I look back...
Week 1: Oncology
Day 1: Internal medicine meeting, out patient clinic, in-patient rounds
Day 2: Internal medicine meeting, out patient clinic, colorectal cancer presentation, target therapy presentation
Day 3: Internal medicine meeting, TIHTC orientation, introduction to pathology equipments and protocol, patient interview
Day 4: Internal medicine meeting, Pathology review of Colon Cancer section, Acupuncture for Chemo-induced nausea and vomiting, Neurology case conference
Week 2: Cardiology/ Cardiovascular surgery
Day 1: Internal medicine meeting, outpatient clinic, inpatient rounds, EKG, pacemaker removal operation/ infected wound cleaning
Day 2: Surgical department meeting, echocardiography, abdominal ultrasound, exercise stress test protocol, EKG, evening outpatient clinic
Day 3: Double lead pacemaker placement, dialysis AV shunt balloon angioplasty, AV graft thrombectomy
Day 4: Introduction to extra-corporeal membranous oxgenator, surgical department conference, Out patient clinic, in-patient rounds
Day 5: Observe stent placement to repair abdominal aortic aneurysm
Week 3: Neurosurgery
Day 1: Finalize group colorectal cancer case presentation with Dr. Chen, visit ICU, introduction to intracranial shunts and ICP monitoring
Day 2: Surgical department meeting, observe C4/C5 disc herniation, disc removal, spinal nerve decompression and prosthetic disc insertion, brain CT discussion Tentorial subdural hemorrhage: differential diagnosis and complications, evening outpatient Clinic with Dr. Chen
Day 3: Tracheo tube removal, discussion of emergent decompressive craniotomy to remove the hematoma, patient chart review, continuous ICP monitoring, lunch time documentary on Herceptin, observe L3/L4 decompression surgery
Day 4: Introduction to trauma neurology: diagnosis, signs, symptoms, and treatment protocol, goals
Day 5: Introduction to cervical ultrasound, intracranial circulation, and economics of private neurosurgery
Week 4: Nephrology
Day 1: Pediatrics meeting, introduction to hemodialysis and protocol, inpatient rounds, interpret imaging studies and lab values (chemistry panel)
Day 2: Internal medicine meeting, out patient clinic, inpatient rounds
Day 3: Internal medicine meeting, admission H&P for recurrent pyelonephritis patient
Day 4: Visit Shenkeng Public Health Center
Day 5: Observe consult with vegetative patient’s family on ventilator removal, epidemiology research data collection, inpatient rounds, observe femoral double shunt placement for emergent dialysis
I remember...
1. Dr. Chin Yi Chen was the preceptor for 3 of us during the first week. He taught us many things in the short 4 days we had. In addition to outpatient clinic and inpatient ward rounds, he presented powerpoint on numerous topics including target therapy, colorectal cancer, case studies, Chinese medicine, and individualized genetic cancer treatment. He also encouraged us to interview patients and learn about their disease and treatment course. Dr. Chen was extremely good at patient education—he was able to tell the patient a story of his/her illness in such a way that patient understand and comply with the medical recommendation he made. Many of his patients emphasized that he was the best doctor in their personal experiences. For the following 3 weeks, Dr. Chen also allowed us to shadow him in his Tuesday evening outpatient clinic. His assistance and guidance went way beyond his duty as our preceptor; he even spent an entire morning to help us re-structure, collect data, and refine our case study presentation on colorectal cancer.
2. I attended various morning departmental meetings: internal medicine, surgery, and pediatrics. These were fantastic ways to start a day. During one hour, one to 15 or 20 cases were presented and discussed. I enjoyed the fast pace and interactive discussion, very conducive to knowledge expansion and application. The pediatric chief and Dr. Wu from internal medicine were especially encouraging and accommodating. They would often emphasize differential diagnosis and pathophysiology principles.
3. Cardiology and cardiovascular surgery worked seamlessly together. Learning from both specialties in one week was an incredibly exciting and productive experience. Dr. Kuei-Feng Chen showed us the breadth and depth of cardiology; he also exemplified high standards for patient care and professionalism. As the director of Cardiology, he led an outstanding team of dedicated physicians such as Dr. Yu (young attending) and Dr. Fong. As I observed (in lead suits myself) Dr. Yu place a double lead pacemaker in a 90-year-old patient, I realized that cardiology is not for the faint of heart. The CV surgeon was also enthusiastic about teaching, welcoming Sandy and I to observe numerous operations (AAA stent repair, AV shunt thrombectomy) even though he was Nicole’s preceptor.
4. I appreciate the multi-faceted learning experience our preceptors/ TIHTC staff structured for us. I was able to observe and learn from numerous surgeries, patient/ family consultation, outpatient clinic, inpatient ward rounds, departmental meetings, case conferences, imagining studies and interpretation, and develop my own research project. I can hardly imagine a more fruitful and meaningful experience than these 4 weeks.
