The end of TCM

The week in TCM has been interesting. Dr. Chen and Dr. Ho have taught us so much and showed us their acupuncture techniques. Dr. Chen even put a needle in my hand to show me what it feels like. I was a little nervous about it and skeptical when people said that it just feels numb. But when Dr. Chen tapped the needle into my hand, I hardly felt it except when he moved it around. It felt very tingly and weird. I left it in for a bit while he saw a patient and then he took it out for me. I thought that as long as I had it in I might as well treat the point a little. The point he used is one that is used to treat motion sickness and since I have been sensitive to that lately, I thought that treatment couldn't hurt. It did help a little, as the next time I was on the bus with the crazy driver I didn't get as sick. It was a good experience for me. I think it is important to experience things for yourself to be able to empathize with others.

Dr. Ho taught us a little about his manipulative technique. He showed us what he is feeling for when he does his diagnostic exam. His palpatory skills are very good and I hope that someday I will have those skills. He is able to treat bones that are out of place and tightness in the tissues. He diagnosed several patients with a "twisted pelvis" and prescribed herbal remedies for it. This was interesting to me because I thought that he would use manipulation to fix it, but instead uses herbs. There was also a patient with a cervical spine injury that was seeking treatment. He said that the patient would first have to take some Chinese medicines first before starting acupuncture treatment. Dr. Ho said that the treatments will help but it will take time and that he wasn't sure how much it would help. Because the nerves might be damaged, acupuncture may not be able to fix anything.

On Thursday, TIHTC took us on a field trip. We went to the Geography Park where there are really interesting rock formations. It was fun to see the different shapes of the rocks and the natural erosion that is occurring. It is apparent that the Taiwanese like food; a lot of the rock formations are named after foods. But it was fun. They are very imaginative with the shapes and there are stories to go with them. In the afternoon we toured the Shenkeng Public Health Center, which is a facility that focuses on public health. They have a small clinic and a lot of educational programs for residents in that area. This was a nice trip and we were very lucky to have been able to go.

This last week in TCM has been a very educational week for me. I have learned so much about Chinese medicine and its uses. All of the doctors in the department were very kind and answered all of our questions. The last 4 weeks at Taipei Hospital have been very educational and have reminded me why I decided to go to medical school. Sometimes in all the studying it is easy to forget the clinical side of things and it is experiences like these that keep me pushing through it all. I have really enjoyed all of the clinical experience that I have gained and all of the pearls of knowledge that the doctors have given me.

Week 4 TCM

Chinese medicine is more similar to Osteopathic medicine than I had expected. They both take the whole body approach to medicine and consider the patient as a person and not a disease. They also believe that the body is a unit and that everything affects everything else. So when treating the patient for back pain, you don't necessarily focus on the back because other factors could be playing a role.

At Taipei Hospital, the Chinese medicine department is quite busy. Dr. Ho, the chair of the department, sees about 60 patients for consultations and does about 20 acupuncture treatments in a morning or afternoon clinic session (about 4 hours). He is quite busy, but still manages to crack jokes with the patients. He includes a structural exam with his consultation and does some manipulative treatments with foot stomping and arm flailing. I'm not quite sure what he is doing, but he said he will explain it tomorrow. During his 4 hour clinic session, he sees patients for herbal consultation and does 2 sessions of acupuncture. The tables are all lined up and patients are called in as a group. Curtains separate each of the tables. Dr. Ho goes to each table and puts in whatever needles he thinks are needed and moves directly to the next patient. He somehow remembers each patient and doesn't need to refer back to the charts. A volunteer follows and counts the numbers of needles so that they can be sure to remove them all. After he applies needles to all the patients he goes back to seeing patients for herbal consultations.

The Chinese Medicine department also has a weight loss section. Dr. Hsieh comes in on Tuesday mornings to do acupuncture and consult patients who are trying to lose weight. She has a set of about 30 points that she uses on all her patients. She also gives them dietary instructions that are very similar to a low carb diet. She asks all the patients to eat less sugar, starch, and fat and to eat mostly proteins and produce. One patient came in who was just using the treatments to maintain her weight without dietary change and Dr. Hsieh told her that this treatment is for weight loss and dietary change is necessary. Patients are given the option of acupuncture and also electroacupuncture, which apparently stimulates the points more and creates more change in the body. Another patient that came in today had lost 16 kg in 2 months with this treatment, diet and exercise. This was her last visit for the treatment. This case in extraordinary and most people lose weight more slowly, which is supposed to be healthier. This treatment seems to be quite effective and patients seem to be quite happy. Dr. Hsieh consulted about 10 new patients to start treatment today.

