7/01/2011- Cardiology - Jessica

The last day of our summer internship was spend in a operation room for me! Although we heard from Dr. Chen that there will be a PAD surgery this morning, it was canceled when we inquired about it. Since our morning was originally scheduled for that, we end up having some time on our own. Like mentioned before, due to the rotations I choose, I did not have a chance to see any live operation throughout this internship. With the unexpected free time, we asked Dr. Ding (the neurosurgeon from Nicole's rotation) if we can join him in the operation room and he graciously allowed. It was an eye-opening experience for me. I scrubbed myself in for the first time, changed into scrubs for the first time, and stepped into a real operation room for the first time! I was worried in the beginning since I did not know anything about the surgery procedure and the fact that we have not covered neurology in class did not help either. However, I was able to pass without any major disturbance to the surgery and even managed to learn many things through the experience. Although we can only observe, I learned many things from Dr. Ding. Not only did I get to see a surgery right in front of me, I was able to see how a slight negligence from another doctor (the patient's back pain was probably due to some loose screws from previous spondylolisthesis treatment) can have enormous effect on the patient's life. Also, I was able to observe how different departments, from surgeons, anesthesiologists, nurses, and even biomedical equipment companies work together in one operation.

As the day draw to a close, we all commented on how we could not believe that four weeks can fly by so fast. This trip was truly an eye-opening experience for all of us. We have learned in this four weeks so much that it is impossible to list all of them here. It not only taught us many clinical knowledge that can only be learned during actual practice and not from the textbooks, it also taught us what it means to be a physician: the responsibility and all the hard work behind the title, and of course, the sense of pride and fulfillment that can only come when you know that what you do each day helps improve and sometimes even save another human being's life and does really make a difference in this world. I will never forget the past four weeks I spend in Taipei Hospital and all the wonderful doctors, nurses, and staffs who mentored us, helped us, and without whom we will genuinely be lost in our exploration. I would also like to say a special thank you to the TIHTC staff (Annie, Yuyu, Jessica, and Angie) and Superintendent Lin for all the hospitality and kindness they have shown us and for making this collaboration possible. I sincerely hope that this collaboration will continue to grow and future classes can also have the chance to experience all the wonders and treasures we found this summer.

6/28/2011, 6/29/2011- Cardiology - Jessica

On the second day of cardiology, we followed Dr. Chen (陳桂峰醫師) in the ultrasound room. Dr. Chen is very knowledgeable in his specialty and taught Nicole and I many diagnostic techniques on the ultrasound as well as clinical features of cardiology. One interesting observation we noticed was that in many valvular diseases, although surgery was indicated and highly recommended by the doctor, the patients still remain highly reluctant to operation. Dr. Chen explained that it is a common dilemma faced by cardiologists in Taiwan. In traditional Taiwanese view, surgery is already a very invasive procedure, regardless the real clinical invasiveness of the procedure, let alone cardiac surgery, where the surgery prognosis was often poor in past decades. Although the technology has gotten a lot better at cardiac surgery and the success rate has been very high, for many Taiwanese people, the stigma still present and the parents often remain reluctant to surgery unless patient life is in immediate danger. This is in contract to the amount of compliance Dr. Chen gets in his outpatient clinic. When we observed him in the outpatient clinic on Wednesday, I noticed that his patients seem to have great compliance to both his drug regiment, life style change, and even keeping a detailed blood pressure log. When I asked him about that, he answered that although many Taiwanese people are reluctant when it come to surgery, they are very welling to comply when it comes to drug, especially many cardiac drugs have immediate effects that makes convincing the patients a lot easier than other specialties. In addition, the fact that Dr. Chen has a good reputation and many year of experience in the field makes the patients respect him and will heed his advise a lot better than other doctors.

In the afternoon, we ran into a pacemaker placement in the catheter room. It was very interesting for me because unlike the other GHP members, it was the first operation that I was able to see during this trip. During the procedure, we talked with Dr. Chen again about cardiology and many aspects of being a physician. He said something that meant a lot to me: being a physician means constant learning and self-education; one must always consider the interaction between drugs and maintain the delicate balance between therapeutic effects of the drug and its adverse effect to the patient. Furthermore, adverse effects from drugs or treatment methods are responsibility of the doctor, not the patient. If a patient show signs of adverse effect from the drug, the doctor must be able to catch it whether the patient realized it or not and change the treatment plan accordingly. He also said that if any of his patient in good compliance with his treatment plan ever developed a MI, than he must have done something wrong and have failed his job as a cardiologist. It touched me to see that even after so many years in the field, Dr. Chen still shows such passion and dedication to his work and to his patients. Dr. Chen is truly a great role model for all the physicians to come.