5. Dr. Yi Gian Chen (Chief nephrologist) and Dr. Shui are amazing teachers. Not only do they teach me a lot about chronic renal diseases and hemodialysis, they also support and guide my intellectual quests in every possible way. I discuss my idea of doing epidemiologic research on end stage renal disease patients with Dr. Chen. He listens to my proposal patiently and helps me collect as much data as possible. He generously shares his experience and knowledge of current research and trends, assisting me to refine my research goals and methods. He even mentioned the opportunity to collaborate with 3rd year resident on future research!
6. Dr. Ding, one of the neurosurgeons at Taipei hospital, gave me the opportunity to assist in spinal surgeries as the first assistant. This was an eye-opening experience and great honor. He also guided us through a complex and interesting discussion of cerebral hemorrhage. He shared about his current pursuit of PhD in Healthcare Queue Management. He explained one project he was working on: how to maximize the utility of emergency beds a hospital maintain. I thoroughly enjoy the richness and multi-dimensions of medicine, from concrete intricate surgeries to abstract mathematic modeling.
7. I really liked Dr. Liao’s powerpoint presentation on trauma neurology. I learned a lot of information; the actual cases he shared were very helpful in solidifying major patho-physiologic principles and treatment protocol.
I would have done this again because TIHTC
1. Solidify and expand the knowledge I have obtained from my first year of pre-clinical studies at Touro University.
2. Rotations such as neuro-surgery served as good preview of selected topics in my second year studies.
3. Prepare me for 3rd and 4th year clinical rotations.
4. Show me ways to improve health care in US. Real time electronic medical records optimize healthcare delivery efficiency and streamline information flow among departments.
5. Taiwanese doctors see their patients as whole persons, not discrete organs of interest or disease states. I witness that even highly specialized physicians such as oncologists, nephrologists, and cardiologists share a holistic approach to patients. This resonates deeply with The Principles of Osteopathy.
6. One of the most meaningful and productive ways to spend the only summer vacation I have in the years to come. My passion for medicine was renewed; my mind challenged and my heart inspired.
Showing posts with label Week 4. Show all posts
Showing posts with label Week 4. Show all posts
Sunday, July 10, 2011
Pediatrics!
Mickey and I began our Pediatrics rotation following Dr. Wu, Chief of Pediatrics, around
the wards. There was a 10-year-old patient suspected of Scarlet Fever caused by GABHS.
Although culture result was not available yet, he had a strawberry tongue (it looked exactly like
a strawberry!). Instead of sandpaper-like rash, he had a smooth rash on his neck. We asked Dr.
Wu about the possibility of him having Kawasaki vasculitis, since the patient would also have a
strawberry tongue. Dr. Wu said that the vasculitis usually affects kids around one-year-old, while
children around ten-year-old are more likely to have Scarlet Fever. Dr. Wu then presented an
Airway presentation, explaining the use of SABA, LABA, ICS etc. He also told us that Taiwan
has the lowest birth rate in the world, so less and less medical students choose to go into Pediatrics
now.
In the afternoon, we had a TIHTC event where some of us gave a case presentation about colon
cancer while others shared their experience in the program. The staff also gave us a mini-award
ceremony, including a birthday cake for 4 people (Amanda and Nicole!). They showed us so much
hospitality, I feel extremely fortunate to be part of this amazing program.
The next day, we followed Dr. Wu (a pediatrics cardiologist) and saw a patient with a suspected
case of Marfan’s syndrome. The teenage boy was tall and lanky, and was diagnosed with
pneumothorax. Dr. Wu asked him to perform a couple of maneuvers, including wrapping his wrist
with his other hand and bringing out his arms. He had one Marfan’s syndrome’s clinical symptom,
but did not fit the criteria for diagnosis. We met with Dr. Wang in the afternoon and saw her
giving allergy tests to some children for dust mite, which all came out to be positive. We also
discussed about her research on examining children (especially boys) due to the recent clouding
agent outbreak. We were surprised that we did not see any patient coming in for that this week,
Dr. Wang said that many came during May and early June, it has since slowed down.
We also had the opportunity to follow Dr. Kao, a general pediatrician. He saw a patient with
horseshoe kidney, which is a rare disease where kidneys fused together. This condition increases
the risk for kidney infections, kidney stones, and kidney cancer. Since many patients came in for
stomach ache, we saw many abdominal ultrasounds. There have been cases where teenagers came
in complaining of stomach ache, and the ultrasound showed a baby inside. He said that parents’
reactions have ranged from immediate outrage to disappointment. That must be a difficult position
to be in as a physician.
The pediatricians mainly saw patients with viral infections. Dr. Wu told us that in this case, he
could only prescribe palliative treatment, and often times, he needs to explain to the parents why
he is not prescribing antibiotics. I learned that Pediatrics requires a three-way communication
system between the physician, the patient, and the patient’s parents. The physician not only has to
comfort the patient, he/she needs to comfort the parents just as much, if not more. Dr. Wu and the
other pediatricians were also very clever. Instead of asking the kids to exhale/inhale, he took out
a yellow windmill and asked the kids to blow as hard as they could. The kids were delighted and
thought it was a game. It reminded me of Mary Poppin’s song “Just a Spoon Full of Sugar helps
the medicine go down,” the way he was able to turn a mindless task to be fun and exciting.
