6/16/2011, 6/17/2011 - Pediatric - Jessica

The last two days at pediatric was fantastic for me! I originally thought that the last two days will be relatively less interesting than the other days because it will be mostly outpatient clinics and thus less time for hand-on patient interaction or preceptor time, I was totally surprised to find myself enjoying every single moment of it! Although I have to admit that sitting in the stools all day long does have its toll on my anatomy, it was well worth it!. Many reasons made the last two day so much fun for me. First, as mentioned before, all of the pediatric department, the doctors, PA, and nurses are all very kind to us and very easy going and fun. Second, the children are just adorable! Although it was heartbreaking to see the actually seriously ill children, it was amazing to see how much endurance and courage the children exhibit against sickness and it was most heartwarming to see how each children recovered so fast after the illness and carry on as if the past few days of pain and suffer never touched them. I especially remember one of the baby girl coming in for vaccination. She smiled like an angel the whole time, even during the needle prick! I think it was this particular trait of children that make pediatric one of the best fields to work on and the pediatricians one of the best people to hang around with. Through working with Dr. Tsai and Dr. Wu, I can really see what it means to be a good physician. I can truly feel their dedication and love toward each and every single one of their patients... even during the trying moments where the patients' family members tried to vend their fear and anxiety toward the child's sickness on the physicians and making the situation more difficult than it has to be. Just like what Karen and I said to Dr. Wu during our last day: I think we are converted life-long pediatric fans from now on!

General Surgery Rotation Day 5 17-June-2011 and Community Service 18-June-2011

The last and final day of general surgery rotation, time flies by too fast. I started the day along with Bor-Han with the book reading meeting in the meeting room on the 7th floor. Today the topic presented was splenectomy. The most interesting thing about the presentation was the discussion about laparoscopic splenectomy being the gold standard for splenectomy for elective spleen removal without splenomegaly. Apparently most of the splenectomy procedures done in the hospital have not been elective cases as after a brief recount by the recount by the physicians at the meeting they could only recall about one video of a laparoscopic splenectomy being done in the hospitals in the records. It seems that in most cases at least in this hospital splenectomy is an emergency procedure and laparoscopic removal would be too slow.

After the meeting at 10:30 I met with Dr. Fan and we continued to discuss about breast cancer management. Dr. Fan gave a brief introduction of the ranking of risk factors for breast cancer in Taiwan and commented about some problems including insurance payouts depending on breast cancer classification. Interestingly Dr. Fan is interested in seeing more studies and research done for breast cancer in the Han Chinese population as he feels eventually specific protocols should be developed as more target therapies are being made available. He also gave a introduction about the different types of surgical procedures for breast cancer starting from the historical perspective of the radical mastectomy, where entire breast, the axillary lymph nodes, and the pectoralis major and minor muscles behind the breast are removed and the serratus anterior and latissimus dorsi are resection to prevent skin necrosis to the move to breast conservation surgery (BCS). Of special interest apparently preserving the shape of the breast after BCS is an ever improving field for plastic surgeons given that they never really know what they are going to get as selective portions of the breast tissue is removed based on what is cancerous. Overall given the short time in the surgery department I am glad that I was given the opportunity to see so much from my preceptor Dr. Fan on the rest of the surgical department.

On Saturday we all got up bright on early to get on the bus at 6:30am to go help out for the integrated community health screening that the Taipei Hospital sponsoring. Bor-Han and I ended up in the oral exam unit where we observed Dr. Li, a dentist examine the local community for various oral problems. For the epidemiologists everyone Dr. Li saw had gingivitis. I am not sure how helpful we were, but I am glad that we had a chance to interact with the community.

Genral Surgery Rotation Day 5 (June 17, 2011)

June 17, 2011

My last day in surgery rotation started with a presentation about splenectomy. The surgery department had the first part of the presentation last week already, so today’s topic focused mainly on follow-up care of asplenic patients. Asplenic patients are known to be more vulnerable to infections especially to encapsulated bacteria like Streptococcus pneumonia, Haemophilus influenzae type b and Neisseria meningitides. Therefore vaccination is important for those who received splenectomy. Early recognition of infection is also important for these patients since they can quickly develop septic shock, DIC, and organ failure.

