp Question #1: Why are tumors more malignant in young people?
My answer: They have more growth factors readily available for the tumor.
Correct answer: The immune system in young people is much stronger so the tumor has to be even stronger to evade the body's defense system.
Pimp Question #2: What are some causes of malignancy?
My answer: Chronic irritation (from persistent infections, etc.)
Answer he was looking for: Oncogene and p53 tumor suppressor gene.
Pimp Question #3: Why do you not want to give this patient who is suffering from oxygen hunger more morphine?
Me: ???
Answer: Morphine decreases breathing rate and in her situation, can decrease it to less than 8 breaths per minute (toxic).
After looking at all the patients' charts, I followed Dr. Hsu on rounds.
Patient 1: Recurrent Tumor
Patient has tumors in lung fields and bone metastatis. Patient presented with leg pain because of L5 destruction. Prognosis is poor. Treatment for this patient is pain management + Erbitux + C.T.
Patient 2: Bone Metastasis
Tumor started in the tonsil and metastasized to the pelvis. CXR shows pneumonia in lung fields. There is a PEG (percutaneous endoscopic gastrostomy) tube to provide nutrition. Again, morphine is prescribed for bone pain and the prognosis is very poor. This patient is put in hospice care.
Patient 3: Esophageal Cancer
Because of dysphagia, the patient is only 47kg now. The first thing we must do here is to recover the patient's body weight. If the patient isn't healthy, he won't be able to handle the cancer therapy. CT scan shows tumor obstruction in the middle to lower 1/3 of esophagus. A jejunum tube is required in this case. Bone scan is negative.
Patient 4: Nasopharyngeal Carcinoma
This patient is a 30yo female who was diagnosed with NPC (very treatable with 90% success rate) 2 years ago, but refused treatment. She opted for chinese herbal treatments instead of chemotherapy but ended up not doing anything about it. The tumor is now malignant and has spread systemically to bone and liver. She does not smoke or use betel nut. The NPC in this case is due to natural causes.
Patient 5: Oropharynx Tumor
This patient did not respond to chemo. CXR shows lung metastasis. Waiting for CT scan for better evaluation of the lung.
Patient 6: Nasopharyngeal Carcinoma
CT shows a large tumor with liver metastasis that is causing abdominal pain. The patient has a very high creatinine level, which suggests renal insufficiency. The x-ray shows effusion (hemoptysis). Treatment is chemotherapy and pain control.
Patient 7: Buccal Cancer
This patient has a recurrent tumor and it is huge - T4. There is perineural invasion. Patient also has infiltrates in lung fields -->baumannii - MDR (multi drug resistant) strain. There's only 1 antibiotic that isn't resistant.
Patient 8: NPC
This patient is dysphagic and required an NG tube. The patient received radiotherapy and chemo (cisplastin) this week and lost 10kg. Before more chemo is given, the patient has to gain more weight or else he won't be able to tolerate it.
Patient 9: Adenocarcinoma
The patient is a 50yo female . Initially, it seemed like the tumor was of axilliary origin. They later found out that it was breast cancer. This is good because if the primary cause is unknown, better chemo drugs are not covered by the insurance. The prognosis is good for this patient.
Patient 10: Unknown Primary Cause
There is bone metastasis to the right pelvis.
Patient 11: Hepatic Duct Cancer
There is no response to chemotherapy. This patient is in dire need of a new liver, but probably won't get one because of his cachexia (he is less than 50kgs). Most likely less than 3 months survival.
Patient 12: Left Tonsil Cancer
Chemotherapy in this patient is stopped because the patient could not tolerate it. Radiotherapy is continued.