6/27/2011- Cardiology - Jessica

I can't believe we are in our final rotation already! It's the first day of our 4th week of rotation and we only have less than a week left in Taiwan! We start the day with Dr. Feng (馮文楷醫師) in the ultrasound room. Like Dr. Lin, the thoracic surgeon we met last week, we met with Dr. Feng before in the public health screen two weeks ago. Coincidentally, both Nicole and I were in the same station with him too. Since we are not familiar with ultrasound, we were a little disorientated in the beginning by the images. But after Dr. Feng's explanation, we quickly managed to be able to identify the key anatomy structures. This morning we saw many valvular and other cardiac diseases that we saw only on the textbooks before. For example, we saw an example of aortic stenosis and a patient with ventricular septal defect (of which we were able to hear the murmur very clearly as predicted by the textbook). We also saw a patient with suspected previous MI that caused hypokinesis of the anterior septal wall. One interesting thing we observed was the interaction between different departments, especially thoracic and the cardiology department, since many respiratory failure symptoms are either cardiogenic itself already or can be induced by heart failure.

The highlight of the day was the afternoon case presentation of colon cancer. The presentation was originally scheduled last week, but due to schedule conflict, was postponed to today. We have prepared ourselves all week long and the anticipation has made me more nervous as the time of the presentation approaches. The fact that I am responsible for the pathology section and Dr. Hsieh from the Pathology department was the only attending physician that day too did not help at all with my anxiety! But luckily the presentation went well for everybody and I didn't make any gigantic mistakes that I somehow have convinced myself would happen by all the anxiety and anticipation accumulated throughout the week. Despite the fact that it was nerve-wracking for me, the presentation was actually a very good learning experience for me, since it gave us the chance to see how different subdisciplines work together in cases like this as well as giving us the chance to practice our presentation skills that will be extremely valuable in the future.

Cardiology Week

Jessica and I started out Cardiology week in the Echo lab. The topic about medical wasting came up when a 70 yo female with bilateral renal stone, h/o MI and treated with PTCA 7 years ago with no active symptoms came in for follow up.I got to hear VSD murmur, which was very awesome because I only heard it from audio file that we used to study for doctoring. Dr. Feng told us that good communication between doctor and patient, the patient's family, and with other doctors/nurses are important. By working closely together, it's more beneficial for the patient and not wasting time.
On day 2, I learned about the 4 degrees of valve regurgitation: 1. mild mitral regurgitation <20% 2. moderate mitral regurgitatioin 20-40% 3. moderate to severe mitral regurgitation 40-60% 4. severe mitral regurgitation >60%.
Dr. Chen - chief of Cardiology, told me that the ability to tell the grading of valve defect is experience-dependent. Therefore, ECHO is done by cardiologist and not by a technician. I learned about the mosaic current (red/blue mix together. When there is a mosaic pattern, it indicates very high velocity of blood flow --> regurgitation. I kept seeing the mosaic current, but sometimes it turned out to be normal. That just means that I have a long way to go in my training.
I also learned that mitral valve prolapse cases are very common and usually not a serious issue.
Angina review: substernal, 2-3 minutes, worsens after exercise/work, not sharp pain, tightened chest pain.
Also looked up indications for AS valve replacement: the most important = symptomatic AS because there's a high risk for sudden death and survival rate is low after symptoms occur.
Coumarin is given to A. fib patients to prevent emboli but no anticoagulant is usu. given to taiwanese patients
There was an 87 yo patient aho had pneumonia, didn't want surgery for valvular replacement but still is doing well despite mitral valve stenosis, mural thrombus attached to IAS, mitral regurg, pulm HTN, RHD, severe MS/MVA, and on Manitor anticoagulation. Sometimes, all the indications point to surgery, but in this case, her choice of not having a surgery has worked out fine. Is it luck or are patients better at knowing what's best for them?
Day 3: in OPC
CAD - broad spectrum, sometimes there is no symptom; control contribution factors (cholesterol, blood sugar, blood pressure) is important; choices of drugs to control these factors are also important
A patient's daughter came in to get medication and for consultation for her parent. I don't know if a consent form or identification is required in the U.S for this case
I saw an RBBB ECG. This makes me appreciate Dr. Lopes' 12-lead ECG lecture.
The govt. insurance wants to stop paying for medication once patient reaches target goal for his/her cholesterol and LDL levels. But patient should still maintain medication to help stabilize lipid levels. Dilemma!
Pacemaker syndrome - AV dyssynchronization
I don't know if this was mentioned in class or I was dosing off and missed this detail, but a small amplitude in R wave means not too many viable myocytes. Sometimes in COPD patient, too much air between electrodes and heart can also give low amplitude R waves.
I saw an 103 yo female patient with infected ulceration wound + gangrene changes on 2nd, 3rd and 5th toes of Rt foot. She has peripheral arterial occlusion and calcification of valves. 103 yo!
We ran into some issues with patient's compliance. there were patients who were very compliant, taking medications on schedule and keeping at-home blood pressure chart, while there are patients who were not compliant at all. Even with patient education and family support, these patients still do not recognize the severity of their disease or the importance of controlling contributing factors. What else can a doctor do for patients who are not very cooperative?
On friday, i had some time to shadow Dr. Ting again. He removed the screws put in for a patient with spondylolithesis. The patient complained of back pain caused by the rubbing of the metal plate so removal of the screws might alleviate the pain. I got to take out a screw myself and it was hard to remove. Required a lot of strength!

