Respiratory Day 4/5 and 5/5 - Sandy

On Thursday morning, Dr. Tseng grimly greeted Jessica and I and said, “I was just told that the patient has expired.” It took me a second to realize what he meant by “expired.” Once the truth clicked, my mind screamed quietly, “No! This can’t be happening!” Despite what we learned in class about breaking bad news (the ABCDEs) I was not mentally prepared for a such heavy task in the morning. My eyes focused on Dr. Tseng as the patient’s son walked into the room to see his mother one last time. Dr. Tseng told the son the official time of his mother’s death while maintaining his composure. The son lightly stroked his mother’s forehead before he walked away with tears in his eyes. I was touched by the son’s simple yet genuine act of love. Dr. Tseng gave the son quiet time for mourning - he showed a great example of what it means to be a physician in times of need, but a bystander in moments of silence. I realized a physician must be ready to deliver bad news at anytime of the day. I hope I will have the resilience to handle these tough situations with compassion, as Dr. Tseng did.

We spent the rest of Thursday morning running around ICU and wards. We saw a patient with septicemia, infected by Aeromonas hydrophila (a very rare opportunistic pathogen). Then, a patient was newly admitted to the wards under the working diagnosis of pneumonia. After Dr. Tseng asked her a few questions for H&P, examined her tender leg, he diagnosed her with cellulites. I was impressed with Dr. Tseng’s quick thinking.

There was a patient’s family who wanted to discuss with Dr. Tseng about the options presented for the patient. They were deciding between prolonged intubation versus tracheotomy. Dr. Tseng talked about the advantages/disadvantages for each. Risks for intubation include higher chance of infection, lack of dental hygiene, dependency of ventilator, chance of extubation failure. Risks for tracheotomy include surgical risks, as well as the fact that the patient is an elderly who might not respond well to surgical intervention. Dr. Tseng acted as a consultant to the patient’s family, giving them the power to decide on best treatment for the patient. I was inspired by the workings of personalized medicine. Dr. Lin had a family emergency in the afternoon, so we were unable to shadow him. We wished him well and began to prepare for the next day’s rotation.

We followed Dr. Chien in OPD on Friday morning. We saw some interesting cases. A patient with coal miner’s pneumoconiosis, more specifically, progressive massive fibrosis. Patients with this serious type of pneumoconiosis typically present COPD symptoms. I noticed some drugs Dr. Chien frequently prescribes. One is Spiriva (long acting anticholinergic bronchodilator) for COPD, and Symbicort (budesonide/formeterol) for COPD and asthma.

A patient came in with scoliosis skewed to the right had an underdeveloped right lung. Her SpO2 =67% (>88% is ideal). Although she had a home oxygen therapy, she did not have a pulse oximeter to measure her oxygen saturation due to financial difficulties. This was the not the first time financial difficulty has been mentioned. I previously mentioned a patient with OHCA in vegetative state. Her mother came to talk to Dr. Chien about palliative care for her daughter. Due to her financial crisis, she had been unable to find a place that would take her daughter for a lesser charge. Dr. Chien reassured her that many hospitals have funds for these situations and referred her to the social work department. It was great to see how Dr. Chien supported his patients both medically and financially. I was also inspired by how well Taiwan’s healthcare is set up to accommodate those in financial need.

Before I conclude my respiratory rotation, I want to share with you this book that Dr. Tseng highly recommended: Sanford Guide to Antimicrobial Pocket Medicine. It has been another amazing week!