--------
On Wednesday, at around 4:00pm I received a call from the chief resident asking if I wanted to see ascites tapping. I said yes and brought along Jack, Bill, and Sean. When we got to the wards, patient 6 was coding. There was blood everywhere. Nurses were running around frantically while two attendings were busy manipulating an endoscope through his nasal cavity. The chief resident was putting in an IV line through the femoral while a nurse was putting in a foley catheter. They also had to intubate him because the blood was obstructing his breathing and he was going into cardiac arrest. I glanced at the heart monitor and it looked like atrial fibrillation. It was exciting and reminiscent of a scene from ER. After about 15 minutes, the patient's condition was under control again and he was sent to the ICU. The attending explained to me that the patient just started to bleed all of a sudden and they didn't know where the blood was coming from. He thinks that the chemotherapy probably caused the hemorrhage.
After this, the chief resident showed us ascites tapping (peritoneocentesis). He emptied 5L out of the woman's abdomen!
------
Although I only got 3hours of experience each day (9:30am-12:30pm), I learned a lot from Dr. Hsu. The way he explains things makes even the most complex mechanisms easy to understand and retain. On day 4, I did a short presentation on telomerase target cancer drugs. Afterwards, Dr. Hsu and I talked about the future of cancer therapy and where he thinks it is going. He doesn't think there will be a cure for cancer because it is an ever evolving disease. But we don't have to find a cure--we can just keep the disease latent. The reason cancer is so harmful is because it metastasizes and invades normal tissues. If we can keep it contained, we can coexist with the disease and not have it affect our daily lives.
Pimp Question #1: Why are tumors more malignant in young people?
My answer: They have more growth factors readily available for the tumor.
Correct answer: The immune system in young people is much stronger so the tumor has to be even stronger to evade the body's defense system.
Pimp Question #2: What are some causes of malignancy?
My answer: Chronic irritation (from persistent infections, etc.)
Answer he was looking for: Oncogene and p53 tumor suppressor gene.
Pimp Question #3: Why do you not want to give this patient who is suffering from oxygen hunger more morphine?
Me: ???
Answer: Morphine decreases breathing rate and in her situation, can decrease it to less than 8 breaths per minute (toxic).
After looking at all the patients' charts, I followed Dr. Hsu on rounds.
Patient 1: Recurrent Tumor
Patient has tumors in lung fields and bone metastatis. Patient presented with leg pain because of L5 destruction. Prognosis is poor. Treatment for this patient is pain management + Erbitux + C.T.
Patient 2: Bone Metastasis
Tumor started in the tonsil and metastasized to the pelvis. CXR shows pneumonia in lung fields. There is a PEG (percutaneous endoscopic gastrostomy) tube to provide nutrition. Again, morphine is prescribed for bone pain and the prognosis is very poor. This patient is put in hospice care.
Patient 3: Esophageal Cancer
Because of dysphagia, the patient is only 47kg now. The first thing we must do here is to recover the patient's body weight. If the patient isn't healthy, he won't be able to handle the cancer therapy. CT scan shows tumor obstruction in the middle to lower 1/3 of esophagus. A jejunum tube is required in this case. Bone scan is negative.
Patient 4: Nasopharyngeal Carcinoma
This patient is a 30yo female who was diagnosed with NPC (very treatable with 90% success rate) 2 years ago, but refused treatment. She opted for chinese herbal treatments instead of chemotherapy but ended up not doing anything about it. The tumor is now malignant and has spread systemically to bone and liver. She does not smoke or use betel nut. The NPC in this case is due to natural causes.
Patient 5: Oropharynx Tumor
This patient did not respond to chemo. CXR shows lung metastasis. Waiting for CT scan for better evaluation of the lung.
Patient 6: Nasopharyngeal Carcinoma
CT shows a large tumor with liver metastasis that is causing abdominal pain. The patient has a very high creatinine level, which suggests renal insufficiency. The x-ray shows effusion (hemoptysis). Treatment is chemotherapy and pain control.
Patient 7: Buccal Cancer
This patient has a recurrent tumor and it is huge - T4. There is perineural invasion. Patient also has infiltrates in lung fields -->baumannii - MDR (multi drug resistant) strain. There's only 1 antibiotic that isn't resistant.