Cardiology Rotation Day 5 The finale 24-June-2011

Bor-Han and I had another day in the ultrasound room to see move echocardiograms. In the morning we followed Dr. Huang Chieh-Yuan (Dr. 黃建元). Of all the cases in the morning the most interesting was that of a patient that is a heart transplant candidate. From the echo that Dr. Huang performed it was estimated that his ejection faction was to be around 20% from multiple views. The patient also had a mitral valve anulus dilation, a tricuspid valve lesion, and a part of the left ventricle that was not contracting much at all. As the patient is also suffering from Diabetes Mellitus and is on hemodialysis, Dr. Huang suspects that the heart condition could be due to ischemic heart disease with multi-vessel involvement. He also commented that it could also be dilated cardiomyopathy, but every other cause had to excluded before that conclusion. In the afternoon we followed Dr. Fung. The highlight was a patient suffering from peripheral arterial occlusive disease (PAOD) and ischemic ulcers. Her Ankle Brachial Pressure index (ABI) was in the 0.2 - 0.3 range much under 0.5 which is a sign of severe arterial disease. After looking through her medications Dr. Fung also commented that is was not a good choice to use beta-blockers to control her hypertension as it might result in vessel spasm further worsening her PAOD. All in all it was a good week in cardiology and I learned quite a bit from the different experiences with all the preceptors.

Cardiology Rotation Day 3-5 (June 22-24, 2011)

June 22, 2011

The third day of our cardiology rotation started with observing pacemaker insertion in the catheterization room. The patient we visited yesterday has sick sinus syndrome, and hopefully the insertion of pacemaker can fix the problem. Dr. Tu was in charge of performing the procedure and Dr. Feng stayed in the monitor room as the supervisor of this operation. Since the X-ray would be frequently used throughout the whole process, Dr. Tu and his assistants needed to wear the heavy lead protection armor all the time. They first worked on the left subclavian area of the patient so that the leads can go from left subclavian artery via ascending aorta to the right chambers of the heart. Having the leads into the heart didn’t seem to be difficult, but inserting the leads into appropriate positions in the heart and ensuring the stable insertion are much more troublesome. Dr. Tu asked Dr. Feng several times to make sure that the leads are at right spots. And every time he inserted the leads into the tissue, he needed to pull the leads back lightly several times to make sure they are stably inserted. It took Dr. Tu more than one hour to insert the leads into the apex and sinus node properly. Once the leads were stably inserted, the expert from the pacemaker company used his programmer to find out the appropriate range of beating speed and adjusted the pacemaker according to that. The pacemaker was then connected with the leads and placed under the skin before suturing. The whole operation took about three hours.

In the afternoon, we met Dr. Po-Han Chou in ultrasonic room and observed him performing echocardiography on patients. Besides estimating the ejection fraction (EF) by measuring the change in width of left ventricle (LV), Dr. Chou showed us another more accurate way to estimate EF. The 2D image showing the entire left ventricle was first taken, and the EF was estimated using the change in LV area and LV length. This method is more accurate than previous one because the one measuring just width is under the assumption that LV is a sphere. Dr. Chou also mentioned that much more accurate estimation of EF can be obtained using 3D sonography. Besides echocardiography, Dr. Chou also used the ultrasound to check the inferior vena cava and hepatic vein for every patient. He said that because of prevalence of Hepatitis B in Taiwan, patients have more risk to have hepatocellular carcinoma and that can cause membranous obstruction of IVC.

June 23, 2011

Before we started observing Dr. Chou performing echocardiography, we got the chance to watch another physician use ultrasound to check the carotid arties. The sonographies of common carotid arteries, external carotid arteries, and vertebral arties were taken and the thickness of each artery was measured. This screening is useful to estimate the progresses of atherosclerosis and helpful to identify patients who have high risk of stroke.

Since Dr. Chou only had one patient this morning, he kindly provided Mickey and I the opportunity to perform echocardiography on each other. Dr. Chou guided us how to position the probe different to get the parasternal long axis view, short axis view, four chambers view, and five chambers view. When I had the probe on my hand, I started to know how difficult to have the probe on the correct spot to gain the view you want. It’s a skill that requires a lot of practice to do it right and obtain correct diagnosis. Dr. Chou told us that he practiced it every day during his fellowship. And his supervisor told him that the first two hundred and fifty times are usually wrong and one thousand times practice is required to start having confidence about the diagnosis. In the afternoon, we met Dr. Chieh-Yuan Huang in ultrasonic room and observed him performing echocardiography. One of the cases he had today had ventricular septal defect, supracristal type. And the echocardiography clearly showed the hole, which was estimated to be 0.8 cm. This experience showed us knowing how to use ultrasound correctly is a skill that required a lot of practices but would be very useful in screening and making diagnosis.