Through research on the NIH website, I have been able to learn about research on acupuncture. Researchers have shown that by stimulating a point on the foot that is good for eyesight, the part of the brain responsible for the eye becomes active. I'm not sure if this phenomena can be explained scientifically yet, but it is quite interesting. It is believed that some hormones or neurotransmitters are released in response to the needle. Researchers have also shown that acupuncture changes resting-state brain activity causing analgesic effects. (All of these can be found at http://nccam.nih.gov/research/results/topics/index.php?title=Traditional_Chinese_Medicine). I am continuing to learn how acupuncture works through continuing education lectures on the National Center for Complementary and Alternative Medicine website.

NSD birth

Today for the first time in my life I saw a live vaginal birth. It really is like squeezing a meatloaf through your nostril. I first saw the patient in outpatient clinic. She had come in for a check up and when the doctor checked her cervix decided to admit her. She has had 2 other children, so this third one was supposed to happen very fast. And it did. I arrived shortly after she began to push and made it just in time to see it all happen. It happened in the course of about 15 minutes. Dr. Yang gave her an analgesic injection and then made the opening larger. She asked the woman to push and the head began to come out. After one more larger push, the baby was out. I got to help clamp the cord and cut it. They then suctioned his mouth and nose and cleaned him up. He began to cry and the group of nurses in the room took him to show the mother. They then took him to the baby room. The doctor then let me help ease the placenta out, slowly twisting it around to keep the membranes intact. The placenta was warm and slippery, and I almost dropped it on the floor. I helped with the episiotomy stitching, which was the bloodiest part of it all. I began to feel a little woozy from it, which I didn't expect to happen since I had survived the rest of it without any problem. I was surprised that the woman seemed to be able to feel the needle going through her tissues. She seemed to be in pain, which made it a little worse for me. The doctor worked fast and she was all stitched and ready to move in about 5 minutes. Dr. Yang and I went to visit the baby in the nursery. He was all wrapped up like a burrito and resting. His face was a little edematous, which apparently happens when the woman squeezes her legs too much during the birth.

After speaking with Dr Yang about episiotomy, she told me that in Taiwan it is done because it heals more beautifully. By cutting with a knife, you create a straight edge to sew back together that heals in a more aesthetically appealing manner. The tissues did come together quite nicely when she finished with the stitching. She said that she has tried the natural way, by letting the tissues tear on their own, but it healed in a jagged way. She also said that women do not experience side effects from it. Episiotomy use in the US has declined in recent decades because of side effects.

This was an amazing learning experience for me. It makes me think about whether I want to have children or not. It looks rather painful and I don't tolerate pain all that well. But I learned so much about the process of having a baby and giving birth. This week in OB/Gyn has been a great experience.

OB/Gyn outpatient clinic

The last couple of days in outpatient clinic in OB/Gyn was quite busy. I have been able to shadow 3 different doctors and see their different styles and bed side manners. The nurses in the department are great and know exactly what the doctors want before they ask for anything. Most of the patients in OB/Gyn come in for itching, pap smears, or OB checks. I've gotten to see and do a lot in the last few days. I have learned how to do a pap smear and have been able to do a few. Some are easier than others because of the location of the cervix. Some are more posterior or superior than others. I've been able to watch a cervical biopy and cerivcal polypectomy, which to my surprise do not require anesthesia. The biopsy is take with a long jaw-like instrument that bites off pieces of the cervix. The polypectomy is really simple; you just grab it with a clamp and twist it to rip it out. The cervix apparently doesn't have many nerves, so cutting and pulling on it doesn't hurt.

One case that required cervical biopsy was an older woman who came in with her family and caregiver. She had been experiencing spotting for the last month and a half. So the doctor did a pelvic exam and found changes in the cervix that looked cancerous. It began to bleed a lot as soon as she touched it, so the biopsy was a bloody procedure. Dr. Yang also did a trans-vaginal ultrasound and said that the cancer looked like it was in the endometrium as well. She suspects squamous cell cancer either originating in the cervix or the endometrium.