Patient 8: NPC
This patient is dysphagic and required an NG tube. The patient received radiotherapy and chemo (cisplastin) this week and lost 10kg. Before more chemo is given, the patient has to gain more weight or else he won't be able to tolerate it.
Patient 9: Adenocarcinoma
The patient is a 50yo female . Initially, it seemed like the tumor was of axilliary origin. They later found out that it was breast cancer. This is good because if the primary cause is unknown, better chemo drugs are not covered by the insurance. The prognosis is good for this patient.
Patient 10: Unknown Primary Cause
There is bone metastasis to the right pelvis.
Patient 11: Hepatic Duct Cancer
There is no response to chemotherapy. This patient is in dire need of a new liver, but probably won't get one because of his cachexia (he is less than 50kgs). Most likely less than 3 months survival.
Patient 12: Left Tonsil Cancer
Chemotherapy in this patient is stopped because the patient could not tolerate it. Radiotherapy is continued.
--------
On Wednesday, at around 4:00pm I received a call from the chief resident asking if I wanted to see ascites tapping. I said yes and brought along Jack, Bill, and Sean. When we got to the wards, patient 6 was coding. There was blood everywhere. Nurses were running around frantically while two attendings were busy manipulating an endoscope through his nasal cavity. The chief resident was putting in an IV line through the femoral while a nurse was putting in a foley catheter. They also had to intubate him because the blood was obstructing his breathing and he was going into cardiac arrest. I glanced at the heart monitor and it looked like atrial fibrillation. It was exciting and reminiscent of a scene from ER. After about 15 minutes, the patient's condition was under control again and he was sent to the ICU. The attending explained to me that the patient just started to bleed all of a sudden and they didn't know where the blood was coming from. He thinks that the chemotherapy probably caused the hemorrhage.
After this, the chief resident showed us ascites tapping (peritoneocentesis). He emptied 5L out of the woman's abdomen!
------
Although I only got 3hours of experience each day (9:30am-12:30pm), I learned a lot from Dr. Hsu. The way he explains things makes even the most complex mechanisms easy to understand and retain. On day 4, I did a short presentation on telomerase target cancer drugs. Afterwards, Dr. Hsu and I talked about the future of cancer therapy and where he thinks it is going. He doesn't think there will be a cure for cancer because it is an ever evolving disease. But we don't have to find a cure--we can just keep the disease latent. The reason cancer is so harmful is because it metastasizes and invades normal tissues. If we can keep it contained, we can coexist with the disease and not have it affect our daily lives.
Bill-Day 4 Craniomaxiollfacial Surgery
Dr. Yu had to go to Taipei for personal reasons, so he asked me to observe Dr.Gou. I saw another cleft palate surgery, he only had 1 surgery for the day. Dr. Gou is from Australia and was at Chung Gung as a fellow in training. Then I met Jonathan in the operating hall way,his preceptor Dr. Chang allowed me to follow them. Dr. Chang is a cosmetic surgeon. Following Dr. Chang I saw a surgery for varicose veins, nipple reduction, under eye surgery. Dr. Chang is a cosmetic surgeon, most of his surgeries are elective and thus not covered by insurance.
Cosmetic Surgery Day 3 & 4 - Jack
Day 3
Today, I was fortunate to observe the first stage to the two part surgery process needed to reconstruct an ear. This time, Dr. Chen had an assistance, non other than the talented fellow, Dr. Por. While Dr Chen worked on creating a pocket for the cartilage on the left side of what was the supposedly ear, Dr Por standing a foot next to him, surgically removed a part of the cartilage from the left rib cage. Even with two surgeons, this procedure will likely take almost the entire day.
The operating room across from where the ear reconstruction was occurring was a case of rhinoplasty with silicone implant. The patient was a 32 year old male patient who was unhappy with the appearance of his nose. He felt his nose bridge was too shallow, making his nose appear shorter, although I could not see anything wrong with his appearance. Perhaps seeing patients with cleft lips or having no ear have obscured my judgement that beauty is in the eye of the beholder.