June 24, 2011

The last day of our cardiology rotation also started in ultrasonic room. In the morning, we observed Dr. Huang performing echocardiography. One of the patients he had today is a 48 years old male with severe heart problem and renal problem that requires hemodialysis. The echocardiography showed mitral annulus dilatation and tricuspid valve lesion that results in ascending jet back into left atrium. The heart was found to have almost no contractility and ejection fraction was estimated to be only 20%. His diagnosis includes multivessel disease and dilated cardiomyopathy is suspected. And according to Dr. Huang, the only treatment for this patient is heart transplantation, so he suggested patient to make consultation with the cardiovascular surgeon.

In the afternoon, we went to ultrasonic room again and observe Dr. Feng performing echocardiography. One patient came in has gauze on her left heel. Dr. Feng told us that he suspected that she has peripheral artery occlusive disease (PAOD) because of the chronic ulcer on her left heel, so he ordered her ankle brachial index (ABI) test. The ABI was found to be 0.55 for her right leg and 0.27 for her left leg. This suggested there is stenosis and confirmed the suspicion of PAOD, and angiogram will be done next week to further confirm the finding.

During this week of rotation in cardiology, I not only got to know various jobs of cardiologists (such as maintaining the BP, blood sugar, and cholesterol level of patients and inserting pacemaker) but also gain more understanding of echocardiography (like how to put the probe in right spot and how to interpret the images and obtain various parameters). Like Dr. Chou told us before, since heart is in charge to pump the blood to every part of our body, problems in various parts of body can be due to heart problem. Therefore these experiences I gained from cardiology are very useful for me no matter which specialty I go to in the future.

Cardiology Rotation Day 4 Learning how to do Echocardiography and more Ultrasounds 23-June-2011

Apparently there was only one patient scheduled for echocardiography in the morning with Dr. Chou and as the patient had not arrived yet Dr. Chou told us to check out the sonography of the carotid artery in the room next door. The whole process seemed a little easier than the echocardiogram process but it was still hard to make out some of the small narrowing and beginning build of plaque that the doctor operating the machine was able to see. Afterwards we returned to follow Dr. Chou as he completed his only morning echo. As the morning was so free Dr. Chou let us perform echocardiography on each other as long as no patients showed up. I started as the operator with Bor-Han as the patient. Dr. Chou walked me through how to position the probe in the second or third intercostal space and orient it so that the probe’s marker line was toward the right shoulder to get the parasternal long axis view. After some analysis we proceeded to go through the short-axis, four and five chamber views. It was really difficult to get the five chamber view and it really made me appreciate the amount of practice and experience it takes to get a real feel of echocardiography. Next up Bor-Han and I switched places and he got to got to go through all the views I did from before and went on to position the probe to visualize my inferior vena cava. Apparently in Taiwan they often check the inferior vena cava (IVC) for blockages, there is a different etiology for ICV blockage in Taiwan compared to the United States with hepatic masses being more common in Taiwan (Hep B and Hep C) compared to renal adenocarcinoma in the United States. I am very happy that I was able to get an opportunity to operate the machine and to have such a good preceptor to learn from in Dr. Chou. Oh and no pictures of us operating the machine this time as all our hands were busy.

Cardiology Rotation Day 3 Cath Lab and more Echoes 22-June-2011

Bor-Han and I started the day in the cath lab at 9:30 where a patient was scheduled to have his pacemaker procedure performed by Dr. Tu. After the patient arrived we watched as Dr. Tu and company got ready by putting on lead protection armor. It seems like it takes quite a bit of endurance and stamina with all the gear on, of course all the staff used back support. As Dr. Tu was doing the procedure Bor-Han and I watched from behind the glass, the angle of watch Dr. Tu was not too good as we could not completely see what he was doing all the time. None the less Dr. Fung and the employee of the pacemaker company (Medtronic) were there to provide explanations of what was going on during the procedure. The total procedure took about three hours, Dr. Tu had a little trouble getting the leads where he wanted a few times and had it dislodge a few other times. I can only imagine how much patience and concentration it takes to be able go through the entire procedure. Overall the procedure itself was interesting; I was able to see how much effort goes into pacemaker implantation and learn a bit about the details.

In the afternoon we visited the ultrasound room again to see and learn more about echoes from Dr. Chou Po-Han (Dr. 周伯翰). We went over many topics including how much the echocardiogram is operator dependant. In fact Dr. Chou said usually in a fellowship of two years you would have to do about 1000 echoes before you could be confident that they were correct. The first 250 are incorrect, the next 500 are maybe correct, and it takes awhile from there to get a good clear image. The whole process is through practice and getting familiar with the different possible results. We also got to see a few new things including the Tissue Doppler that is useful for assessing diastolic dysfunction and a review of why it is important to see the heart chambers from multiple views (non-ideal heart is not as spherical so equations to calculate the ejection fraction are less accurate if only one view is used).