I was also able to see a case of problems conceiving. The husband had already had his sperm checked, so the wife was coming in to check on her. The husband's sperm was normal. They have been trying for 2 years. Dr. Tsao was reassuring to the patient and then performed a hysteosalpingogram. This is an x-ray to test the pathway that sperm would travel in the uterus and fallopian tubes. Dr. Tsao injected contrast agent slowly into the cervix and took sequential pictures of the pelvis to see the ability of fluid to enter the uterus and fallopian tubes. This patient turned out to be normal.

I have also learned about IUD's and their placement. Many women in Taiwan use IUDs instead of hormonal contraception. The hormonal contraception that is available at Taipei Hospital through the national health insurance is apparently a high dose. Many woman in Taiwan do not like to take hormones because of the side effects of the high dose. Young women who have irregular menses are not usually given hormonal therapy because parents are afraid of growth retardation. The oral contraception available in the US is a low dose of estrogen, so is more commonly used. The doctor told me that most people use condoms as their contraception in Taiwan. This seems to be a good thing, as there don't seem to be a lot of cases of STDs. In the last few days I've only seen a few (at most 5) cases of STDs. I learned that HSV is more common in older woman than other STDs.

I've also learned that pregnancy terminations are done in Taiwan up until the 24th week. A woman came into the clinic who was about 24-weeks pregnant asking for a termination. She said that she had taken foreign diet pills and was concerned for the baby. So a dilation and curettage was scheduled for her next week. The intern also told me about a case of twins that were terminated earlier this month. The doctors are not required to do this procedure and can decline if they want.

Another woman came into clinic today asking to schedule her delivery. C-sections can be scheduled for woman if they want, but the national insurance plan will not cover the surgery without indications for it. The intern told me that it costs about $10,000 NT for the surgery, not including the anesthesia. This is inexpensive compared to the US.

In the midst of the business of clinic, Dr. Tsao taught me about IVF and ovarian cancer. He and the intern each gave a presentation about the subjects between patients in clinic. IVF is not done at Taipei Hospital, but Dr. Tsao told me that he has done it before. It is not covered by the national health insurance in Taiwan, so people must pay to do it. It is much cheaper in Taiwan than in the US. The intern's presentation covered everything about ovarian cancer. Ovarian cancer is not treated at Taipei Hospital and those patients are referred to a larger hospital. This hospital doesn't have radiotherapy equipment. There are many different types of ovarian tumors. I learned that bilateral ovarian tumors usually arise from metastases from the GI tract.

In OB/Gyn I have learned a lot about the reproductive health of woman. I've been able to watch numerous ultrasounds (trans-abdominal and trans-vaginal). I've learned a lot about how to read them. I've also seen ultrasounds of pregnant women and how to measure the baby. It has been a great week and I have learned so much. The department has taught me so much and I'm so grateful for the time they have taken to teach me.

Pediatrics- end of the week

This week in pediatrics we have seen and learned so many things. We spent 3.5 days in outpatient clinic and saw some of the patients in the hospital. Sitting through outpatient clinic showed us the types of cases that a pediatrician sees on a normal basis. A lot of the cases have to do with upper respiratory infections, asthma, or abdominal pain. Fevers appear quite often, some more severe than others and some more persistent than others. Some fevers last for days and days that are admitted to the ward for observation. Other times the fevers are good and need to be there to help the body heal. This is hard to explain to parents; parents want their kids to be healthy and worry when there is any sign of illness. We saw a few parents who were frustrated with persistent fevers and/or coughs (usually from asthma) that are being treated, but apparently not fast enough. I can understand where the parents are coming from; they will do anything to make sure that the kid is healthy and when treatments don't seem to work it can be frustrating. If I have learned anything from this week, it is that pediatricians have many roles, but first and foremost they act as a health advocate and educator. They must teach the parents not to worry so much and help them to understand their child's illness or symptoms. Children are very resilient and heal very quickly; a stomachache in the morning can be nothing in the afternoon after some treatment. In most cases, parents worry a little too much. I may not be a parent right now, but I think I can empathize. If I were to become a pediatrician, I now have a good idea of the skills that I would need and those that I would need to work on. Being a good teacher and communicator are key and hopefully things that I can improve.