6/24/2011- Respiratory and Thoracic Medicine - Jessica

Today is the last day of our shift in the respiratory and thoracic medicine department. We are with Dr. Chien again in his outpatient clinic. As before, Dr. Chien discussed each case with us after each consultation and Sandy and I were able to not only learn more new medical facts and clinical practices as well as review the things we have learned before from both Dr. Chien and back in Touro. In addition to clinical facts, we also talked about the general differences between the medical environment in US and Taiwan, from the national insurance Vs. private insurance, the different working environments, and even to the different social status doctors have in the two nations. Among all of the things we discussed, the most memorable part is the different social status the doctors here have as opposed to Taiwan. Although in Taiwan, doctors are still considered one of the most respected occupations, the image is rapidly changing now. As the national insurance policy started to take effect, the extremely affordable health care that sometimes disproportionally favored the patients than the health workers made the services from doctors seemed insignificant and relatively lower in value. The negative reports from the news about some bad practices from corrupted or incompetent doctors did not help either. As a result, the image for doctors start to deteriorate lately. For example, just in the three weeks I have observed so far, I have seen at least one patient treated doctors disrespectfully in each week of rotation. The first week in TCM, I have seen a patient have a fifteen minute argument with the doctor for prescriptions that did not fit her condition and symptoms. During the pediatric week, I saw a patient yelling at the doctor since the day before in the ER department and again the next day in the outpatient clinic. I can't say these situations never happened in the US, but it will be very rare. Combined with the already low salary of  the doctors in Taiwan compare to other countries and the fact that health care budget is limited and many hospitals are forced to absorb the difference by themselves when the government subsidies fell short, many incoming students are having second thoughts on entering the profession now. Although the Taiwan national health system is famous for its affordable coverage to all citizens and its extreme convenience for the patients (see my previous blog about my "trip" to the dermatologist), it is arguably based on the expanse of health workers and hospitals. I hope in the future the Taiwanese government can revise to a more balanced system that benefit both the patients and the health workers, since I really think the national health system in Taiwan is really successful in improving general public health and making it affordable and available to all citizens and I hope that it will still be around for the generations to come.

Cardiology Rotation Day 5 The finale 24-June-2011

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

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!

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

June 22, 2011

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

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

June 23, 2011

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

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

June 24, 2011

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

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

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

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

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

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

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

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

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.

Learning happens when it's fun!

Today is the first day I wrote down more than an index card of notes. There was so much new terminology and interesting concepts that I wrote down several pages of notes within 2 hours. So I’m made a mindmap of the notes; you can view the converted outline here. I’ve also attached an outline format in this blog.

We had so much fun today. Dr. Liao treated Nicole and me to a big lunch: all-you-can-eat BBQ seafood and hotpot during lunch. He even invited Maggie, a female surgical resident, to accompany us to add to our fun conversation and cultural exchange! We had a lot of fun chatting, before and after our long, delicious lunch, we learned quite a bit (as you can tell from the notes) about traumatic neurology. I realized that successful and brilliant people like Dr. Liao have a great sense of humor and a sense of wonder; they love what they do, and can’t stop talking about the field of study they have chosen; they make analogy between their medical specialty and daily life stuff. I begin to see that having fun is the key to success. Passion turning into drudgery is the greatest tragedy of all. Switch task, take a break, go shopping, or hang out with friends—always be refreshed and excited when I encounter new knowledge or skills in medicine and in life. The learning will naturally take place when my mind is fresh and inquisitive.