Cardiology Rotation Day 1 & 2 (June 20-21, 2011)

June 20, 2011

Our first day in cardiology started with observing Dr. Kuei-Feng Chen in his outpatient clinic. Since he is the director of the cardiology department, he had so many patients that I wonder if he can finish all of them in the morning. But my doubt got cleaned up right away after I saw that he finished each patient visit in less than four minutes. He explained that he can do it so fast because most of them are his long-term patients and he knows each of them pretty well. From Dr. Chen, we learned that it’s important for cardiologists to control patients’ blood pressure, blood sugar, and blood lipid level. The side effect of medications (e.g. peripheral edema from Amlodipine, a long-acting calcium channel blocker) is another thing a cardiologist often needs to deal with.

After leaving Dr. Chen’s outpatient clinic, we went to ultrasonic room where cardiologists perform echocardiography. For rest of the day, we observed Dr. Wen-Kai Feng and Dr. Chung-Chih Tu performing echocardiography on patients. From them, we learned that echocardiography is a very useful diagnosis tool to screen possible heart problem on the patients. For example, echocardiography was used on a pneumonia patient to see if there is any vegetation on his heart valves. They also showed us how to gain important parameters such as left atrium diameter, flow velocity, and ejection fraction using various features on the echocardiography machine. This experience gave me an idea what the echography can do to help us making diagnosis regarding heart.

June 21, 2011

Mickey and I met Dr. Chen, the director of the cardiology department, in the ultrasonic room. We observed Dr. Chen performing echocardiography, and he told us what he interpreted from the image. Dr. Chen usually checked the patient’s EKG or/and CXR first before performing the echocardiography. He told us that EKG, CXR, and echo are the three most common diagnosis tools used in cardiology and each has its own advantages. For example, CXR can give us the size of the heart. EKC can tell us if the patient has bundle branch block, arrhythmia, MI, etc. And echo allows us to know if there is any shunt or heart valve problem. We also observed that a lot of patients receiving echo have mitral prolapse. According to Dr. Chen, mitral prolapse is pretty common. Patients with echo showing mitral prolapse usually are still considered normal and don’t receive treatment for that.

Besides mitral prolapse, we also got chance to see other valve problems such as vegetation, mitral regurgitation, and aortic regurgitation. Actually one of the patients Dr. Chen had today has regurgitation of all four heart valves (mitral, tricuspid, aortic, and pulmonic). And it’s amazing to be able to see the heart with all four valve regurgitated on echo. Another rare case we observed is a patient having mitral valve replacement with mechanical valve due to mitral stenosis. The prosthetic valve cannot be seen very well on the CXR unless the valve is totally close as the moment of taking X-tray. But the echo clearly showed the valve and the blood flow passing through it. And it’s astonishing to see the valve still working well after almost twenty years since the replacement.

We also saw many of the patients receiving echo are young healthy male before going to military service. Conscription is still used in Taiwan to recruit people to military service, and complete physical examination will be performed to check the body condition of each man before serving the nation. Many of those young men having history of heart problem (especially those with congenital heart defects) will come to get echo for further checking their heart condition. And we are lucky to see one of the classical congenital heart defects, tetralogy of Fallot. The patient received surgery to fix it when he was small, and according to Dr. Chen, that operation is really successful since he didn’t see any sequela from tetralogy of Fallot on his echo. Dr. Chen also said that this case is rare and a little bit difficult to interpret even for experienced cardiologists.

Besides observing echocardiography, Dr. Chen also kindly provided us the opportunity to perform 12-lead EKG on each other. So Mickey and I went to EKG room and learned how to use it by observing the technician doing it. Then we performed 12-lead EKG on each other. And it’s exciting to be able to look and study my own EKG. In the same EKG room, Dr. Chen also showed us some EKG from stress test while he was making final diagnosis. One case he showed us had the “delta wave”, the classical sign of Wolff–Parkinson–White syndrome (WPW).

After finishing the interpretation of EKG from stress tests, we went to the wards with Dr. Chen. One patient we visited will have pacemaker insertion tomorrow. He is a long-time patient with Dr. Chen for more than twelve years. And Dr. Chen showed us the old charts and pointed out how he changed the patient’s medication over time as the heart rate of the patient went slower and slower (From beta blocker to no beta blocker to aminophylline). Since the operation will be held in catheterization room, Dr. Chen brought us to the room and provided us the opportunity to observe the operation tomorrow.

Cariology Rotation Day 2 Echocardiograms, EKGs, running around the ward 21-June-2011

Following Dr. Chen Kuei-Feng (Dr. 陳桂峰), Bor-Han and I were very lucky today to see very different echocardiograms (echo) right after another. The first echo was a patient with regurgitation of all four valves (mitral, tricuspid, aortic and pulmonic). Dr. Chen used the opportunity to show us different views including the five chamber view (all four heart chambers, plus the aorta), how to use the doppler to get quantitative measurements of the heart and also how to use the color mode to assess turbulence (it shows up as a mosaic of red and blue, and usually indicates abnormal flow). For completeness Dr. Chen also showed us the chest x-ray depicting cardiomegaly and the EKG with Atrial fibrillation (A-fib).
The next echo was that of a normal heart with a mitral valve prolapse. Apparently mitral valve prolapse is fairly common and usually part of normal variation, in fact all of the hearts we saw today at least had mitral valve prolapse. Dr. Chen also commented the echo sensitivity attributes the common finding of mitral valve prolapse.