Going to the wards and sitting in the morning meeting taught us about the care that inpatients get and the types of cases that are admitted to the hospital. A baby was finally put in the nursery last night. She is 2 months old and has a urinary tract infection with fever. She was admitted for observation and antibiotics. Young babies with fever are admitted to observe and make sure it doesn't get worse. She lies alone in the baby room, but is receptive to visitors. We were able to read through her chart and spend some time with her. The antibiotics had helped her fever subside. We saw a boy with a viral infection who was waiting for test results. He had a rash, which could be EBV but also had symptoms of adenovirus. We discussed a case of cellulitis in a girl's mouth which resulted from an untreated dental carry. After treatment with antibiotics, her cellulitis had subsided and she was being discharged. Another case we discussed was a boy with pharyngoconjunctival fever (PCF). This was a good opportunity to remember the antibiotics that we studied so long ago and forgotten. He was administered sulbactam with ampicillin (called Unasyn) which in Taiwan must be approved before they can be given. This is to prevent the strains from becoming resistant to the drugs from overuse.

In outpatient clinic we also saw several cases of latent TB infections. In Taiwan, if kids are exposed to an active infection of TB and then have a positive PPD test, they have to go on anti-TB drugs for 3 months. If they retest positive after that time, they have to take an additional 9 months of treatment. Several kids were taking isoniazid for latent TB. One girl will be taking an additional 9 months of drugs because her test was borderline positive. Her younger brother will not have to take the drugs anymore. It was very informative to be able to see these cases, since we studied them in class.

These few days in pediatrics has allowed me the opportunity to learn outside of the classroom and better understand everything that we have been lectured on this past year. I have enjoyed my time in the pediatrics department and look forward to next week in OB/Gyn.

OB/Gyn day 1

Given the things I learned in Pediatrics, I thought that this week in OB/Gyn I would not get to see a delivery at all. But the hospital's first birth for the month of June happened on the first day I was there. There was a scheduled C-section and the doctor told me to come and watch. I had been hoping to be able to see a birth in this department and I was so privileged to have the opportunity to see it happen. The intern in the department, Vicky, watched with me and explained some things. When we got to the surgery, the doctors had already started cleaning the area to prepare for the incisions. They then started cutting carefully through each layer of tissue separately, peeling them apart as they went through. After they cut through the endometrial layer, Dr. Tsao (my preceptor and head of the department) reached his hand in to find the head. He then took a tool that looks like a toilet plunger and grabbed the head. He moved it around in a circular pattern, which resembled stirring a large pot, and slowly pulled the head out. He wiggled the baby out, cut the umbilical cord, and then gently shook her to make her cry. She cried and the nurses cleaned her up and put a clip on the cord. A newborn baby is bluer than I expected and it took a while for her to turn pink. They woke the mother up to show her the baby while the surgeons were working to start closing everything. Stitching each layer of tissue took just as long as getting the baby out. They started with the endometrial layer and have to make sure that there is no fluid leaking out of the incision. They cauterize where needed to stop bleeding and fluid leaking, and then move to the uterus, peritoneal sac, abdominal muscles, fascia, fat and skin. The skin is stapled shut and the mother is wrapped in bandages and a brace. Seeing this surgery was amazing to say the least, but also a great learning experience. Seeing tissues in their live form is so different from the cadavers. And birth is nothing short of incredible; seeing new life for the first time is indescribable.

Outpatient clinic in OB/Gyn consists of A LOT of PAP smears. Women older than 30 in Taiwan are allowed to get one per year with the National Insurance. There are 4 basic cancer screenings that Taiwanese people do yearly: cervical, breast, colon and oral. Each of these cancers have a better prognosis when caught early. So many women come to get their screening. It is very fast as they usually don't really have to speak to the doctor unless there is a problem. The nurse and intern take care of most of them. They even let me try to do one. It is a really simple procedure but I think I will need to work on it a little more. Between cases, Dr. Tsao presented about acute abdominal pain in urgent care. I learned a lot from his presentation. He went over differential diagnoses for abdominal pain and how to treat it. He told us about the more emergent cases and which you need to rule out first. He also did several ultrasounds and I got to hear a baby's heartbeat and watch its heart beating. He showed me IUD placement and removal as well. In the afternoon, another doctor showed me a CT scan of a woman who has a ovarian cyst that is about 25 cm. It takes up a large portion of her lower abdomen. I imagine that after the surgery she will lose a few pounds. She is scheduled for surgery on Friday, so I'll be able to watch them remove it. She had initially declined surgery, but is now going to go through with it.