The surgeon that performed the rhinoplasty was undoubtedly very experienced. He was able to complete the entire surgery in 20 minutes. Within this short period, he explained his technique of making a small incision near the septum, then separating the fascia from the cartilage below, and finally inserting the silicone bridge snugly in the space created. The pocket had to be large enough for the implant to fit but small enough to prevent the implant from migrating. Throughout the entire process the patient was semi-sedated and locally injected with anesthetic. To my surprise the patient, upon request, was able to open his eyes and look at his new nose in the mirror with a smile. In the cosmetic surgery world, it is no surprise that success is determined by the satisfaction of the patients.
Upon completion of the rhinoplasty, I decided to check on what Mariko and Bill were observing. As I look through the small window of OR 5, I see Mariko sitting to the side of Dr. Chen, and mesmerized by his art of creating an artifial ear. I suddenly remember that this will take the entire day, so I walk down the hallway, looking through the window of each OR. Several OR's were empty. Many meetings are held in Taipei so surgeries tend to be lighter on Thursday. Standind outside OR 9, I look through the obsured window covered by a piece of paper but could not see Bill who I saw earlier getting ready to observe a cleft lip. Thinking that he may have stepped out, I tap the door sensor with my foot and walk in to see the progress of the surgery. To my surprise, the gentleman in scrub assisting with suction and clamp was not a fellow, resident or intern, but our "not yet OMS-2" student doctor Bill Chou.
Bill needed extra large gown and gloves.
Today, I was fortunate to observe the first stage to the two part surgery process needed to reconstruct an ear. This time, Dr. Chen had an assistance, non other than the talented fellow, Dr. Por. While Dr Chen worked on creating a pocket for the cartilage on the left side of what was the supposedly ear, Dr Por standing a foot next to him, surgically removed a part of the cartilage from the left rib cage. Even with two surgeons, this procedure will likely take almost the entire day.The operating room across from where the ear reconstruction was occurring was a case of rhinoplasty with silicone implant. The patient was a 32 year old male patient who was unhappy with the appearance of his nose. He felt his nose bridge was too shallow, making his nose appear shorter, although I could not see anything wrong with his appearance. Perhaps seeing patients with cleft lips or having no ear have obscured my judgement that beauty is in the eye of the beholder.
The surgeon that performed the rhinoplasty was undoubtedly very experienced. He was able to complete the entire surgery in 20 minutes. Within this short period, he explained his technique of making a small incision near the septum, then separating the fascia from the cartilage below, and finally inserting the silicone bridge snugly in the space created. The pocket had to be large enough for the implant to fit but small enough to prevent the implant from migrating. Throughout the entire process the patient was semi-sedated and locally injected with anesthetic. To my surprise the patient, upon request, was able to open his eyes and look at his new nose in the mirror with a smile. In the cosmetic surgery world, it is no surprise that success is determined by the satisfaction of the patients.Upon completion of the rhinoplasty, I decided to check on what Mariko and Bill were observing. As I look through the small window of OR 5, I see Mariko sitting to the side of Dr. Chen, and mesmerized by his art of creating an artifial ear. I suddenly remember that this will take the entire day, so I walk down the hallway, looking through the window of each OR. Several OR's were empty. Many meetings are held in Taipei so surgeries tend to be lighter on Thursday. Standind outside OR 9, I look through the obsured window covered by a piece of paper but could not see Bill who I saw earlier getting ready to observe a cleft lip. Thinking that he may have stepped out, I tap the door sensor with my foot and walk in to see the progress of the surgery. To my surprise, the gentleman in scrub assisting with suction and clamp was not a fellow, resident or intern, but our "not yet OMS-2" student doctor Bill Chou.
Bill needed extra large gown and gloves.
At noon Mariko and I headed back to Linkou to have lunch with Dr. Lin before her flight back to the US.