After the presentation, Dr. Kuo told me that he will be pretty busy until later afternoon, so I went to follow Mickey’s preceptor, Dr. Fan. He gave us a lecture about breast cancer, which is increasing rapidly in Taiwan. He pointed out several risk factors of breast cancer. For example, previous finding of atypical ductal hyperplasia can increase the risk to 8-10 folds and family history of breast cancer can increase the risk to 4 folds. Birth age > 30, menarche age < 10, and menopause age > 55 all can increase the risk too. Like Dr. Chen from my previous oncology rotation, Dr. Fan also said that the information we learned can be out of date or incorrect in the future. So he suggested us to focus on learning how to make the decision for treatment instead of memorizing all the possible treatments.

In the afternoon, Mickey and I met Dr. Kuo in the conference room again. Since we will have a case presentation next Monday and I am in charge of the surgery part, I discussed with him about how much material I should put into my presentation and made sure anything I have is correct. He suggested me to keep my presentation short and simple and not provide too detailed information since a lot of our audiences may not know much about surgery. His corrections and suggestions are really useful and prepare me well for the upcoming case presentation.

During this week of general surgery rotation, I not only learned a lot about common surgeries such as appendectomy and laparoscopic surgeries but also gained experiences in basic surgical skills such as suture and using laparoscopic instruments. I deeply appreciate Dr. Kuo for giving me the lectures about those basic and common surgeries and providing me the access to practice basic surgical skills. I also want to thank Dr. Ou and Dr. Fan for providing us the opportunity to watch real laparoscopic cholecystectomy surgery and guide us through the operation. The experiences I had in this week of general surgery rotation not only prepare me well for my future surgical rotation but also are helpful even I go to other non-surgical specialty in the future.

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.

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.

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.

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.

Genral Surgery Rotation Day 4 (June 16, 2011)

June 16, 2011

Today we attended the journal reading meeting of surgery department. Dr. Xiao, a resident physician in the department, gave us a presentation of an article about the use of extracorporeal membrane oxygenation (ECMO) vs. interventional lung assist membrane ventilator (iLA) on ARDS patients. She made a comparison between these two techniques. For example, unlike ECMO that can remove CO2 and add O2, iLA can only remove CO2 from the blood passing through it. Even though iLA has less distance of circuit, they both have anticoagulation complications as result of using heparin. Dr. Chen, the cardiovascular surgeon in the hospital, gave his comment after the article presentation. He mentioned that more and more hospitals in Taiwan will perform ECMO because it’s covered by the National Health Insurance. He also pointed out that even though no scientific evidence supports ECMO as treatment for ARDS, it’s logical to use this technique to buy patients more time so that other treatments can work out. This idea will be important for me when I deal with the patients with lung or/and heart failure.

Since Mickey’s preceptor would be pretty busy whole day, Mickey came to Dr. Kuo’s lecture with me. His first topic for today is hemorrhoid, a pathological change of anal cushions that can lead to bleeding, swelling, or/and pain. It’s associated with not only constipation but also diarrhea and pregnancy. It’s classified to external or internal depending on if it’s outside of dentate line. He also introduced different treatments (e.g. rubber band ligation, hemorrhoidectomy, and procedure for prolapse hemorrhoid) for different stages. Then he switched the topic to talk about inguinal hernia. We learned the different etiologies between children and elders and two types of operations, tissue repair and tension-free repair, used to treat it. Dr. Kuo ended his lecture by talking about soft tissue infections such as cellulitis and necrotizing fasciitis. The symptoms include redness, swelling, tenderness, and local heat. But he also pointed out that the symptoms can vary depending how deep the infection is. For example, the infection of deep soft tissue like fascia and muscles usually show no redness and swelling until advanced stage. The treatment for soft tissue infections usually starts with antibiotic therapy, and drainage and debridement operations are used when the symptoms persist. After the lecture, Dr. Kuo checked the gauzes I used to practice suture yesterday and said that we can get more suture lines from the operating room to practice. We later got more suture lines from the OR and practiced to improve our suture skill.