The first day in OB/Gyn was wonderful. It was definitely a day that I will not forget and I learned so much in such a short time. We have not studied the reproductive system yet, so this has been a crash course. I will definitely have a good head start in the things that we will study next year. I can't wait for the rest of the week.

Week 2 Pediatrics

Pediatrics in Taiwan is becoming a dying art. After speaking with a resident today, we found out that around 60 babies were born in Taipei Hospital last year and no deliveries have occurred in the month of June as of today. The neonatal ward and the nursery are empty. The population in Taiwan is getting older and less people are having children, leading to a decreasing patient population for pediatric physicians. I didn't realize that this would be a problem; in the US, pediatricians seem to be in higher demand. The birthrates for 2008 shows that the birth rates in the US are almost twice that of Taiwan. And apparently Taiwan has the lowest birth rate in the world. Dr. Tsai told us that there is a shortage of pediatricians in Taiwan because they work hard and are not paid well. It is not a popular specialty for new physicians. In spite of this fact, the pediatric department meeting discussed 15 inpatient cases in the course of about one hour. It very fast-paced to say the least. But it was very interesting to observe.

After the meeting Dr. Wu took us to see some of the patients. He discussed each of the cases with us and showed us around the ward and the floor. It was very helpful to learn how things are organized and see where everything is. We saw four patients and then Dr. Wu gave us a presentation on airway diseases in pediatrics. His presentation was very informative and a good review of the things we learned in our respiratory classes. He also showed us the different types of inhalers and how they work. Listening to his presentation reminded me how much we have learned in the last year and how much more there is to learn in the clinic.

We later met Dr. Tsai who presented us with a case and asked us to give a diagnosis. It was a 10 year old boy who presented to the hospital with dyspnea and abdominal pain. Jessica and I were able to correctly diagnose the patient with a bronchopneumonia and appendicitis. I really enjoyed applying the knowledge that we have gained in the last year. It was rewarding to know that the hard work in studying everything was actually useful. After discussing the patient, we were able to go and visit him and see how he was. Dr. Tsai said that he was very sickly in the morning. After treatment with IV fluids and antibiotics, his abdominal pain had subsided and he seemed to be in good spirits. It was interesting to see how resilient children are and how fast they can recover from illness.

Outpatient clinic in pediatrics was very informative and great experience to observe. Pediatricians in Taiwan can follow their patients for a longer time than in the US. The oldest patient of one of the doctors is around 40 years old. This patient has been seen by this doctor since he/she was 3 or 4 years old. I found this very interesting since my pediatrician told me to find a new doctor when I was 16. Asthma is becoming a big problem in Taiwan; about 90% of children are presenting with allergies to dust mites which often leads to asthma. I was interested to learn that dust mites are the biggest cause of allergies in Asia, whereas in the US pollen is the biggest culprit. Variation in genetics and environment can be attributed to this difference. Many of the cases in the outpatient clinic had to do with asthma or allergy. This experience has shown me the similarities and differences in diseases between the Asian population and the American population, as well as the differences in health care in Taiwan and the US. I have really enjoyed my time in pediatrics and am definitely considering it as my specialty.

neurology last day

The last day in neurology was very interesting but short. We went on rounds in the morning and visited all of the same patients that we had seen the last few days. Most of them hadn't had a lot of change. The only one that had significantly changed had moved into the ICU because he needed ventilation. A couple of the others were being transferred to rehabilitation because their conditions were stabilized. At lunch a neurosurgeon gave a seminar on case studies of drug overdose and Stevens-Johnson syndrome. He lectured really fast and in Chinese. It was interesting and it gives me something to research so that I can understand it better.