I asked Dr. Wu why he chose to become a pediatrician and he told us that after he finished his
rotations, he realized that being around kids made him happy. I thought about all the criteria that
we, as students, try to evaluate before deciding on a future path- salary, schedule, workload –
often overlooking the fact that in the end, we all just want to feel happy and fulfilled in life. Dr.
Wu also told us that the most important trait of being a pediatrician is to be patient, as kids may
not do what they are told. Once, I saw Dr. Wu placing a stethoscope on a child who began to
scream. I couldn’t imagine the sound amplified through the stethoscope, yet Dr. Wu patiently
maintained his composure. Although I saw some screaming kids, I was also surprised by well
behaved majority of the kids were, considering that kids usually do not hide their feelings.
One of my favorite parts of the Pediatrics clinic was seeing babies getting their shots. A one-
year-old came with his grandpa and mom, and grandpa happily said, “Today is his one-year-
old birthday and he is due for 2 shots!” The baby was bouncing, giggling, chuckling and had the
most infectious laughter. He earnestly played peek-a-boo with us, not knowing what was about to
happen. Then it was time. The nurse told the mom to strap him on her thigh as she brought in the
syringe. He sensed exactly what was going on, and his face immediately turned from smiling to
frowning to crying continuously. After he received his shots (his birthday present), we cheerfully
wished the tearful baby goodbye. Although I felt sympathy for him, I couldn’t help but be amused
by the situation and be envious of how many precious moments like these a pediatrician gets to
experience.
Wednesday, July 6, 2011
7/01/2011- Cardiology - Jessica
The last day of our summer internship was spend in a operation room for me! Although we heard from Dr. Chen that there will be a PAD surgery this morning, it was canceled when we inquired about it. Since our morning was originally scheduled for that, we end up having some time on our own. Like mentioned before, due to the rotations I choose, I did not have a chance to see any live operation throughout this internship. With the unexpected free time, we asked Dr. Ding (the neurosurgeon from Nicole's rotation) if we can join him in the operation room and he graciously allowed. It was an eye-opening experience for me. I scrubbed myself in for the first time, changed into scrubs for the first time, and stepped into a real operation room for the first time! I was worried in the beginning since I did not know anything about the surgery procedure and the fact that we have not covered neurology in class did not help either. However, I was able to pass without any major disturbance to the surgery and even managed to learn many things through the experience. Although we can only observe, I learned many things from Dr. Ding. Not only did I get to see a surgery right in front of me, I was able to see how a slight negligence from another doctor (the patient's back pain was probably due to some loose screws from previous spondylolisthesis treatment) can have enormous effect on the patient's life. Also, I was able to observe how different departments, from surgeons, anesthesiologists, nurses, and even biomedical equipment companies work together in one operation.
As the day draw to a close, we all commented on how we could not believe that four weeks can fly by so fast. This trip was truly an eye-opening experience for all of us. We have learned in this four weeks so much that it is impossible to list all of them here. It not only taught us many clinical knowledge that can only be learned during actual practice and not from the textbooks, it also taught us what it means to be a physician: the responsibility and all the hard work behind the title, and of course, the sense of pride and fulfillment that can only come when you know that what you do each day helps improve and sometimes even save another human being's life and does really make a difference in this world. I will never forget the past four weeks I spend in Taipei Hospital and all the wonderful doctors, nurses, and staffs who mentored us, helped us, and without whom we will genuinely be lost in our exploration. I would also like to say a special thank you to the TIHTC staff (Annie, Yuyu, Jessica, and Angie) and Superintendent Lin for all the hospitality and kindness they have shown us and for making this collaboration possible. I sincerely hope that this collaboration will continue to grow and future classes can also have the chance to experience all the wonders and treasures we found this summer.
As the day draw to a close, we all commented on how we could not believe that four weeks can fly by so fast. This trip was truly an eye-opening experience for all of us. We have learned in this four weeks so much that it is impossible to list all of them here. It not only taught us many clinical knowledge that can only be learned during actual practice and not from the textbooks, it also taught us what it means to be a physician: the responsibility and all the hard work behind the title, and of course, the sense of pride and fulfillment that can only come when you know that what you do each day helps improve and sometimes even save another human being's life and does really make a difference in this world. I will never forget the past four weeks I spend in Taipei Hospital and all the wonderful doctors, nurses, and staffs who mentored us, helped us, and without whom we will genuinely be lost in our exploration. I would also like to say a special thank you to the TIHTC staff (Annie, Yuyu, Jessica, and Angie) and Superintendent Lin for all the hospitality and kindness they have shown us and for making this collaboration possible. I sincerely hope that this collaboration will continue to grow and future classes can also have the chance to experience all the wonders and treasures we found this summer.
