Never shall I forget the days I spent with you. Continue to be my friend, as you will always find me yours - Beethoven

The driver dropped off Amanda and me at TPE. Before Amanda left to security checkpoint, she said, "It's been nice getting to know you better."

As I'm sitting in the "Barista Coffee" shop on the 4th floor, it's come to me that during this entire trip I was too busy learning as much as I could and making new friends to let it gone unaware that I have also learned more about my colleagues than I did in the entire first year of medical school.

I always talked about how amazing the program and the staff were whenever someone asked. Yet, one of the greatest parts about this trip was the people I traveled with, Amanda, Sandy, Karen, Jessica, Mickey and Bor-han. I cannot imagine having experienced Taiwan with anyone else.

Bor-han is such a gentleman. He always looked out for seats for us girls in the subway and bus. I have a picture of Bor-han sleeping while standing in a packed train. That takes skills! He was a dedicated tour-guide as well. Mickey told me that he spent hours looking through his Taiwanese hot spots book, making plans of where to eat and what to do. I know Bor-han will be an amazing doctor, but he could definitely excel as a tour guide too.

Mickey was also awesome! Some of the things Mickey did that make him so great are his knowledge of technology, economy and history. He seems to know everything!!! I enjoyed his little rams about politics. Also, he refilled our tea cups constantly whenever we ate at a sit-down restaurant. How attentive!

Jessica. Oh, where to start?! Her mom was so nice. She sent us delicious food and Jessica had to cook them in the boy's room. I can see from where Jessica got her kindness. It was so much fun having dorm-cooked meals. Since there was no actual kitchen or cookware, we had to improvise. We ate out of rice cooker's lids, washed dishes in the bathroom sink, used a face cloth as sponge. I have pictures to prove that these things did happen!

I like Sandy. She's always funny and up for fun things, like helping me turn a tour bus into a party bus, and was not afraid to dance with me and sang at the top of her lungs without a care in the world. Years from now when I watch the videos I took of us dancing in the bus, I will have a good laugh at our foolishness.

Amanda and I had many good conversations. She's such a motivation! Being a mother and medical student while working, volunteering and doing research is not easy. I don't know from where she got her strength but I would love to have some of that strength. I will try to not complain too much when I'm overwhelmed with school works, because if Amanda can do it, so can I!

Karen and I didn't really talk much in school perhaps because we were in different groups. It's been nice getting to know her. She's a very thoughtful and considerate person. She doesn't seem to talk much, but when she does, whatever she says is very well thought-out. I hope to talk to Karen more when we get back to school.

I could go on and on about how great they are, but it would take too long and my fingers might get tired from typing.

I also learned so much about Taiwanese culture and healthcare system. The food is so good and I'll miss going to night markets and the food vendors on the streets. I'll probably go through withdrawal the first couple of days when I'm back to the US, not because of the jetlag but because I'll feel weird not waking up early in the morning to go work in the hospital. Oh the breakfast food in the back of the hospital, the hospital smell (I love hospital smell for some weird reasons), the people walking around with their papers, the chatting noises, the catheter lab, the scrubs, the food from cafeteria, etc. I'll miss all of that!

I know when I come home, I'll be telling stories about Taiwan for days and maybe years from now.

I'll be boarding in 5 hrs and am experiencing separation anxiety!
再見 Taiwan! You've been really good to me! Hope to see you again one day. By then, Taipei 101 will be the 3rd tallest building in the world.

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!

Neurosurgery week

My week started out at the ICU. Dr. Liao introduced with an increase ICP. He stayed up all night to perform emergency surgery on this patient. Later in the day, he gave a presentation on ICP monitor insertion.

Indications for ICP monitor insertion: traumatic brain injury; non-traumatic hemorrhage; ischemic stroke; tumors; encephalopathy (hepatic, ischemic, encephalitis, etc.)

Monro-Kellie Doctrin: brain, CSF, blood, something else (clot, tumor, etc.)

Classifications of ICP monitor: EVD (usu. as 1st choice); Fiberoptic monitor; subarachnoid bolt and cup; epidural air-coupled strain-gauge; others

Definition of monitor = no therapeutic effect; only shows you a patient's condition (except EVD)

Optimal ICP = 15 mmHg or 18 cm H2O.

EVD vs. Fiberoptic ICP monitor:

EVD: fluid coupled; CSF drain; inexpensive; skill required; recalibration; not portable

Fiberoptic: fiberoptic; no CSF drain; expensive; can by place "any" place (only if the brain swelling resolves quickly and early); no recalibration; portable. Right now, Taiwanese insurance doesn't cover for fiberoptic ICP

Complications of ICP monitor: intracerebral and/or intraventricular hemorrhage (refer back to Dr. Chen's statement about how Asians seem to have bleeding problem more than Caucasians. I might look into this more, since it has come up a couple of times already. Maybe do a little research on this???); infection; transducer breakage; error in reading

EVD - more risks for infections b/c of use of biological materials. Place the monitor away from main wound to prevent infections.