Trauma Neurology
• + - Glasgow coma scale
o classify head injuries
o evaluate and score the best side
o E
• (best) eye opening
• 1-4 pts
o M
• (best) motor
• 1-6 pts
o V
• best verbal response
• 1-5 pts
o total
• minimum: 3 pts
• max: 15 pts
o head injury classification
• minimal
• 15
• clear consciousness w/o prolonged neuro deficit
• no LOC, on amnesia
• discharge w/ head injury sheet
• frank vomiting
• sign of increase ICP
• pupil enlarge
• seizures
• no pain meds stronger than tylenol
• no asprin
• CSF leak
• rhinorhea, otorhhea
• minor
• skull x ray
• not senitive to hemorrhage
• (-) observe for 6 hrs
• (+) head CT
• pt history
• age>65, anticoagulant
• present illness
• mild
• 14
• moderate
• 9-13
• often deteriorate
• severe
• severe
• 6-8
• 3-5
• + - Monro- Kellie doctrine
o brain
o CSF
o blood
• hyperemia
• CO2 retention triggers cerebral vaso-dilation
• more blood in the brain
• ICP
• obstruct venous outflow
• CO2 retention
• more dilation
• CBF
• cerebral blood flow
• k(MAP-ICP) d^4/ (8* length* viscocity)
• modified F = ΔP π r 4 / 8 η l
• laminar blood flow
• clinically we manage MAP, ICP to control CBF (CPP)
• 3 H's
• hypertensive tx
• hypervolumia
• hemodilution
• not necessary in most trauma pts due to blood loss (blood is already thin)
• dilation cascade
• vicious cycle
• brain herniate
• trans-tentorial hernia
• or out of foramen magnum
• dilate
• constrict vaso
• mannitol/hypertonic saline
• draw cerebral ECF into circulation, remove from brain
• IICP
• surgical decompression
• maitain physiologic parameters at normal ranges
• lesion, hematoma removal
• ventriostomy
• sedation
• lower intrathoracic, ABD pressure
• CCP
• increase CCP w/ colloid infusion
• vasopressin=hypertensive tx
• cerebral blood V
• elevate head
• head neutral
• head turning collapse IJV, prevents venous retunr
• repeate 1-4
o others
• brain edema
• trauma, cytotoxic, vasogenic
• hydrocephalus
• less due to trauma
• more due to vascular problem
o hyperemia vs. brain edema
• hyperemia
• cerebral perfusion
• SjO2 <50% • hypoperfusion • SjO2 >80%
• hyperperfusion
• =hyperemia
• jugular venous O2 sat
• =too much blood passes thru brain w/o brain extracting O2
• jugular [lactate]
• =decrease anearobic respiration
• brain edema
• hypo-perfusion to brain
• [lactate] due to less O2 supply to brain
• both have IICP
• ICP monitor can help distinguish the 2
• + - brain resusitiation
o "squeeze (oxygenated) blood into swollen brain)
o patient suffers increase intracranial pressure
• cerebral blood flow
• cerebral perfusion pressure
• manage by increasing MAP
o CPP cerebral perfusion pressure
• =MAP (mean arterial pressure)- ICP (intracranial pressure)
• so if ICP higher
• tranditionally increases MAP aggressively to maintina ICP
• but aggressive vasopressor to increase MAP risk CV collapse
• + - brain injury
o + - by mechanism
• contact (blow)
• focal lesion
• eg. fracture, contusions, lacerations, hemorrhage
• acceleration/deceleration
• eg. whiplash
• diffuse (axonal) injury
• spectrum mild to severe
• physiological -->pathologic disturbances
• small petechia--> prolonged LOC (loss of consciousness)
• axis of rotation (center of gravity)
• more severe shear injury
o + - by stage
• primary
• causes by the above mechanisms
• hematomas
• epidural
• best progonsis, b/c dura's intact, protects brain
• sources
• middle menigial artery
• sigmoid sinus
• venous EDH
• subdural
• sources
• briding veins b/w dura and brain
• brain contusion, brain superficial blood vessels
• couter coup intracranial hemorrhage
• tx
• craniectomy
• store skull bone subcutaneously
• dura-plasty
• w/ external periosteum
• expand dura capacity to buffer ICP increase while brain heals
• ICP monitor
• restore live-preserved skull fragment to the cranium
• skull closure
• CCI
• =counter coup injury
• analogy
• 80% full bottle
• when hit from the bottom, the water near the air/fluid interface moves the most
• more mov't, greater injury
• occiput grounded fall
• frontal CCI
• frontal base, temporal tip
• frontal skull more tortuous than occiput
• frontal grounded fall
• less occipital CCI
• b/c occiput is smoother
• parenchymal
• intraventricular
• hypertensive intracranial hemorrhage
• hematoma signs
• racoon's eyes
• anterior cranial fossa
• battle sign
• middle cranial fossa near petrous ridge of temporal bone
• secondary
• tissue reaction to primary injury
• systemic condition caused by primary injury
• eg. ischemia, stroke
• brain's reponse to injury is more dramatic than rest of body
• inflammation, hyperemia
• + - CCP demand
o sedation
• less work for brain/body voluntary movement
o paralysis
• conscious m't controlled by brain
o hypothermia tx
• metabolic rate
• lower than body temperature, more infection
• hence controversial
o sugar control
• avoid hyperglyacemia
• avoid hypoglycemia
o prevent seizure
• seizures require lots of ATP, increase metabolic rate
• + - CCP supply
o old time
• aggressively increase MAP to counter IICP
• risk, lung edema, cerebral hemorrhaging
• large V fluid in fluid out
• up to 1L/hr
• electrolyte imbalance
• frequent blood test
o now
• CPP maintain at 60 mmHg
• less aggressive
• tx underlying IICP cause
• remove lesion/hematoma ASAP
• normalize physio parameters
• need good baseline cardio-pulmonary-renal fxn to save brain
o manage
• if ICP>20 mmHg
• CSF drainage
• sedation (decrease CCP demand)
• mannitol (decrease ICP)
• hyperventilation