Sunday, July 3, 2011
Pediatrics Day 3 & 4 Outpatient Clinic and Shenkeng District Public Health Center 29-June-2011 to 1-July 2011
Sorry all, for the delayed update everything these last three days has been like a whirlwind. Now that I am in Hong Kong time to reflect back on the final days I spent in Taiwan.
29-June-2011
Another day in the outpatient clinic today with Dr. Wu, Wen-Chiu in the morning and Dr. Wang, Yi-Jen (Dr. 王怡人) in the afternoon. I am starting to like the relaxing pace of the outpatient clinic. Dr. Wu is a dedicated teacher and always goes over each patient with us. The most valuable experiences were when Dr. Wu would let us listen in on lung sounds on the peds patients; I would have never imagined that the wheezing in the doctoring labs recordings. In the afternoon with Dr. Wang, Sandy and I had more time to talk about the current affairs in pediatrics in Taiwan including the declining birthrate, clouding agent problems and more. In particular Dr. Wang’s research on the clouding agent problem seems to be in full swing, she collected about 50 urine samples last week and has a total about 6000 or so samples and is ready to be analyzed. With previous urine analysis samples as controls I am sure something interesting will come out from her efforts. On our side Karen and Bor-Han will be helping her on Friday to tabulate the latest samples and I am looking forward to seeing the results when they are available.
30-June-2011
We all had a wonderful time, in Yeliu for the beginning of the day. Got to see some natural land and rock formations that seem to be ever changing due to different effects of corrosion. After which we all went to the Shenkeng District Public Health Center for a tour and information session. It is comforting to see that Taiwan seems to have a good amount of money put into public health, judging be the size the number of people that they have on staff, in many offices in the United States it seems there are too many budget cuts in this area. The center has integrated health screenings for different age groups during different set times, a mobile unit and many other services such as tobacco cessation. As expected there is an extensive screening program for TB there is an increased incidence of cases in Taiwan. Overall I felt the presentation the center gave was a good review of all the basics I learned from the MPH program at Touro and it was great to learn about some of the issues that Taiwan has in the public health arena.
1-July-2011
Today was the final day in Taiwan. I can’t believe how fast time has flown by. In the morning after the meeting we ended up following Dr. Wu around the ward, it was good to see that the scarlet fever patient that we saw at the beginning of the week was much improved due to his treatment with Penicillin G. After a quick run the rest of the morning we spent in the outpatient clinic with Dr. Kuo, I-Ting (Dr. 郭怡廷). Dr. Kuo always seemed to spent extra time to talk about every case and gave us lengthy detailed answers to every question that we asked. One of the most fascinating discussions with Dr. Kuo was about a condition known as horseshoe kidney, a congenital disorder that, where the patient has their two kidneys fused resulting in one super kidney. Being a rather rare condition I feel that we were very lucky to be able to see a patient with this condition that was here for a return check-up. In the afternoon we finished our rotation with Dr. Wu. The most interesting highlights included more breath sounds including more wheezing and ronchi both of which are very much like the recordings from lab and a visit to the wards to see a premature baby (30 weeks). Overall I am very happy with the experience I have had in Taiwan and hope that one day I will get to return for some more exchange. It was a pleasure and I will cherish everything I learned.
29-June-2011
Another day in the outpatient clinic today with Dr. Wu, Wen-Chiu in the morning and Dr. Wang, Yi-Jen (Dr. 王怡人) in the afternoon. I am starting to like the relaxing pace of the outpatient clinic. Dr. Wu is a dedicated teacher and always goes over each patient with us. The most valuable experiences were when Dr. Wu would let us listen in on lung sounds on the peds patients; I would have never imagined that the wheezing in the doctoring labs recordings. In the afternoon with Dr. Wang, Sandy and I had more time to talk about the current affairs in pediatrics in Taiwan including the declining birthrate, clouding agent problems and more. In particular Dr. Wang’s research on the clouding agent problem seems to be in full swing, she collected about 50 urine samples last week and has a total about 6000 or so samples and is ready to be analyzed. With previous urine analysis samples as controls I am sure something interesting will come out from her efforts. On our side Karen and Bor-Han will be helping her on Friday to tabulate the latest samples and I am looking forward to seeing the results when they are available.
30-June-2011
We all had a wonderful time, in Yeliu for the beginning of the day. Got to see some natural land and rock formations that seem to be ever changing due to different effects of corrosion. After which we all went to the Shenkeng District Public Health Center for a tour and information session. It is comforting to see that Taiwan seems to have a good amount of money put into public health, judging be the size the number of people that they have on staff, in many offices in the United States it seems there are too many budget cuts in this area. The center has integrated health screenings for different age groups during different set times, a mobile unit and many other services such as tobacco cessation. As expected there is an extensive screening program for TB there is an increased incidence of cases in Taiwan. Overall I felt the presentation the center gave was a good review of all the basics I learned from the MPH program at Touro and it was great to learn about some of the issues that Taiwan has in the public health arena.