Use Kocher point: located 2.5 cm from midline and 11 cm posterior to nasion; at least 1 cm anterior to coronary suture to avoid motor strip (from Wiki)

Day 2 is a day I'll never forget. Amanda and I got to scrub in and be first assistants for a C4-C5 herniated IV disc. Dr. Ting removed the entire disc and replaced it with an artificial disc with coral bones. We got to hold the clamps and helped suction. Dr. Ting used microscope to help him as he moved toward the posterior side of the spine. It was pretty amazing. It was difficult as well. You have to be ambidextrous and know where your left and right vs. the patient's left and right are. Ah, I really have a long way to go! After the surgery, Dr. Ting talked to us about some other cases. He told us complications of acute hemorrhage which include chronic subdural hemorrhage, delayed hemorrhage; seizure; stroke-like vasospasm.

I got food-poisoning the next day, so I missed the Lspine herniated disc surgery. I was a little sad but I needed to get better so I wouldn't miss the rest of the week.

On day 4, Dr. Liao gave us a presentation on Trauma care. In Amanda's blog, she wrote down some of the main points. If you guys want additional notes, you can copy mine. It's really too long to type down everything. He also gave us an article "Encephalopathies Caused by Electrolyte Disorder." You can probably google the article up. It's pretty interesting and easy to read. Later that afternoon, Dr. Liao treated us out to all-you-can-eat hotpot. The food was really good. It's funny how I ate a lot just after my food poisoning/stomach flu experience a day prior.

On the last day, Amanda and I watched a couple of videos.

Common carotid a. has low resistance flow, even has flow during diastole.

Internal carotid a. has low resistance flow, diastolic flow falls all the way to base line

External carotid a. has high resistance, sharp rise in systole and sharp fall in diastole

Vertebral a. has low resistance flow, low velocity

Abnormal flow patterns: stenosis to an artery causes tubulent flow. Flow uses non-stenotic pathways which serve as collateral arteries

There was a good picture of the circle of Willis if anyone wants to copy it. The way it was drawn looked like a heart. So cool!

Cardiovascular Surgery 2-5

For anyone who wants to read the article on ECMO, it's called "Extracorporeal Lung Assist in Severe Respiratory failure and ARDS Current Situation and Clinical Application."

At the OPC, I learned that stens used for coronary artery surgery are not recommended for use in lower limb vessels b/c vessels of lower limbs lie within the muscles. Thus there's a concern that shear force/tearing force will break the stent and cause more serious issues. So for now if there's a stenosis of deep vessels of lower limb, only dilation technique is used. If stenosis repeats, dilate again. In some other countries like France, stent in lower limb vessels is used.

At the clinics, I found that a lot of patient with PAD have DM and also develop gangrene.

For the rest of my CV surgery week, I got to observe many embolectomy/thrombectomy procedures that precede dilation of vessels in patients who have had grafting. Dr. Chen removed the thrombi in patients' vessels then perform PTA balloon to dilate the stenotic vessels. In these cases, stenosis seems to be recurrent.

I also got to see PTA done on a branch of the circumflex and LAD done by a cardiologist. It was amazing! During the procedure, there was an acute thrombus and the surgeons were very calm and quick to remove it. It would have been a serious complication if they hadn't caught that thrombus. Talk about performing under pressure!

On Friday, Dr. Chen performed the AAA surgery. It was the 2nd AAA surgery ever performed at the hospital. I felt privileged to be there. Again, I was so amazed by the complexity of the surgery and the skills that Dr. Chen possesses. I was outside watching the surgery through a glass mirror and from a monitor, admiring modern medicine and technology which allow these kinds of procedures to be done, and a lot of people are saved. Before closing up the patient, Dr. Chen allowed me to be next to him to take a look at the incision site where it all began a couple of hours prior. The surgery went smoothly and ended beautifully with a round of applause.

During my CV surgery rotation, Dr. Chen reminds me that being a good surgeon is mostly about practice and improving one's skills. The intellect is important too, because it helps guide a surgeon's skills. But knowing everything in the textbook is not everything. Sometimes, you need to improvise during a surgery because nothing goes exactly like it is described in books. Surgery is like art; sometimes a good piece of art is purely improvising.

Cardiovascular Surgery - Day 1

I started out with a review on DVT. The 3 main causes of DVT are: 1. blood stasis 2. deficiency of coagulation system 3. trauma leading to injury of endothelium.