After lunch at Ikari and saying goodbye to Dr. Lin, some of us headed back to our rooms to rest while others returned to their roations. Soon after arriving in our rooms, like a scene from Gray's, Viet received a call from his preceptor about a procedure about to take place. Through the thick accent and broken English, Viet was not able to repeat what was said, but none the less, any procedure was exciting and worth seeing to us newbies. We quickly put back on our white coats and headed to the 7th floor of the Pathology Building.
Exiting the elavator we were greeted by a chaotic scene of nurses running back and forth with what looked like syringes and vials in hand. We follow the wake left by the frantic nurses to a room just around the corner. A sea of white uniforms surround a patient in distress. We quickly realize it was a patient in cardiac arrest. Among the nurses was Viet's preceptor unusually calm. He came over and told us that the patient had gone into hypovolemic shock, and they were frantically trying to determine the source for the loss of blood. Within several minutes, they determined that the bleeding was from the Eustacian tube and were able to seal it by inflating a tube. The patient had nasal pharangeal cancer and was likely terminal. Throughout the whole ordeal, I couldn't help but notice the family outside the room in dispair. A man in his early 30s clenches his fist and holding back his tears paces back and forth along the corridor while outside the patients room an elderly lady sits deep in prayer. I could feel my heart sink as I empathized with the anguish of the family. The dichotomy of the situation was disconcerting. On one hand I was very fortunate to have witnessed such a medical procedure, but I also felt a sense of selfishness. Even as I know that people get sick and some die no matter what, it is still a challenge each day.
My heart began to ease when I heard that the patient's prognosis was stabilized. Thinking that this was the medical procedure, I was surprised when Viet's preceptor directed us to another room to observed what he had invited us to see. We walked pass the nurse's station and he grabs three bottles that had a small amount of yellow liquid at the bottom, iodine, and a syringe. While we walk towards the patients room he tells us that he needs to perform an "ascites tapping" on a patient. We arrive at the room and observe a frail female patient in her 60s who has been complaing of loss of appetite. I perform percussion over the abdomen and notice dullness all around except for the midline. The preceptor then went ahead and showed us what ascites (fluid in the abdominal space) looks like on an ultrasound. He then inserted a needle into the abdomen and attached one end of a tube to the needle while the other to an empty bottle with the yellow fluid. He tells us that the bottle is under negative pressure and it helps with sucking the fluid out, while the yellow fluid is an anticoagulant. Amazingly, the procedure removed approximately 3L of fluid. We also learned that contraindications for ascites tapping include presence of blood and low hemoglobin count.
Day 4
Today was my last day rotating through cosmetic surgery, and this time it was over at the Taipei branch. I took the shuttle bus over and met Dr. Hsiao in his office. His office was on the 12th floor, a combined floor of dermatology and cosmetic surgery. Exiting the elavator, I thought I was transported to a five star hotel. The department was decorated modern Japanese chic, wooden floors and sparkling glass pannels throughout the "lobby" or wait area. In the middle, there were individual rooms with sliding doors, and each room had it's own flat screen. Modern Asian art hung along the walls. Towards the back, lighted glass cabinets show off the many beauty products available to purchase. One could easily think they were in Bloomingdales, except for one difference. On this side of the world, women loath the effects of the sun. Many women desire the appearance of white porcelain but the softness of a baby's skin. Westerners may be surprised by the number of skin whitening products.
Dr. Hsiao saw 4 patients within half an hour of my arrival. The first patient was a little boy who had a laceration across his left eye canthus. Dr. Hsiao told his parents that he needed to have the wound debrided and sutured or else a deep scar would form, potentially deforming his eye. Although the procedure could have been covered under the national health care plan if they had gone to the emergency room, the little boys parents wanted Dr. H to do the surgery. They wanted assurance that the scar will be minimal and was willing to pay out of pocket NT$ 15, 000 (US$470).