1-July-2011
Today was the final day in Taiwan. I can’t believe how fast time has flown by. In the morning after the meeting we ended up following Dr. Wu around the ward, it was good to see that the scarlet fever patient that we saw at the beginning of the week was much improved due to his treatment with Penicillin G. After a quick run the rest of the morning we spent in the outpatient clinic with Dr. Kuo, I-Ting (Dr. 郭怡廷). Dr. Kuo always seemed to spent extra time to talk about every case and gave us lengthy detailed answers to every question that we asked. One of the most fascinating discussions with Dr. Kuo was about a condition known as horseshoe kidney, a congenital disorder that, where the patient has their two kidneys fused resulting in one super kidney. Being a rather rare condition I feel that we were very lucky to be able to see a patient with this condition that was here for a return check-up. In the afternoon we finished our rotation with Dr. Wu. The most interesting highlights included more breath sounds including more wheezing and ronchi both of which are very much like the recordings from lab and a visit to the wards to see a premature baby (30 weeks). Overall I am very happy with the experience I have had in Taiwan and hope that one day I will get to return for some more exchange. It was a pleasure and I will cherish everything I learned.
Saturday, July 2, 2011
6/30/2011- Culture Exploration - Jessica
Today is a special day for us, since it is the only week day that we spend outside the hospital. We will be going to YehLiu National Geographic Park in the morning and ShenKeng District Public Health Center in the afternoon today with other physicians from Russia, Salvador, and China. I was surprised when we got on the bus that the bus was actually a tour bus in the most traditional Taiwanese sense. The bus features fancy curtains, entertainment system that includes multiple TV screens, microphones(for Karaoke), and even with disco balls and neon lights that can be turned on on request as well as an extremely experienced bus driver who can almost double as a tour guide who kindly took us all over Taipei for good stores to by souvenirs.
I have heard about Yeh Liu when I was still a child living in Taiwan but never really had the chance to go. Although I have seem many photos of the famous "Queen's Head" stone before. On our way there, the bus driver played a concert DVD from the very famous late singer Teresa Teng (鄧麗君) and we were delighted to find out that we actually know many of her songs from all the years of listening to our parents and grandparents playing her songs at home. I personally think that it was great to be able to find a common ground between the Taiwanese and Chinese passengers on the car despite the many different point of views due to the political situation. After arriving on the park, we were greeted by one of the staff in the park and she took us around the park introducing us to all the scenery and the stories behind each of them. Since our group consisted of such mixed group that speak many different languages, it was extremely hard for her to accommodate everyone and I really appreciated her effort.
After a delicious lunch, we went to ShenKeng to take a tour of the public health center there. The director of the center gave us a presentation on the center and it was especially interesting for me because she does it in both Chinese and English for each slide and I was able to practice my medical Chinese vocabulary as I can instantly find out unknown Chinese words from the English version later. One interesting I noticed was the amount of foreign wives (mainly from Vietnam and China) in the area and the different screenings specific for them (ie: specific parasite screening...etc). Also, Sandy ran into one of her friends from Berkeley who's studying at the National Taiwan University medical school today in the health center. Such a small world!
I have heard about Yeh Liu when I was still a child living in Taiwan but never really had the chance to go. Although I have seem many photos of the famous "Queen's Head" stone before. On our way there, the bus driver played a concert DVD from the very famous late singer Teresa Teng (鄧麗君) and we were delighted to find out that we actually know many of her songs from all the years of listening to our parents and grandparents playing her songs at home. I personally think that it was great to be able to find a common ground between the Taiwanese and Chinese passengers on the car despite the many different point of views due to the political situation. After arriving on the park, we were greeted by one of the staff in the park and she took us around the park introducing us to all the scenery and the stories behind each of them. Since our group consisted of such mixed group that speak many different languages, it was extremely hard for her to accommodate everyone and I really appreciated her effort.
After a delicious lunch, we went to ShenKeng to take a tour of the public health center there. The director of the center gave us a presentation on the center and it was especially interesting for me because she does it in both Chinese and English for each slide and I was able to practice my medical Chinese vocabulary as I can instantly find out unknown Chinese words from the English version later. One interesting I noticed was the amount of foreign wives (mainly from Vietnam and China) in the area and the different screenings specific for them (ie: specific parasite screening...etc). Also, Sandy ran into one of her friends from Berkeley who's studying at the National Taiwan University medical school today in the health center. Such a small world!
Never shall I forget the days I spent with you. Continue to be my friend, as you will always find me yours - Beethoven
The driver dropped off Amanda and me at TPE. Before Amanda left to security checkpoint, she said, "It's been nice getting to know you better."
As I'm sitting in the "Barista Coffee" shop on the 4th floor, it's come to me that during this entire trip I was too busy learning as much as I could and making new friends to let it gone unaware that I have also learned more about my colleagues than I did in the entire first year of medical school.
I always talked about how amazing the program and the staff were whenever someone asked. Yet, one of the greatest parts about this trip was the people I traveled with, Amanda, Sandy, Karen, Jessica, Mickey and Bor-han. I cannot imagine having experienced Taiwan with anyone else.