• lower CO2 pressure
• encourage cerebral vasoconstriction
• don't go too far or compromise CBF
• brain CT, pre-op
• delayed hemorrhage
• stroke after injury (esp. atherosclerotic pt)
o ICP
• head up 30 degree
• neutral, non-rotated head
• PaCO2 35-40
• PaO2 100
• sedation especially for pain, derease energy demand
• gentle nursing care
• sedation prior to uncomfortable, painful care
• Na 140-145
• burnt patient may have hyponatremia
• not too high, >155 may cause arrythmia
• seizure control
• dilantin
• mannitol/hypertonic saline
• draw cerebral ECF fluid into circulation
• + - prognosis depends on
o age "remaining viable/ functional brain"
o parenchymal damage, more severe than epidural damage
o 2nd insults
• hypoxia, shock, metabolic
• metabolic encephalopathy
• hyperglycemia
• alter biochemistry in brain cells
• cell death
• hypoglycemia
• energy deficit
o ABC
• airway, breathing, circulation
• + - mneumonics
o external carotid branches
• "Some Attendings Like Freaking Out Potential Medical Students."
superior thyroid, ascending pharyngeal, lingual, facial, occipital, posterior auricular, maxillary, superficial temporal
o coma ddx
• AEIOU TIPS
Alcohol, encephalopathy, insulin, opioids/other drugs, uremia, trauma, infection/inflammation, psychiatric, syncope
o ER/Trauma Hx
• AMPLE
• allergy, medicatio, past medical Hx/pregnancy, last meal, event (precipitating)
• + - cases
o infected craniotomy
• 10 cranial surgery to treat infection
• pt still expired
o hyperglycemia pt
o intoxication
• cocaine
• seizure related to drugs
• alchohol withdrawal
• sympathethomimetics
• cocaine, methamphetamine
• intravascular vasculitis, untractable seizures
• doesn't exclude additional causes
• drunk patient may also have head trauma
•
• sedative+alchohol
• may cause airway obstruction
o TCD
• no net cerebral flow
• anisocoria
• uneqaul pupil size
• ET intubation, hyperventilation, mannitol
• cerebral net flow
• CS score
• craniectomy
o open skull fracture
• pneumocephalus
• dx procedure
• massive CSF leak
• air enter into brain
o aged M
• frequent falling
• brain tumor obstruct ventricle outlet
• distended ventricles
o serial brain CTs
• 6 hrs
• EDH, SDH, ICH
• dangerously high ICP
• remove infarcted brain
o delayed ICH
• R hemi-dysplagia
• + - hospital care
o ABCD
• airway
• breathing
• circulation
• disability
o baseline ABCD
• CHF, COPD, old CVA
o CPR vs CPCR
• intubate if GSD<8 • confirm CS injury • adminster sedatation before intubation o more urgent to head truma • Cardio thoraci trauma with ABC problems • airway compromise o quick id of assocaited trauma • massive nasal oral bleeding • pelvic bleeding • external fixation, tran-catherter arterial embolization • thighs: packing, suture • ABD trauma • simultaneous operation • + - radiological exam o plain films • portabl unit • open mouth (atlanta-axio joint) • "odontoid view" • CXR • pelvis Xray for total hip relpacement o CT • must have stable vital sign • at least 10 minute • shoudl scan all suspicious parts simultaneously • ABD, lower chest, pelvis • facial/C spine o no need • alert, awake, normal neurology, no distracting injuryng • no neck pain, mental status changes • + - trauma guidelines o ABCDE • E: enviromental exposure o high risk • EMT applies collar (C spine protection) o prolonged immobilization • if normal=> may remove collar
• not all injuries need fixation
o wear collar
• if pt's neck muscle is spasmic
• can't visualize the whole C spine
o monoplegia
• brachial plexus injury
• + - 1st tier tx
o gentle care
• w/o sedation
• ICP
• CPP
• >5 minutes of IICP
• nursing activity
• retaping of intubation
o fever
• metabolic rate, inflammation
• more water production
• ICP
o irritable patient
o improper position, sedation
• taper sedation gradually
• keep sedation until day of extubation
• NMB
• neuro-muscular block
• short acting
o rebound IICP
• intermittent mannitol
• now mannitol PRN
o propofol infusion
• anesthetic
• dipropyl phenol
• lipid soluable
• dissolved in water by soymilke
• propofol infusion syndrome
• younger pt insufficient lipid metabolism
• intermittent dose
• rebound ICP
• now continuous infusion
o hyperventilation
• hyopcapnia
• cerebral vaso-constrict
• but avoid hypercapnia
• cerebral vaso-dilate
• ICP
o intraventricular catheter
• IVC
• CSF drain
• bacterial infection higher than fibrostic monitor
o not synchronize w/ ventilation
• pt inspire when machine not delivering O2
• + - 2nd tier
o hypertensive
• blood pressure balance
• bleeding vs. perfusion
o hypothermia
o craniectomy
• don't put the skull bone back during 1st surgery
• +ICP monitor
• 1-3 days
• decompress one side
• after 1 surgery
• IICP persists
• 2nd cranietomoy
• ICP doesn't tell the whole story
• w/o ICP, neurological diseases worsen
• decompressive craniectomy
• frontal, temporal, parietal, lateral flap
• bi-frontal
• smaller window than lateral lesion side
• ICP return to normal
o hyperventialtion
o barbiturate coma
• or increase, more typeso f sedateive
o hypertonic saline
• + - summary
o 15: no medical tx
o 20: meds, NMB
o 30: aggressive tx
o 40: another CT, operation
• decompressive measures
• remove bone
• open dura (duraplasty)
• volume of skull removed accomodate IICP
• close skin
• insert ICP monitor
• pre-op
• poor diastolic perfusion
• post-op
• good dialstoic perfusion
o persistent >40
• bad prognosis
• frank lobectomy
• frontal lobe syndrome
• brain contusion
• mostly superficial