The second was a female patient in her late 20s from China. She had a shoddy breast augmentation done that resulted on bursting of her silicone implants. The silicone was removed a month ago, but she presents to the office with pus from her surgical wounds. Dr. Hsiao advised her to have an X-ray completed by the following weak so he could further evaluate the next step for her.
After two more patients that came in for scar revision evaluations, we headed to the 8th floor for surgery, but not before changing into scrubs. On the operating table was a 32 year old male for keloid excision of the anterior chest wall. Dr. Hsiao began with an incision across the keloid, then cauderized the flibrotic tissue below before suturing the incision. He advised the patients to used wet saline gauze in order for the wound to heal nicely. The surgery took about 30 minutes to perform. Most of the work involved evenly removing the fibrotic tissue below and fine suturing.
Right after he completed the keloid excision, we went back to the 12th floor to debride and suture the boy with the left canthal laceration. The boy needed to be under generalized anesthesia and intubated because he was too young for local anesthesia.
Soon after, we headed back to the 8th floor again, but this time the procedure involved a removal of a lipoma posterior to the left popliteal fossa. The patient was a 56 year old female. Like many of his procedures, the patient was only required to be under local anesthesia.
Like a yoyo, we went back to the 12th floor for the last surgical case of the day. It involved a woman in her early 30’s for a scar revision. An excision was made circumferencial of the scar, fibrous tissue cauderized to even out the the skin, and hair-thin sutures used to close the wound.
Only after all his surgical cases, did we finally have a little break to have lunch, and the time was already 2:30pm.
But lunch was short, as he was running late and his next patient was already getting ready for lazer treatment for the face. The patient was a 30+ female. She was there for her "appearance maintenance". A device called the IPL was used to whiten the skin. A second lazer device with another acronym was used to shrink the pores. And lastly, another device was used to zap age spots. With each procedure, the patients face became redder, however, at the end of it all, she was given an ice face mask to sooth her face. The cost for the three procedures was US$400. Results were instant, and total recovery is 3-5 days.
After lunch at Ikari and saying goodbye to Dr. Lin, some of us headed back to our rooms to rest while others returned to their roations. Soon after arriving in our rooms, like a scene from Gray's, Viet received a call from his preceptor about a procedure about to take place. Through the thick accent and broken English, Viet was not able to repeat what was said, but none the less, any procedure was exciting and worth seeing to us newbies. We quickly put back on our white coats and headed to the 7th floor of the Pathology Building.
Exiting the elavator we were greeted by a chaotic scene of nurses running back and forth with what looked like syringes and vials in hand. We follow the wake left by the frantic nurses to a room just around the corner. A sea of white uniforms surround a patient in distress. We quickly realize it was a patient in cardiac arrest. Among the nurses was Viet's preceptor unusually calm. He came over and told us that the patient had gone into hypovolemic shock, and they were frantically trying to determine the source for the loss of blood. Within several minutes, they determined that the bleeding was from the Eustacian tube and were able to seal it by inflating a tube. The patient had nasal pharangeal cancer and was likely terminal. Throughout the whole ordeal, I couldn't help but notice the family outside the room in dispair. A man in his early 30s clenches his fist and holding back his tears paces back and forth along the corridor while outside the patients room an elderly lady sits deep in prayer. I could feel my heart sink as I empathized with the anguish of the family. The dichotomy of the situation was disconcerting. On one hand I was very fortunate to have witnessed such a medical procedure, but I also felt a sense of selfishness. Even as I know that people get sick and some die no matter what, it is still a challenge each day.