Bor-han is such a gentleman. He always looked out for seats for us girls in the subway and bus. I have a picture of Bor-han sleeping while standing in a packed train. That takes skills! He was a dedicated tour-guide as well. Mickey told me that he spent hours looking through his Taiwanese hot spots book, making plans of where to eat and what to do. I know Bor-han will be an amazing doctor, but he could definitely excel as a tour guide too.
Mickey was also awesome! Some of the things Mickey did that make him so great are his knowledge of technology, economy and history. He seems to know everything!!! I enjoyed his little rams about politics. Also, he refilled our tea cups constantly whenever we ate at a sit-down restaurant. How attentive!
Jessica. Oh, where to start?! Her mom was so nice. She sent us delicious food and Jessica had to cook them in the boy's room. I can see from where Jessica got her kindness. It was so much fun having dorm-cooked meals. Since there was no actual kitchen or cookware, we had to improvise. We ate out of rice cooker's lids, washed dishes in the bathroom sink, used a face cloth as sponge. I have pictures to prove that these things did happen!
I like Sandy. She's always funny and up for fun things, like helping me turn a tour bus into a party bus, and was not afraid to dance with me and sang at the top of her lungs without a care in the world. Years from now when I watch the videos I took of us dancing in the bus, I will have a good laugh at our foolishness.
Amanda and I had many good conversations. She's such a motivation! Being a mother and medical student while working, volunteering and doing research is not easy. I don't know from where she got her strength but I would love to have some of that strength. I will try to not complain too much when I'm overwhelmed with school works, because if Amanda can do it, so can I!
Karen and I didn't really talk much in school perhaps because we were in different groups. It's been nice getting to know her. She's a very thoughtful and considerate person. She doesn't seem to talk much, but when she does, whatever she says is very well thought-out. I hope to talk to Karen more when we get back to school.
I could go on and on about how great they are, but it would take too long and my fingers might get tired from typing.
I also learned so much about Taiwanese culture and healthcare system. The food is so good and I'll miss going to night markets and the food vendors on the streets. I'll probably go through withdrawal the first couple of days when I'm back to the US, not because of the jetlag but because I'll feel weird not waking up early in the morning to go work in the hospital. Oh the breakfast food in the back of the hospital, the hospital smell (I love hospital smell for some weird reasons), the people walking around with their papers, the chatting noises, the catheter lab, the scrubs, the food from cafeteria, etc. I'll miss all of that!
I know when I come home, I'll be telling stories about Taiwan for days and maybe years from now.
I'll be boarding in 5 hrs and am experiencing separation anxiety!
再見 Taiwan! You've been really good to me! Hope to see you again one day. By then, Taipei 101 will be the 3rd tallest building in the world.
再見 Taiwan! You've been really good to me! Hope to see you again one day. By then, Taipei 101 will be the 3rd tallest building in the world.
Friday, July 1, 2011
The end of TCM
The week in TCM has been interesting. Dr. Chen and Dr. Ho have taught us so much and showed us their acupuncture techniques. Dr. Chen even put a needle in my hand to show me what it feels like. I was a little nervous about it and skeptical when people said that it just feels numb. But when Dr. Chen tapped the needle into my hand, I hardly felt it except when he moved it around. It felt very tingly and weird. I left it in for a bit while he saw a patient and then he took it out for me. I thought that as long as I had it in I might as well treat the point a little. The point he used is one that is used to treat motion sickness and since I have been sensitive to that lately, I thought that treatment couldn't hurt. It did help a little, as the next time I was on the bus with the crazy driver I didn't get as sick. It was a good experience for me. I think it is important to experience things for yourself to be able to empathize with others.
Dr. Ho taught us a little about his manipulative technique. He showed us what he is feeling for when he does his diagnostic exam. His palpatory skills are very good and I hope that someday I will have those skills. He is able to treat bones that are out of place and tightness in the tissues. He diagnosed several patients with a "twisted pelvis" and prescribed herbal remedies for it. This was interesting to me because I thought that he would use manipulation to fix it, but instead uses herbs. There was also a patient with a cervical spine injury that was seeking treatment. He said that the patient would first have to take some Chinese medicines first before starting acupuncture treatment. Dr. Ho said that the treatments will help but it will take time and that he wasn't sure how much it would help. Because the nerves might be damaged, acupuncture may not be able to fix anything.
On Thursday, TIHTC took us on a field trip. We went to the Geography Park where there are really interesting rock formations. It was fun to see the different shapes of the rocks and the natural erosion that is occurring. It is apparent that the Taiwanese like food; a lot of the rock formations are named after foods. But it was fun. They are very imaginative with the shapes and there are stories to go with them. In the afternoon we toured the Shenkeng Public Health Center, which is a facility that focuses on public health. They have a small clinic and a lot of educational programs for residents in that area. This was a nice trip and we were very lucky to have been able to go.