General Surgery Rotation Day 4 Suture Practice Time 16-June-2011

Start off the day at the Surgery meeting at the 7^th floor meeting room. Today was a presentation about using extracorporeal devices in the management of ARDS with extrapulmonary involvement, in particular the use of ECMO (extracorporeal membrane oxygenation) and iLA (Interventional lung assist) in patients that have compromised lung function. I got a good review about the criteria of ARDS compared to acute lung injury. Both the advantages and limitations of using ECMO and iLA were presented. In regards to ECMO there is little to no support supporting its use as an effective treatment and the cost often limits its use. However as Taiwan national insurance pays for ECMO (very surprising as it is deemed expensive) it is often utilized as more a supportive care rather than treatment for patients that come in with ARDS and/or lung function compromise. At the meeting they explained that often the ECMO will be set up in the venous to venous (veno-venous ECMO) to bypass the heart as while ECMO can replace the heart when set up in Veno-arterial orientation, ECMO has not been shown to support the heart as it does support other organs in any format.

After the meeting Bor-Han and I received a mini-lecture from Dr. Kou about some common surgical procedures including hernia repair, and hemorrhoid management. Then we remained in the meeting room to practice suturing using gauze. Again pictures below:

The set up:

Bor-Han suturing

Me suturing:

General Surgery Rotation Day 3 OR Observation 15-June-2011

This was the first day that I was able to see a complete surgery done at the OR. At the start of the day I met with Dr. Fan at 9:10 where he performed a removal of a suspected cancerous lesion (firm and immobile) in a patient’s lower extremity. Even though Dr. Fan said it was a very simple procedure I was excited to see him in action and interesting to hear him explain about the whole process. Later on in the afternoon Bor-Han and I got to see a laparoscopic cholecystectomy (gallbladder removal) which uses four ports. The procedure was done by one of the residents with the chief resident as a teacher and under the supervision of Dr. Ou, Liang-Hung (Dr. 歐亮宏), Dr. Fan was also present most of the time and offered us many explanations on what was happening during the procedure. Dr. Ou also took some time to explain to us about the different types of laparoscopic procedures currently in use including ones done with natural orifices such as with an endoscope and offered to let us see a single port laparoscopic procedure such as an appendectomy if one becomes available. Overall it was very interesting to see a complete procedure from the start, anesthesia to finish, removal of the gallbladder and suture. I will be looking forward to the rest of the days in the surgical department. Now for some pictures with our scrubs on, guess mine turned out blurry:

Me in scrubs:

Bor-Han in scrubs:

6/14/2011- Pediatric - Jessica

The second day of pediatric was a totally different experience from yesterday. Yesterday was mostly lecture, with occasional opportunities to visit the patients in their hospital rooms. On the contrary, today was all outpatient clinics and with many opportunities to observe real patients. We begun the day with Dr. Wu (吳俞哖醫師), a pediatric cardiologist. Dr. Wu has actually retired recently and is only holding outpatient clinic now for the patients that she has seem over the years and had developed a close relationship with. Dr. Wu is a very easy going and gregarious person and we were able to discuss many things, from medical facts to the Taiwan medical culture. But the most memorable part of it was her enthusiasm and attitude toward pediatric and her patients. After talking to her, I was able to renew my determination of becoming a physician once again and I sincerely hope that one day I will be able to become a physician like her.

During lunch, we learned a surprising news from Yuyu, that our colon cancer presentation has been moved up to next Monday instead of next Friday. We were a little caught off guard by the new due date, since we are still in the preliminary stage of our presentation (Mickey just got the surgery materials today), but I think if we work hard the next few day, we should still be able to have fun and still do a good job on the presentation.

The afternoon was spent in the outpatient clinic with Dr. Su (蘇冠文醫師), a pediatric immunologist. Dr. Su did his research in pediatric respiratory allergies and taught Karen and I many interesting aspects of pediatric allergic diseases, such as the correlation and possible cause of allergic shiner by chronic allergic rhinitis/sinusitis and the epidemiology of  asthma in Taiwan: its strong correlation with dust mite allergy for the Taiwanese people (about 80 %). During our conversation, we found out that he actually studied at the US for a short time and is quite familiar with a lot of the US's health system. In fact, Dr. Su had researched about Touro prior to our meeting and we had a short conversation about the DO profession. Dr. Su also mentioned that this coming Thursday's outpatient clinic feature a three-panel special clinic from the pediatric, developmental rehabilitist, and psychiatric department specifically designed for children with behavioral problem. Both Karen and I think Thursday's clinic will be a great learning opportunity and we are both looking forward for it with excitement.