6/23/2011- Respiratory and Thoracic Medicine - Jessica

Due to Dr. Yu's ER schedule today, Sandy and I shadowed Dr. Tseng (曾常新醫師) instead doing patient rounds. The first case this morning was already out of the ordinary for us. We ran into Dr. Tseng just as we were going to knock on the door of the internal medicine morning meeting room. Right from the beginning, we can tell from Dr. Tseng's expression that he was somewhat stressed and preoccupied by something. After explaining that we will be following him today, he explained the situation to us: he had just receive the news of the death of a patient due to sepsis in the ICU ward and was hurrying to the ICU to meet with the family and deliver the news. When I first heard him say "a patient expired this morning", my brain went blank for a second before the thought finally sank in and I finally understood that a human live has just slipped away unbeknown to me all through this morning when I was so busy struggling through the morning commute crowd to get to the hospital from home, my thoughts spent on mundane things that have absolutely no importance in comparison to someone's life. When we arrived at the ICU, the patient laid there motionless, her face and skin an indescribable shade of pale. As Dr. Tseng went over the patient chart with us, I couldn't help but notice how the son gently stroked his mother's forehead with teary eyes and his face filled with sorrow and yet still managed to show such love and tenderness. My eyes teared up at the moment, in fact, just typing about it now is making me emotional still. Even though I knew death is something that all of us will experience one time or another during one's life time, especially for us working as health workers, it was still hard to see it. No matter how much preparation we had in doctoring courses about loss and grief, I think death is something that we can never train ourselves to be truly unaffected by it. I may not even know the patient at all, the only connection between the patient and I based on the couple pages of notes and test results on the chart, her death still saddened me and affected me on a human level. Although the fact that her face was peaceful and her son was by her side to send her off her final journey comforted me and I can only assume that it was a painless transition and suffering was limited to the bare minimum on both the patient's and family's sides.

After talking to the family and documenting the time of death and other necessary paperwork, we continued our morning round with Dr. Tseng. In one of the wards, we joined with a cardiology doctor to visit two patients hospitalized for heart conditions. One of the patient's case was very interesting because a 24 hour EKG report was done on the patient and revealed a >4sec prolonged period between heart beats. Although the arrhythmia can be a side effect from the current infection, but a pacemaker may need to be installed if the arrhythmia persists.

After a quick lunch, Sandy and I returned once again to Dr. Lin's outpatient clinic, looking forward for the surgery video he promised for today. However, when we arrived Dr. Lin was no where to be seem. The nurse told us that due to personal matter, Dr. Lin will be slightly late for today's clinic. Not thinking much of it, Sandy and I just sat and chatted for about 10 minutes in the room. But when Dr. Lin arrived, he seemed flustered and distressed. Dr. Lin informed us that due to a family emergency, he is suspending his afternoon clinic for any further appointments and will see the patients who already had the appointment made as soon as possible and leave immediately after. He apologetically asked us to leave early this afternoon and said that he will show us the videos later next week on a more convenient time. Not wishing to add to his distress and seeing him pressed for time, we replied quickly that it was of course fine and wished the best for him and his family before we left. Although we were able to get a much needed rest this afternoon, Sandy and I were still quite worried for Dr. Lin and sincerely hoped that everything will work out for Dr. Lin and his family.