The third echo was from a patient with a prosthetic heart valve (metallic mechanical disc valve) from an operation more than ten years ago. It was interesting to see the distortion in the echo from the interference of the metal valve. One of the most fascinating things that Dr. Chen showed us was the chest x-ray (CXR) where we were able to see the valve when it was closed (showed up as a dark line) but not when it was open; he explained that disc valves are usually not very radiolucent, compared to the old ball and age valves where you were able to see the cage on the CXR. Dr. Chen also explained that the acceptable mitral area for prosthetic heart valves can be smaller, in this case the mitral area was calculated to be 2.8 cm² compared to the 4-6 cm² found in normal valves.

The forth echo with a patient with Tetralogy of Fallot, a congenital heart disease. This was the most interesting heart as everything was atypical. Dr. Chen also commented it was a very advanced case and that the echo will not be able to tell everything, such which surgical repair was perform (primary repair or two-stage repair). This also sparked a conversation about how long charts are kept as it would be interesting to know which operation was done, but apparently there were not records as charts are kept for about 11 years in Taiwan.

In addition to all the echoes in the morning Dr. Chen also outlined the thought process around how to use various physical exam signs, clinical presentations and the main diagnostic tools for cardiology (CXR, EKG and echo). CXR is usually used to check for cardiomegaly, EKG is a good way to assess arrhythmia, MI, and ischemia, while echo is good for valve assessment.

After lunch we were able to see a few more interesting echoes including another case where the patient had a congenital heart disease (ventricular septal defect) and other patient with rheumatic heart disease where Dr. Chen pointed out vegetative growth and the bend knee sign of mitral valve. Before Bor-Han and I went over the EKG room to observe how to place the EKG leads, before taking each other’s EKGs.

Me hooked up to the EKG leads below:

We concluded the day following Dr. Chen through the ward as he checked on several patients. The most fascinating case was a patient that he had been following for over 12 years. Dr. Chen went over the patient’s chart that was currently in the hospital awaiting pacemaker placement due to sick sinus syndrome. Originally the patient was on a beta-blocker to manage his hypertension which was withdrawn in favor of a mixed alpha and beta-blocker in hope to improve his bradycardia. Later the mixed blocker was removed and aminophylline was added to try and increase heart rate before the diagnosis of sick sinus syndrome and pacemaker placement was recommended. One interesting note is that this is the same patient we will be seeing Dr. Tu place a pacemaker in tomorrow morning. In any case today was filled with many exciting topics and I ended up learning a wealth about what cardiologists do.

Cardiology Rotation Day 1 Outpatient clinic and Ultrasound Room 20-June-2011

9:00 am started the day off in the outpatient clinic with Dr. Chen Kuei-Feng (Dr. 陳桂峰). The clinic was very busy; it almost felt like the pace I saw in the TCM department every patient was seen for about 2-3 minutes. Dr. Chen commented that it was possible as most of the patients he has followed for a long time and are in for chronic disease management (hypertension, diabetes mellitus, and hyperlipidemia most common). During the clinic Dr. Chen took time to familiarize Bor-Han and I with the ICD-9-CM International Classification of Disease method of coding and with the drug coding used by the hospital. We also got a review on calcium channel blocker side effects as a few of his patients came in with peripheral edema from Amilo (amlodipine besylate), a long acting calcium channel blocker. There was also a case involving the long term use of NSAIDs to manage joint pain that has resulted in gastric ulcers; Dr. Chen mentioned he had recently switch the patient over to a COX2 NSAID but it has not done much to stop the gastric ulcers. Other interesting things included a discussion about the importance of having patients with high blood pressure keep a daily long of blood pressures as it is more reliable compared to office blood pressure readings due to possible White Coat and other factors.

Later on we end up following Dr. Feng Wen-Kai (Dr. 馮文楷) and later Dr. Tu Chung-Chih (Dr. 涂崇誠) in the ultrasound room as they performed echocardiograms. We ended up learning about some of the basics of echocardiograms including the visualization of the different heart valves and the assessment of ventricular and atrial size. We also got a good introduction about how to correlate chest x-rays, EKGs and echo results to physical exam findings to get a good grasp of a patient’s condition. At the end of the day Dr. Tu, mentioned that he will be doing a pacemaker placement on Wednesday and invited us to observe.

Cardiology Day 5/5 - Sandy

During entire Friday morning, the cardiovascular and surgery team were in anticipation for the Abdominal Aorta Aneurysm surgery, the second one to be done in this hospital since it opened 40 years ago. The patient was a 78y/o male with a 6.5cm diameter AAA, w/ h/o CAD, HTN and ESRD. Nicole, Amanda and I felt so fortunate to be part of this exciting surgery! Dr. Chen (from Surgery) taught us the concept behind endovascular aneurysm repair. Stents were placed through the femoral arteries, balloon used to press stent against arteries and then the graft was inserted to the surrounding aneurysm site. The procedure took about 4 hours, and it was so exciting to see almost all of the cardiologists and Dr. Chen’s mentor coming to witness this historical procedure.