My heart began to ease when I heard that the patient's prognosis was stabilized. Thinking that this was the medical procedure, I was surprised when Viet's preceptor directed us to another room to observed what he had invited us to see. We walked pass the nurse's station and he grabs three bottles that had a small amount of yellow liquid at the bottom, iodine, and a syringe. While we walk towards the patients room he tells us that he needs to perform an "ascites tapping" on a patient. We arrive at the room and observe a frail female patient in her 60s who has been complaing of loss of appetite. I perform percussion over the abdomen and notice dullness all around except for the midline. The preceptor then went ahead and showed us what ascites (fluid in the abdominal space) looks like on an ultrasound. He then inserted a needle into the abdomen and attached one end of a tube to the needle while the other to an empty bottle with the yellow fluid. He tells us that the bottle is under negative pressure and it helps with sucking the fluid out, while the yellow fluid is an anticoagulant. Amazingly, the procedure removed approximately 3L of fluid. We also learned that contraindications for ascites tapping include presence of blood and low hemoglobin count.
Day 4
Today was my last day rotating through cosmetic surgery, and this time it was over at the Taipei branch. I took the shuttle bus over and met Dr. Hsiao in his office. His office was on the 12th floor, a combined floor of dermatology and cosmetic surgery. Exiting the elavator, I thought I was transported to a five star hotel. The department was decorated modern Japanese chic, wooden floors and sparkling glass pannels throughout the "lobby" or wait area. In the middle, there were individual rooms with sliding doors, and each room had it's own flat screen. Modern Asian art hung along the walls. Towards the back, lighted glass cabinets show off the many beauty products available to purchase. One could easily think they were in Bloomingdales, except for one difference. On this side of the world, women loath the effects of the sun. Many women desire the appearance of white porcelain but the softness of a baby's skin. Westerners may be surprised by the number of skin whitening products.
Dr. Hsiao saw 4 patients within half an hour of my arrival. The first patient was a little boy who had a laceration across his left eye canthus. Dr. Hsiao told his parents that he needed to have the wound debrided and sutured or else a deep scar would form, potentially deforming his eye. Although the procedure could have been covered under the national health care plan if they had gone to the emergency room, the little boys parents wanted Dr. H to do the surgery. They wanted assurance that the scar will be minimal and was willing to pay out of pocket NT$ 15, 000 (US$470).
The second was a female patient in her late 20s from China. She had a shoddy breast augmentation done that resulted on bursting of her silicone implants. The silicone was removed a month ago, but she presents to the office with pus from her surgical wounds. Dr. Hsiao advised her to have an X-ray completed by the following weak so he could further evaluate the next step for her.
After two more patients that came in for scar revision evaluations, we headed to the 8th floor for surgery, but not before changing into scrubs. On the operating table was a 32 year old male for keloid excision of the anterior chest wall. Dr. Hsiao began with an incision across the keloid, then cauderized the flibrotic tissue below before suturing the incision. He advised the patients to used wet saline gauze in order for the wound to heal nicely. The surgery took about 30 minutes to perform. Most of the work involved evenly removing the fibrotic tissue below and fine suturing.
Right after he completed the keloid excision, we went back to the 12th floor to debride and suture the boy with the left canthal laceration. The boy needed to be under generalized anesthesia and intubated because he was too young for local anesthesia.
Soon after, we headed back to the 8th floor again, but this time the procedure involved a removal of a lipoma posterior to the left popliteal fossa. The patient was a 56 year old female. Like many of his procedures, the patient was only required to be under local anesthesia.
Like a yoyo, we went back to the 12th floor for the last surgical case of the day. It involved a woman in her early 30’s for a scar revision. An excision was made circumferencial of the scar, fibrous tissue cauderized to even out the the skin, and hair-thin sutures used to close the wound.
Only after all his surgical cases, did we finally have a little break to have lunch, and the time was already 2:30pm.
But lunch was short, as he was running late and his next patient was already getting ready for lazer treatment for the face. The patient was a 30+ female. She was there for her "appearance maintenance". A device called the IPL was used to whiten the skin. A second lazer device with another acronym was used to shrink the pores. And lastly, another device was used to zap age spots. With each procedure, the patients face became redder, however, at the end of it all, she was given an ice face mask to sooth her face. The cost for the three procedures was US$400. Results were instant, and total recovery is 3-5 days.
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