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.

6/22/2011- Respiratory and Thoracic Medicine - Jessica

Today was a exciting day for Sandy and I. We had a "field trip day" today! Instead of going to outpatient clinic today in Taipei hospital, we were going to meet with Dr. Chien in a special outside clinic for in 名權西路 called "中華民國防癆協會" (Taiwan Anti-Tuberculosis Association). The clinic used to be only for TB cases only, but with the national insurance change couple years ago, now it is a general clinic; although it still has more TB cases due to its renowned expertise in treating the disease. Since we need to be there at 8:45 am today, Sandy and I woke up early and had our first encounter with the Taipei rush hour crowd this morning. Although I knew the MRT is often very busy during the rush hour and that "personal space" is a strictly American thing and often does not apply to Asians, we were attacked by surprise when all of the crowd rushed into the MRT car and squeezed us against each after we got into the car. It was so crowded that we didn't even need to hang on the handrails for balance; we were squeezed so tight against each other that it was impossible for us to move, let alone falling down. Even though we were a little intimidated by the morning commute crowd it was still a good experience, it gave us a new facet to the Taiwanese culture that we have not had the chance to see before.

We met with Dr. Chien at the clinic and begun our day with observing Dr. Chien in the outpatient clinic. Many of the patient were here for previous TB infection follow up and asthma, only 1 or 2 patients were here for general illness like upper respiratory tract infections. Dr. Chien graciously introduced us to the staffs of the clinic and asked the head nurse if she had the time to give us a brief tour and history of the place after the clinic. Dr. Chien then proceed with the clinic and taught Sandy and I more about TB (we saw a real-life case of MAC today!), asthma management, and also more practice on interpreting patients' spirometry (we also had the chance to try it ourselves too) results. After the clinic, the head nurse kindly took us around the facility and gave us a brief introduction of the place and its history. One interesting thing we learned was the selling of stamps in the past to gather funds for TB patients who could not afford the long and expensive treatment course of TB before national health insurance became available to all citizens in 1995. It was especially interesting to me because I also recalled my aunts recounting the tale of patriotic stamp buying during there school days and was able to make the connection too. We also learned about the patient distribution and patient number change in different seasons. For example, as the weather have became quite sunny and drier in Taiwan, the number of patients significantly decreased in this clinic, as most of the patient population (ex-TB, asthma, upper respiratory infection) has less symptoms or fewer chance of infection at this time. However, during the winter months, the clinic will be filled with patients. The head nurse told us as many as 200 patients will be seem in one morning during the peak time!

Decompression for the brain and for the mind.

Dr. Liao (chief of neurosurgery) first took me to remove a tracheo-tube from a patient who had two brain surgeries due to a traffic accident. This 59-year-old female was admitted to the ER with a subdural hematoma and severe scalp lacerations. The hematoma was nearly .8cm in the CT scan near her left frontal-temporal region. The midline of the brain was shifted nearly 1cm over to the right, (larger than the size of the hematoma), indicating a brain tissue reaction, most likely hyperemia to the trauma. So Dr. Liao performed a decompressive craniotomy to remove the hematoma. He also removed a segment of cranial bone and embedded it in the patient’s left lower abdominal subcutaneously. After the cranial bone removal, he performed a dura-plasty to expand the intracranial space to allow the brain to heal without secondary injury from increasing intracranial pressure. He used an autograph in the dura-plasty by extracting the outer-periosteum from the patient’s exposed scalp. He could have sent the segment of skull he cut out to be frozen for preservation until the patient’s healed and ready to put the skull bone back. However, he chose to preserve her skull bone subcutaneously in her left abdominal region so that the bone would be alive. He explained that the freezing process would form crystalline water, which would pierce through osteocytes and kill the living bone tissues. If the bone segment was frozen rather than subcutaneously embedded, it would be innominate upon the cranium reconstruction surgery. The dead piece of skull would be just a bridge for the living cranial bones around it; it would depend on the osteophytes to grow into it. I admire how Dr. Liao opted for a longer surgery because it would preserve the patient’s bone better than the freezing option.