6/15/2011- Pediatric - Jessica

We spent today in the outpatient clinics again, but with different preceptors. We joined Dr. Wu (吳秋文醫師) in the morning and Dr. Wong (王怡人醫師) in the afternoon. Like Dr. Ho from TCM before, as the director of the pediatric department, Dr. Wu has a heavy patient load and worked past lunch to see all of his patients. Unlike yesterday, where most of the patients were here for the doctors' specific specialties, many patients are just here for general complains unrelated to Dr. Wu's specialty, which is pediatric immunology. Especially after the clouding agent problem started, many of the patient were here for testings to determine possible exposure to the clouding agents. The clouding agents were found in many different type of food/health supplement in Taiwan. Among them, the most worrisome for parents are the contamination of certain brands of probiotics and even a syrup of Augmentin, since many were consumed regularly by their children in an attempt to improve their health. The crisis this time created such scare largely because clouding agents over stimulates femalization of developing children and thus, in a culture where continuing the family bloodline is of the utmost importance, created unprecedented panic among the parents. I have been following the news for the past week on the new development and was quite curious to see the actual effect of the clouding agents on the pediatric patients. To my surprise, contrary to the news coverage, out of the 20 patients examined for the sexual organ abnormalities throughout the last two days, only one patient seemed to have underdeveloped genitals. However, that patient also suffer from hypothyroidism, so the actual effect of the clouding agents cannot really be ascertained at this point without further testings. We also notice several interesting points about clouding agent testing. For example, we were surprised to found out that the test for sex hormones in pediatric children is often inconclusive, since most of the children will be prepuberty, their testosterone levels will be inevitably lower than the normal amount for adults and thus not entirely reliable when it is lower than expected value and require obtaining separate list of standard values for each age group to accurately determine the results.

Other than the clouding agent testings, we also saw many interesting cases. We begun the day with a case of hip dislocation where the child was too old that tissue has grown between the gap that surgery is the only option now. Remembering our training in our pediatric physical exam lab, we were reminded again the importance of early diagnosis of congenital abnormalities like hip dislocation. In addition, Dr. Wu also pointed out that when asked about abdominal pain, many children tend to just point to the umbilical region for diffuse pain and it should not be taken literally as a sign of localized pain around the umbilical area. Similarly, when the child specifically point to a place far away from the umbilical area, it is usually a good indicator for localized abdominal pain.

Genral Surgery Rotation Day 3 (June 15, 2011)

June 15, 2011

In the morning, Dr. Kuo gave me an introduction of basic skills and tools they used in surgery. He first showed me how to hold the tweezers and scalpel blades like holding pens. He said that’s why you can distinguish surgeons from internists when they are eating steak. He also demonstrated surgeon’s way to hold the forceps, scissors, and needle hold. He grasped by the finger loops by thumb and ring fingers and used the index to help guide the instrument. He then introduced the absorbable and non-absorbable suture lines. He also talked the four suture methods that can be used in different situations and demonstrated how to do two of them, simple and vertical mattress. With his help, I finished my first simple and vertical mattress sutures on gauzes, and I practiced more sutures later by myself.

Before Dr. Kuo left, he told me that he will be busy later today for the outpatient clinic but he can arrange me to watch a laparoscopic cholecystectomy leaded by Dr. Ou in the afternoon. Since Mickey’s preceptor also provided Mickey the opportunity to watch this surgery, we went together to the operating room. The patient is a 69 years old male who had pacemaker installed for more than ten years. Since the patient is obese (95 kg weight), it took longer time to make penetration to abdominal cavity so that CO2 can be pumped in to distend the abdomen, which will allow more space for the surgery. Four small incisions were made to allow access of laparoscope and other instruments. Surgeons started with cutting through the connective tissue to find the cystic duct and cystic artery. Once they were identified, titanium clips were put on and then they were cut. After complete detachment, the gull bladder was put into a bag in the abdominal cavity. The surgeon then broke the gull bladder and bile was sucked out. This way the size of gull bladder got small enough to be taken out through the small incision. Dr. Ou told us that the gull bladder will be sent to pathology to check if there is any malignancy. This experience to watch laparoscopic cholecystectomy not only gave me an idea what a real surgery is like but also helped prepare me better for later surgical rotation.