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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.
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