A couple interesting terms I noticed while scanning the patient’s chart
1. Bovie stops bleeder during craniotomy. Bovie is the inventor and commonly used informal name for electrosurgery. Electrosuergy applies a high-frequency electric current to biological tissue as a means to cut, coagulate, desiccate, or fulgurate tissue.
2. Galea suture is made by “few pairs of oblique holes (made by drilling in the surface cortex of the bone flap) through which suture materials may pass. The galea aponeurotica is sutured to the bone flap by means of these holes. These galea-cranium sutures reduce the subgaleal free space in which pooling of CSF or hematoma may occur.” (pubmed article) http://www.ncbi.nlm.nih.gov/pubmed/10481444
3. Silastic sheet: I researched about this and found it in preventing keloid scar formation in plastic surgery. From the context of the patient’s chart, it sounded like the silastic sheet was placed between the patient’s scalp layers during the first surgery. It helped the surgeon separate the layers more easily during the second surgery. I will ask Dr. Liao about why and how he used the silastic sheet on this patient.
4. Hemostasis by monopolar coagulator before wound closure.

He also took me to the ICU, updating me on the patient who’s had continuous ICP monitoring with an intraparenchymal fibroptic probe inserted through a cranial bolt. He said in general we were more concerned about the lower threshold for cerebral perfusion pressure than the higher limit. A low CPP can lead to brain ischemia and subsequent infarction. From the monitor, one can see that CCP is the difference between arterial pressure and the ICP (intra-cranial pressure). He also pointed out to me the difference between an arterial versus a venous catheter. The arterial tubing was a lot more rigid and smaller caliber than the venous one, which were engineered to mimic human vessels. Also he said that surgeons liked to insert catheters away from the surgical sites. This meant craniotomy often has femoral vein catherization to prevent collapse of medication tube during surgery; lumbar spinal procedures have subclavian catheter. He also showed me CT scan of the pelvic vessels—NAVEY (femoral nerve, artery, vein, empty space, and lymphatic’s). The CT scan was captured during arterial phase, so we could see the round femoral artery light up, while the larger caliber, collapsed vein rest against it. It’s generally more challenging to catherterize femoral vein than the subclavian vein due to its smaller caliber, but the latter risks pneumothorax.

Venous infarction
Another interesting concept he mentioned today was venous infarction, quite unique to the brain. Infarction following ischemia in most of the body often is due to lack of blood supply from arterial blockage. However in the brain, you can have infarction caused by venous stasis. This is because the brain has very few lymphatic vessels, and it depends solely on the venous system to drain its blood supply. So if there is a venous blockage, for example due to venous thrombosis, venous pressure would build up relentlessly. Due to the rigidity of the skull and incompressibility of cranial composition, the arterioles would be compressed as venous pressures hikes up. This leads to decreased supply of oxygenated arterial blood entering the brain, hence ischemia and infarction.

Lunch meeting:
Documentary on Herceptin (targets HER2 receptors on breast cancer cells) The movie was very touching and uplifting. I did not finish watching due to the surgery but would love to watch it later.

L3/L4 decompression surgery
Dr. Ding had me scrub in to assist him with the procedure. It was a great honor and pleasure. The case turned out to be more complicated than expected because the disc was completely degenerated and the nerve root got squeezed out laterally. This meant that the patient had lived with the herniated disc symptoms for a while, more than a couple months. It was 2 inches deep before we reached the transverse processes. Dr. Ding removed the deformed disc in bits and pieces. He then soaked the wound with morphine and steroids. I look forward to visiting the patient tomorrow to follow up on post surgical recovery.

Neuro mnemonics of the day
“SCALP” (5 layers of the tissue surrounding the brain): Skin, connective tissue, aponeurosis (epicranial aponeurosis), loose connective tissue, periosteum.

Respiratoy Day 3/5 - Sandy

This morning, Jessica and I took the MRT to Dr. Chien’s clinic at the Anti-Tuberculosis Center in Taipei. It is an internationally-recognized center for Tuberculosis control, and the all of the physicians there are TB experts.

Dr. Chien had a number of patients with latent TB, asthma, COPD and pneumonia. He uses the GINA guideline to stage asthma and GOLD guideline for COPD. One of his patient has a prior history of TB now infected with M. avium (MAC). Although this is an atypical mycobacterial infection that usually occurs in AIDS patients, in Taiwan, it is mostly elderly men with COPD who have this. Patients who once had active TB are also more susceptible to new infections because of structural damages done to their lungs. This patient was allergic to Ethambutol, so Dr. Chien changed his medication to a macrolide.