Dr. Chen discussed a very interesting topic. He told me that pulmonary emboli is not as a severe concern in Asian population as it is in Caucasian population. Asians, however, do not clot well so thrombolytic agents are used in lower dose. There are no solid research studies yet, but the doctors in many Asian countries all notice this pattern in their patients.

Note: tumor of pelvic area can have similar effects as DVT. CT scan is more sensitive to rule out tumor.

We also talked about how insurance will always affect doctor's decisions to what treaments will be given to patients. Whatever type of insurance a patient has, a doctor's responsibility is always find the best treatment that the patient can afford.

Then we talked about a case of abdominal aortic aneurysm.

Risk factors: smoking; genetic influences; atherosclerosis; infection; trauma; etc.

Criteria of for operation of aneurysm: 5cm or 1.5 x diameter of your normal size artery. If the aneurysm is less than 5cm or 1.5x diameter, then follow patient for 1/2 year. If the rate of increase is 5 mm in size in 6 months, then surgery is recommended.

I also learned about hybrid procedure. it combines minimally invasive coronary artery bypass surgery (TECAB or MIDCAB) with catheter-based coronary intervention(PTCA, stenting) (can read more on umm.edu/heart/hybrid.htm)

At the outpatient clinics, I saw many patients with PAD, with diabetes, gangrene (wet/dry), varicose veins

Some review:

PAD = obstruction of large arteries not within coronary, aortic arch vasculature or brain. Etiologies: atherosclerosis; stenosis; emboli; thrombus. Can cause acute or chronic ischemia.

Fontaine classification for chronic PAD: 1. claudication, incomplete blood vessel obstruction. 2. intermitten claudication 3. pain at rest, mostly feet, increase when elevate limbs (serious in PAD) 4. gangrene and difficulty walking (biological tissue loss)

5 P's for acute PAD: pain; paralysis; pale; pulseless; parathesis

Aortic dissection: inner wall of aorta causes blood to flow btw layers of wall of aorta and forces the layers apart. Classification: Stanford (A. ascending aorta and/or aortic arch, possible descending aorta B. descending aorta without involvement of ascending aorta or aortic arch)

First day in CV surgery was so much fun. I was lucky to see different presentation of PAD.

Neurology - Last day

I went to the ICU and saw the old lady whom I first met on day 3 in the ICU. She was still in a semi-coma state. The nurses were washing her. She was still being monitored closely.

We then went to ward run and saw the patients we did the last couple of days. They were more stable.

My day ended with the conference in the afternoon. The presentation was about ARDs of AED and SJS. The discussion was in Taiwanese so I did not understand much. But there was handout of the main points so that helped.

I had some time to reflex on the neurology rotation week. I feel so blessed to have been able to come to Taiwan to intern. My preceptor was amazing and I learned a lot from him. Ms. Yu Yu, Jessica and Angie were so kind. I cannot ask for a better first week than this.

Neurology - Day 3

On Thursday, we went to NCV/EMG lab but there wasn't any study so the doctors in Physical Therapy dept. showed us around their facility. Again, the head of physical therapy told us that some patients do come in more than they should. So we asked how they determined who get tx if the patient # becomes more than the facility could accomodate for each session, and he told us that they prioritize patients (who will get the most of out this, who could really improve from the tx's, severity, etc).

We went to meet with the superintendent at 11. That was pretty cool. He's so nice. He is a busy man and he took time to meet with us students.

In the afternoon, we went on ward run. I saw the same patients I did on Monday. They all seemed to be doing better. They were more alert this time.

In the ICU, an old female patient suffered ischemic stroke, most likely due to her A.Fib. She was being monitored carefully to prevent edema which develops 4 days, and she had been in the hospital for 2 days. I learned about neurological index: eyes are rated 1-4; best verbal respponse 1-5; best motor response 1-6; arms 1-5 (There are more categories but I didn't get them all down).

I also learned about:

Cogwheel rigidity (def from medical dictionary): muscle response with cogwheel- like jerks to the use of force in bending the limb (e.g. Parkinson)

Lead pipe ridigity: a state of inflexibility and stiffness that remains uniform throughout the range of passive motion --> associated with disease of basal ganglia

I would go on youtube to watch how the techniques are performed

On brain CT, old stroke appears as dark as CSF while new stroke is darker than brain matter but lighter than CSF

Plasticity develops 1-2 weeks after stroke

Later that day, we went to EMG lab

Indications for NCV include: CTS; ulnar neuropathy; peripheral neuropathy; brachial plexopathy; radiculopathy; myasthenia gravis; muscle disease

Indications for EMG include: radiculopathy; neuropathy; muscle diseases; motor neuron diseases

Neurology - Day 2

I spent the afternoon in the clinic. Dr. Yu did consultations in the clinic. Here in Taiwan, the patients come into the clinic room. Dr. Yu knew most of the patients and their conditions really well. The pace was really fast.