neurology

The last few of days in neurology has only shown me how much I still have to learn. Nicole and I have learned so many things in the last 2 days. We learned the cardinal signs of Parkinson's disease: tremor, rigidity and bradykinesia. We have also learned about the examination and diagnostic tests used in neurology. The technicians in the EMG and EEG labs have been very helpful in showing us how the tests are done. We watched a 2 year old have an EEG done, which was a little difficult to watch as he was not happy at all to have electrodes in his hair. The second patient was an adult and was much easier to watch. The EEG is a test to look at the conductance in the brain to see if there is any sort of seizure-like activity. The EMG is a test to that looks at the status of the nerves of muscles. The patients often have some sort of spinal injury and this test shows which specific nerve is damaged. We watched 2 EMGs done on 2 young men. The first one was rather painful to watch. A needle probe is put into the belly of the muscle and the patient is asked to contract that muscle to test for the neurological stimulus that is being sent by the brain. A polyphasic wave suggests that there is a problem in the innervation of that muscle. The first patient we saw was in quite a bit of pain as he contracted the muscles with the needle. His test was done on his calf muscles and lower back. The second patient that we saw had his test done on his arms and didn't seem to be in any sort of pain. He must be a stoic. I can only imagine how much pain there would be if I had to contract my muscle with a needle stuck through it. It was quite difficult for me to watch the first patient as he lay in pain. The last test that we were able to watch was an EP (evoked potentials). The patient's brain is monitored with electrodes as they play sounds in each ear. This tests the auditory pathway in the brain stem and the acoustic nerve. It seems like a very easy and non-invasive way to test the sensory pathways to the brain. The patient just lays down on a table and listens to sounds. Much easier to watch than the EMG.

While we were waiting to see the EMG we were able to tour the physical therapy department and see the different modalities they use to rehabilitate patients. It was quite interesting to see the different machines and tools they had for the patients. It is also interesting to note that patients can continue physical therapy as long as they want. All they have to do is pay $60 (Taiwan) per visit to use the facility. The therapists said that many patients take advantage of this and use the facility far more than is necessary for their condition. Even though the facility remain quite busy all the time, it seems nice that the national insurance program allows patients to use the facility for their condition.

Going to the wards showed the realities of patients with serious neurological problems. The doctor is prepped by a nurse who sees all of his patients. She also follows him during the rounds to understand what the doctor is ordering for the patients. We saw several patients that had gone through a stroke and were recovering. One of the patients was in the ICU and the doctor was monitoring her closely because brain edema could occur in the next couple of days. She also had congestive heart failure and hypertension which also required close monitoring to keep her condition stable. Using the things that we studied last year, we were able to discuss her condition and understand the fine balance in fluid intake/outtake that the staff was trying to achieve. We learned about the coma scale and the tests that are done to determine the consciousness of a patient. The neurological workings of the body are quite intricate and interesting; I am privileged to get this sneak peak into the things that we will be studying this fall. I have so much to learn not only in neurology but in patient care in general. It makes me nervous about our year to come in school but this rotation will definitely give me a head start.

outpatient clinic

Having seen two days of outpatient clinic (in neurology and oncology) has shown me the differences between Taiwanese and US styles of patient care. The Taiwanese clinic seems to be more efficient because the doctor is able to see 10-20 patients per hour. The doctor here sits in his office/exam room with 2 nurses and patients come in and out to speak with him. The patients are all numbered and, like the DMV in the US, are called in by number outside of the door. The doctor spends about 5-10 minutes with the patient, answering any questions and doing any quick exam that is necessary. If the patient needs lab tests, the patient is sent directly to the lab and the results are sent back to the doctor fairly quickly to be discussed with the patient. The insurance system is electronic and the doctor does the billing while speaking with the patient. The charting is also done simultaneously and is printed out for the nurses to paste into the patients chart. And this all occurs in the short time that the patient sees the physician. The doctors that I have shadowed also seem to make time to explain small things to me in English, which is quite impressive considering the speed at which they are working. Comparing this to the US, where the doctor probably sees four patients in one hour, and has to do his charting and billing separately, this seems to be very efficient. I have really enjoyed seeing this difference and appreciate the fact that the US should possibly learn from other countries to make the system more efficient.