Dr. Chien then showed us spirometry graphs and we reviewed the factors (FVC, FEV1, etc….). Patients with asthma showed reversible lung functions after bronchodilator. The staff there were also kind enough to let us try out the spirometer. It was my first time blowing into it, and it was much easier said than done. Both of us were glad when our results came out as “Normal ventilator function.”

Dr. Chien also talked about the differences between learning academically and actually clinical work. He gave an example about blue bloaters and pink puffers (chronic bronchitis and emphysema patients, respectively). Although we considered these diseases individually in class, they are clinically grouped together under the big umbrella of COPD. So patients are diagnosed with COPD, instead of chronic bronchitis, emphysema, or bronchiectesis. It was eye-opening to shadow Dr. Chien at the clinic today, what a great exposure!

6/21/2011- Respiratory and Thoracic Medicine - Jessica

Today is the 2nd day of the respiratory rotation. We will be following Dr. Yu (游承翰醫師) today in the morning and Dr. Lin (林振嵩醫師) in the afternoon. Dr. Yu's morning shift was in the ICU, although we were here yesterday with Dr. Chien, we still find the ICU quite eye-opening for us. Dr. Yu is a very friendly person, easy going and made us felt very welcomed. He went over two patients' charts with us and went through the process of developing the diagnosis and treatment for each patient. It was very helpful to hear the thought processes behind the diagnosis and treatment course, since it really drives home a lot of the medical background we learned during class as well as the differential skills we developed. We then followed Dr. Yu around in other wards for each of his patients. Again, he explained the condition of each of the patient to us and was very helpful again in reinforcing the things we have learned in school as well as teaching us new clinical information that we have not covered yet. Dr. Yu was able to taught us many things in one morning. For example, we learned about the various aspects of the endotracheal tube, including its adverse effects, limitations, and the different ways the patients family arrived in the decision of whether to replace with tracheotomy, to leave it in, or to remove it. We also learned about the various multi-drug resistant pathogens that is common in Taiwan. We were shaken when we heard about the extended-drug resistant pathogens that does not response to almost all of the antibiotic we know and were even more surprised to see 2 patients in the ward to already have the infection. Dr. Yu's teaching style worked very well for me for some reason, probably because he present each case like a puzzle that require us to take in all the information and arrive on the right diagnosis and treatment that makes me retain the information better. Thus, I was quite sad to hear that we won't be able to have our Thursday morning shift with him again as scheduled because of his ER shift that morning.

In the afternoon, we joined Dr. Lin (on a side note, I found it interesting, although somewhat inconvenient when it comes to blogging, that there are so many Dr. Lin's and Dr. Chen's that sometimes I confuse even myself while typing :P ) at his outpatient clinic. Coincidentally, I have actually met Dr. Lin last Saturday during the community clinic and shadowed him during that time in the physical examination station. From our conversation that day, I have already learned that he is one of the few MD/PhDs in the hospital, with current research in mitochondria genetic. It was a change of pace for me because Dr. Lin is the first surgeon I have encountered during this internship. However, I was surprised to find that most of the patients in the clinic today were here for certification of their previous injury/hospitalization for insurance/school/work purposes. Only few of these patients were here for thoracic problems, mostly for uncomplicated fractured ribs that can be healed spontaneously and only required supportive care (NSAID, painkiller...etc). One interesting thing we heard today was that a 6 week monitor period should be used when dealing with rib fractures, since sometimes fractures undetectable through x-ray before may show up later as the pain subsided and the patient starts to move around and caused the fractures to be visible now.

One other highlight of the day was our first-hand experience with the Taiwanese medical system as the patient. Since I started to have skin allergy on my face and arm a day after the community clinic (probably the dust...etc in the basement of the activity center), I decided to go see a dermatologist today before the itchiness eclipses all of my sanity. Even though we have been hearing a lot about the Taiwanese health system being very convenient for the patients, it was still very surprising for us when we finished the whole registration (walk-in), waiting, consultation, paying, and finally getting all of the drugs in less than 30 minutes. The grand total turned out to be about NT$320, including the appointment fee, doctor fee, drug fee, and a week's worth of 4 types of drug (2  different strengths of corticosteroid cream, oral anti-histamine, and topical anti-histamine lotion).