This last week in TCM has been a very educational week for me. I have learned so much about Chinese medicine and its uses. All of the doctors in the department were very kind and answered all of our questions. The last 4 weeks at Taipei Hospital have been very educational and have reminded me why I decided to go to medical school. Sometimes in all the studying it is easy to forget the clinical side of things and it is experiences like these that keep me pushing through it all. I have really enjoyed all of the clinical experience that I have gained and all of the pearls of knowledge that the doctors have given me.
TCM Rotation Day 3&5 (June 29 & July 1, 2011)
June 29, 2011 and July 1, 2011
We gained more understandings about TCM from Dr. Chen and Dr. Ho on the third and last days of our TCM rotation. From Dr. Chen, we received an introduction of the ten most commonly used acupuncture points and got the opportunity to perform acupuncture on our own. He also told us some rare and severe complication of acupuncture such as pneumothorax and kidney bleeding especially when long needles are used. From Dr. Ho, we got the opportunity to really touch some of his patients and felt the change in muscle tones or bone structure before and after his special Tui-Na. And we got to see how a patient who could not lift her arm to the level of shoulder can lift her arm after treatment. We also got to see a lot of stroke or cerebral palsy patients receiving acupuncture to facilitate recovery or relieve the symptoms. During this week of rotation in TCM department, I not only gained more understanding about TCM (especially acupuncture) but also got an idea about how to use TCM in weight loss. This experience gave me a more open mind toward using alternative medicine such as acupuncture in treating patients.
Thursday, June 30, 2011
6/28/2011, 6/29/2011- Cardiology - Jessica
On the second day of cardiology, we followed Dr. Chen (陳桂峰醫師) in the ultrasound room. Dr. Chen is very knowledgeable in his specialty and taught Nicole and I many diagnostic techniques on the ultrasound as well as clinical features of cardiology. One interesting observation we noticed was that in many valvular diseases, although surgery was indicated and highly recommended by the doctor, the patients still remain highly reluctant to operation. Dr. Chen explained that it is a common dilemma faced by cardiologists in Taiwan. In traditional Taiwanese view, surgery is already a very invasive procedure, regardless the real clinical invasiveness of the procedure, let alone cardiac surgery, where the surgery prognosis was often poor in past decades. Although the technology has gotten a lot better at cardiac surgery and the success rate has been very high, for many Taiwanese people, the stigma still present and the parents often remain reluctant to surgery unless patient life is in immediate danger. This is in contract to the amount of compliance Dr. Chen gets in his outpatient clinic. When we observed him in the outpatient clinic on Wednesday, I noticed that his patients seem to have great compliance to both his drug regiment, life style change, and even keeping a detailed blood pressure log. When I asked him about that, he answered that although many Taiwanese people are reluctant when it come to surgery, they are very welling to comply when it comes to drug, especially many cardiac drugs have immediate effects that makes convincing the patients a lot easier than other specialties. In addition, the fact that Dr. Chen has a good reputation and many year of experience in the field makes the patients respect him and will heed his advise a lot better than other doctors.
In the afternoon, we ran into a pacemaker placement in the catheter room. It was very interesting for me because unlike the other GHP members, it was the first operation that I was able to see during this trip. During the procedure, we talked with Dr. Chen again about cardiology and many aspects of being a physician. He said something that meant a lot to me: being a physician means constant learning and self-education; one must always consider the interaction between drugs and maintain the delicate balance between therapeutic effects of the drug and its adverse effect to the patient. Furthermore, adverse effects from drugs or treatment methods are responsibility of the doctor, not the patient. If a patient show signs of adverse effect from the drug, the doctor must be able to catch it whether the patient realized it or not and change the treatment plan accordingly. He also said that if any of his patient in good compliance with his treatment plan ever developed a MI, than he must have done something wrong and have failed his job as a cardiologist. It touched me to see that even after so many years in the field, Dr. Chen still shows such passion and dedication to his work and to his patients. Dr. Chen is truly a great role model for all the physicians to come.
In the afternoon, we ran into a pacemaker placement in the catheter room. It was very interesting for me because unlike the other GHP members, it was the first operation that I was able to see during this trip. During the procedure, we talked with Dr. Chen again about cardiology and many aspects of being a physician. He said something that meant a lot to me: being a physician means constant learning and self-education; one must always consider the interaction between drugs and maintain the delicate balance between therapeutic effects of the drug and its adverse effect to the patient. Furthermore, adverse effects from drugs or treatment methods are responsibility of the doctor, not the patient. If a patient show signs of adverse effect from the drug, the doctor must be able to catch it whether the patient realized it or not and change the treatment plan accordingly. He also said that if any of his patient in good compliance with his treatment plan ever developed a MI, than he must have done something wrong and have failed his job as a cardiologist. It touched me to see that even after so many years in the field, Dr. Chen still shows such passion and dedication to his work and to his patients. Dr. Chen is truly a great role model for all the physicians to come.