Sucess! The stent graft was inserted!
Dr. Chen, Amanda, me and Nicole all in surgical scrubs!

In My Heart of Hearts.

I was going to write about an abdominal aortic aneurysm case through the patient’s point of view. After one paragraph, I realized that I was still writing about a case, only in first rather than third person. As much as I read over his file and learned about his medical history, I had learned merely about one aspect of his life in great details, while knowing very little about the person that he is. My attempt to write from the patient’s perspective helps me become more aware of the physician-patient relationship. A doctor often has the most pertinent information regarding her patient’s health, merely an initial/ admitting interview includes family history, social history, sexual history, and much information that no one shares with a stranger in brief encounters other than a medical interview. The doctor tries to learn about everything about the patient that assists their medical diagnosis and treatment. To have the patient’s best interest at heart at all time is not easiest thing. For instance, where do you draw the line between whether an interview question is out of intellectual curiosity or out of medical necessity? How do you decide if a medical procedure needs to be done when the mortality rate of the procedure is 70% and that without the said procedure is 100%? I don’t exactly have the answer for my musing. From what I observed in Taipei hospital, I see that all healthcare providers here put their patients best interest at heart and they genuinely respect their patients’ wishes.

The procedure to repair the AAA was an incredibly intricate and challenging procedure. It was a great honor to witness it. The 78-year-old male patient had ESRD and CAD. His AAA was largest at 6.5 cm diameter. Dr. Chen, the CV surgeon, invited his mentor/professor to observe and advise at the OR. Both femoral arteries were opened; stent was inserted in 3 separate segments. Balloons were inflated to press the stents against the blood vessels. Finally artificial grafts were inserted within the fixed stents. The operation took nearly four hours. I asked about the long-term effectiveness of these operations, Dr. Fong (cardiologist) stated that these procedures are so young that, there has not been follow up studies about the durability and benefits 10-20 years post operation.

The observation room was packed with cardiologists, nurses, and residents. This was the second such case this year in Taipei Hospital. Sandy, Nicole, and I felt very fortunate to be watching real time radiography of the procedure. After the stent and graph were both in place, Dr. Chen even asked us to enter the OR so he could show us the femoral arteries before he closed up the incision.

This week had been lots of fun and reflection; I saw much that I’d only dreamed about and seen on TV. My respect and admiration for cardiologist and cardiovascular surgeons have grown much with what I have witnessed first hand. In the years to come, I hope to nourish and pass on the passion, dedication, and fearlessness they have instilled in me during this brief yet impactful rotation.

Brave heart, tender heart.

Dr. Chen started our day with a presentation on the ECMO (extra-corporeal membranous oxgenation). He showed us the basic set up, veno-arterial (VA) and veno-venous (VV). For the venous arteriole set up, a catheter connected to a pump (artificial heart) draws blood from the femoral vein). The blood goes through the a heater (to maintain body temperature) and the oxgenator (artificial lung); then the fully oxgenated blood returns to the patient via femoral artery. The VA system provides both supportive heart and lung functions, while the VV ECMO provides ventilation without the damage to the lungs caused by mechanical ventilation. Taiwan government supports and pays for ECMO treatment. Dr. Chen says that ECMO is a very good supportive treatment which buys patients time to heal or to receive transplant. He says that infants and children usually benefit more from ECMO because they often heal better and regain their own cardiac and pulmonary function. In adults, ECMO are often used in ARDS and or heart failure, which often deteriorate and can't reverse its course.

The only female cardiovascular surgical resident Dr. Yu gave a presentation on a review article of ECMO. She presented the costs and benefits of ECMO. ECOM is expensive and requires highly trained personnel to implement. It also requires anti-coagulation because the circuit, especially the membranous gas exchange compartment is highly thrombogenic. Dr. Yu also talked about pumpless extracorporeal interventional lung assist in patients with acute respiratory distress syndrome. It is passive flow system without the artificial cardiac function of AV ECMO. It is good for CO2 removal but not oxygenation, so for respiratory compromised patient, intubated-ventilation needs to be used in conjunction with ECMO.

After Dr. Yu’s presentation, Dr. Chen added that if a patient with severe cerebral injury requires ECMO, he may have to administer ECMO without heparin to avoid cerebral hemorrhage. But a patient usually can not rely on ECMO for heart function over two weeks. VAD (ventricular assistance device) can buy a heart-failure patient more time when waiting for a cardiac transplant.