Many of the patients had Parkinson disease. Cardinal signs of Parkinson's: rigidity, resting tremor, bradykinesia.

I also learned about:

Tinel sign: performed by tapping over the nerve to elicit a sensation of tingling/pins or needles. It is used to detect irritated nerves. (e.g. test median nerve for Carpal Tunnel Syndrome)

Romberg sign: to test drunken drivers and neurological disorder. if +, suggests poor propioception

Phalen test: used to diagnose Carpal Tunnel Syndrome.

Later in the afternoon, EEG lab:

Indications: altered consciousness; seizure disorders; tumors; head trauma; headaches; brain absess; mtabolic encephalopathy; behavioral changes; adolescent disorders; intermitten explosive disorder; OCD; anxiety & panic disorder; bi-polar; RLS; Shaken baby syndrome; ETOH (from telemedx.com)

The use of hypoventilation in EEG lab is to wash out CO2 --> vasoconstriction of vessels in brain --> enhance abnormality

The use of light in EEG lab is to stimulate alpha wave

Ask patient to close eyes --> alpha waves should be present. Open eyes --> alpha waves should go away

Epileptic discharge --> see spiky alpha waves

Dr. Yu told me, at our level, it is important to know when to order EEG. The interpretation part of EEG takes a "life time."

I asked Dr. Yu on Day 1 which I forgot to blog what differences he noticed btw US Health care and Taiwan Health care system (since he's been to the US). He told me that most people have the government insurance, which is fairly cheap, so a lot of patients come to see doctors more often. Health care is very accessible in Taiwan, and some patients take advantage of this and come in to see doctors more often than they should, which is not good sometime. He also said that in the US, we have stricter requirements about ordering tests (order necessary tests with appropriate reasons).

I noticed that everything at TIHTC is very fast paced, while as Dr. Yu mentioned there are many procedures or "layers" to US health care system.

Neurology - Day 1

We started off the day with a case study. That was pretty interesting. It totally reminded me of our pathology labs in which we had to discuss cases with our TBL group. I always found myself learning a lot from case studies.

So, at 9am I went on rounds with Dr. Yu.

Case 1: 65 yo female found unresponsive at home for 2 days. H/o DM which is under control with diet and medication. General weakness (3/5) upon admission. Stable after 2 days at the hospital. On Furosemide to help with pitting edema. Was given ASA but had GI bleed so stopped ASA. Give 1st generation Cephalosporin because of lower UTI.

Case 2: 56 yo male with h/o HTN and DM. Present with right hemiplagia. He has cerebromuscular disease. Severe hematuria present in urine but is getting better. Continuous flushing blood clots with intravesicular water

Case 3: 80 yo male present with behavioral dysfunction after stroke. Came to hospital in May because of 2nd stroke. Has central nystagmus, suspect central lesion of brainstem. Dysmetria. Brain CT: no hemorrhage (we need to know the differences btw ischemic vs. hemorrhage stroke). An ischemic stroke usually takes 24 hrs to show on CAT, so do MRI (diffusion MRI very sensitive) which is more sensitive to early sign of ischemia. MED: Persantin which enhances ASA effect, Diphenidol for stroke, Colchicine for Gout. Entrococcus spp. found in culture

What I learned on the rounds:

1. How to perform Babinski reflex

2. A. Fib --> blood stasis and blood deposits in dead spaces in atrium--> heart pumps out emboli --> to brain --> can occur major arteries or small vessels

3. Clinical presentations are very important to diagnosis. They guide reasons to order appropriate tests

In the Doppler lab, I got to see how technician performs the study. RI = resistance index. Increase RI if stenosis of arteries.

Indications for Doppler study:

1. Syncope

2. Suspect of atherosclerosis of arteries supplying brain in high-risk patients

3. others (I need to look these up)

What I learned from Doppler lab:

1. Know the circle of Willis anatomy

2. Toast classification of ischemic stroke: a. thrombosis or emboli due to artherosclerosis. b. embolism of cardiac origin. c. occlusion of small vessels. d. other determined or undetermined causes

3. Know hemodynamic criteria for ICA stenosis

At Botox clinic:

1. Indications: dystonia, local pain, cosmetic reasons, writer's cramp, etc.

2. Effects of botox on facial muscle spasm take about 1 week. Do not wash face with hot H2O because that will speed up the effects of botox which last about 3 months (The government only allows 3 tx/yr so most patients come in with full on signs of dystonia)

What I learned at the clinic:

1. Know the muscles of face and neck (very important)

2. #1 sign of dystonia = excessive blinking

3. Meige's syndrome = a type of dystonia, usu. a combination of blepharospasm and OMD