Dr. Yu took us on rounds. The cases were PDA (peripheral arterial disease), AAA (abdominal aortic aneurysm), DVT (deep vein thrombosis), and OHS (occluded hemodialysis shunt). The PDA patient also suffers from severe microcytic anemia possibly due to iron deficiency. Dr. Yu was originally planning to perform angiography and balloon angioplasty on this patient tomorrow. But in their discussion, the patient expressed that he wanted to address his anemia first before getting lower limb angiography. Dr. Yu supported the patient’s wish without a hint of pressure. His genuine respect for his patients and his exquisite command of medicine exemplify the ideal physician. The AAA patient was an elderly man, with a kind and peaceful smile; he let us feel the pulsation on his upper right ABD. Dr. Yu said that the AAA diameter was 6.5 cm. He will insert a stent to fortify the vascular wall tomorrow. He said that the operation room does not have the equipment for general anesthesia, so he is slightly concerned about patient’s movement or awaking during the procedure. Instead of general anesthesia, Dr. Chen will apply local anesthesia and IV to help the patient sleep during the procedure. In a similar but more complicated case, which required a double stent (aorta and iliac artery), the patient moved his extremities around in sleep on the operation table. Although this past experience made Dr. Chen slightly nervous, he says tomorrow’s aortic stent should be fine. I admire the fact that he works with the equipment available and demonstrates incredible skills and elegance in his work. The ability to deliver the best medical care in all situations should be all healthcare providers’ goal. I am glad to witness how it is done, by so many dedicated and improvising physicians at Taipei Hospital.

The DVT onset was acute, so Dr. Chen administered thrombolytic drugs first. On average, the downstream swelling caused by the thrombotic occlusion resolve with 3-5 days of thrombolytic treatment. The patient’s progress was not satisfactory, so Dr. Chen increased the dosage today. He also discussed the possibility of thrombectomy with the patient. There were several cases of OHS. There are 3 main types of hemodialysis vascular access (hemodialysis shunt): AV fistula, AV graft, and venous catheter. Dr. Chen performed clot removal from both AV fistula and AV graft. In both cases, he used local anesthesia and small incision, suctioned the thrombus out, checked the vascular lumen with angiography, and performed angioplasty when necessary. One case had a more severe occlusion, one of the clot removed was a “white thrombus,” with organization and re-canalization. There was a lumen within the organized thrombus! This brought me back to Dr. Liisa Russell’s pathology lectures, when she emphasized several times the difference between fresh and old thrombus. He also replaced a venous catheter, executing roughly the same steps. He then treated Sandy, Nicole, I, and the cath lab staff to delicious lunch boxes.

In the afternoon, Sandy and I shadowed Dr. Chen (Cardiology Chief) in his outpatient clinic. In addition to reviewing some HTN, CAD, DM drugs, learned 2 main principles. One, the Taiwan national health care insurance and electronic medical files make healthcare incredibly efficient and assessable for the public. Patients see Dr. Chen, can get blood tests, echocardiogram, chest Xray, EKG results back the same day. After seeing the patient, Dr. Chen will help them order diagnostic tests, the patient will return to Dr. Chen’s office to discuss the results in as short as 1 hour. Many patients had been seeing Dr. Chen for awhile, managing long term CV diseases. But even new patients could get focused cardiac exam, preliminary diagnostic tests (EKG, chest Xray), and test result follow up in ONE afternoon. Dr. Chen saw nearly 80 patients this afternoon without compromising the quality of care the slightest bit.

Second, many Taiwanese doctors believe in caring for their patients as whole and unique persons. Cardiologists or oncologists, they all commit to their patient’s complete well being, body, mind, and soul. Both Dr. Chen’s (chief cardiologist and chief oncologist) expressed that an essential part of their job, aside from delivery accurate diagnosis and optimal treatment, was “psychotherapy.” Dr. Chen said, many patients who were referred to him with “chest pain,” did not have true CAD disease. The 2 most common non-cardiac etiologies include autonomic nerve disturbance (due to stress or congenital nerve abnormality) and neurosis (psychological need for support, medical or otherwise.) I saw one patient like this today; his daughter accompanied him to the clinic. She said that he had been seeing many doctors, who looked into almost all his major systems and found no problems. She said that another doctor referred them to Dr. Chen because he was known for his patience with elderly patients. Cardiac exam, EKG, and chest radiograph led Dr. Chen to reassure the elderly man that he was quite healthy. Then, the daughter, Dr. Chen, the nurse, and the volunteer, all reassured him again. I noticed the elderly man’s feet were dark purple with patches of redness and asked Dr. Chen. He explained to me that he was a fisherman and suffered chronic inflammation due to exposure to harsh conditions of UV light, wind, salt water, and pollutants so his feet were hyper-pigmented. He reminded the patient to wear socks to protect his feet before the daughter, with great relief, wheeled her father out.

The cardiology chief, CV surgeon, attending cardiologist and the resident are all brave hearts—they dauntlessly complete 12-15 years of medical training and fearlessly embrace intellectual challenges and operational complexities. They are also tender hearts—they care for patients beyond the organ system that they study and persist to finish nearly impossible procedures regardless of fixed compensation. I marvel daily at this amazing opportunity to be amongst such individuals.