6/27/2011- Cardiology - Jessica
I can't believe we are in our final rotation already! It's the first day of our 4th week of rotation and we only have less than a week left in Taiwan! We start the day with Dr. Feng (馮文楷醫師) in the ultrasound room. Like Dr. Lin, the thoracic surgeon we met last week, we met with Dr. Feng before in the public health screen two weeks ago. Coincidentally, both Nicole and I were in the same station with him too. Since we are not familiar with ultrasound, we were a little disorientated in the beginning by the images. But after Dr. Feng's explanation, we quickly managed to be able to identify the key anatomy structures. This morning we saw many valvular and other cardiac diseases that we saw only on the textbooks before. For example, we saw an example of aortic stenosis and a patient with ventricular septal defect (of which we were able to hear the murmur very clearly as predicted by the textbook). We also saw a patient with suspected previous MI that caused hypokinesis of the anterior septal wall. One interesting thing we observed was the interaction between different departments, especially thoracic and the cardiology department, since many respiratory failure symptoms are either cardiogenic itself already or can be induced by heart failure.
The highlight of the day was the afternoon case presentation of colon cancer. The presentation was originally scheduled last week, but due to schedule conflict, was postponed to today. We have prepared ourselves all week long and the anticipation has made me more nervous as the time of the presentation approaches. The fact that I am responsible for the pathology section and Dr. Hsieh from the Pathology department was the only attending physician that day too did not help at all with my anxiety! But luckily the presentation went well for everybody and I didn't make any gigantic mistakes that I somehow have convinced myself would happen by all the anxiety and anticipation accumulated throughout the week. Despite the fact that it was nerve-wracking for me, the presentation was actually a very good learning experience for me, since it gave us the chance to see how different subdisciplines work together in cases like this as well as giving us the chance to practice our presentation skills that will be extremely valuable in the future.
The highlight of the day was the afternoon case presentation of colon cancer. The presentation was originally scheduled last week, but due to schedule conflict, was postponed to today. We have prepared ourselves all week long and the anticipation has made me more nervous as the time of the presentation approaches. The fact that I am responsible for the pathology section and Dr. Hsieh from the Pathology department was the only attending physician that day too did not help at all with my anxiety! But luckily the presentation went well for everybody and I didn't make any gigantic mistakes that I somehow have convinced myself would happen by all the anxiety and anticipation accumulated throughout the week. Despite the fact that it was nerve-wracking for me, the presentation was actually a very good learning experience for me, since it gave us the chance to see how different subdisciplines work together in cases like this as well as giving us the chance to practice our presentation skills that will be extremely valuable in the future.
Wednesday, June 29, 2011
Pediatrics Day 1 27-June-2011
8:10 am started the day on the 5th Floor meeting room situated behind the nursing station at the pediatrics meeting. Over the course about 30 minutes many cases were discussed, the major concerns seemed varied from otitis media, unknown skin rashes to asthma and infant jaundice. The most interesting discussion at the meeting was about a patient with a strawberry tongue, as it sparked a talk about Kawasaki disease and scarlet fever. After the meeting Sandy and I followed Dr. Wu, Wen-Chiu (Dr. 吳文秋), he showed us around the ward including the neonate-infant room and the empty new born room. Dr. Wu commented on the low birth rate in Taiwan (the lowest in the world currently) explained that there had only been two deliveries in the hospital for the entire month which occurred last week. As we continued through the ward I was able to see a real strawberry tongue, I don’t think I will ever forget what a text book strawberry tongue after that experience. At 9:30 Dr. Wu gave Sandy and I a lecture on common Airway problems in pediatrics. There was some review in the lecture including common pathogens that will be encountered, how different seasons and school affects transmissions of infectious diseases. Also the mechanism, treatment, screening and testing for asthma. Dr. Wu had a series of different inhalers and peak flow meters that are used for patient education which he ran us through. The time seemed to fly by in pediatrics for some reason or another as it the end of the day before I noticed.
Tuesday, June 28, 2011
Cardiology Week
Jessica and I started out Cardiology week in the Echo lab. The topic about medical wasting came up when a 70 yo female with bilateral renal stone, h/o MI and treated with PTCA 7 years ago with no active symptoms came in for follow up.I got to hear VSD murmur, which was very awesome because I only heard it from audio file that we used to study for doctoring. Dr. Feng told us that good communication between doctor and patient, the patient's family, and with other doctors/nurses are important. By working closely together, it's more beneficial for the patient and not wasting time.
On day 2, I learned about the 4 degrees of valve regurgitation: 1. mild mitral regurgitation <20% 2. moderate mitral regurgitatioin 20-40% 3. moderate to severe mitral regurgitation 40-60% 4. severe mitral regurgitation >60%.
Dr. Chen - chief of Cardiology, told me that the ability to tell the grading of valve defect is experience-dependent. Therefore, ECHO is done by cardiologist and not by a technician. I learned about the mosaic current (red/blue mix together. When there is a mosaic pattern, it indicates very high velocity of blood flow --> regurgitation. I kept seeing the mosaic current, but sometimes it turned out to be normal. That just means that I have a long way to go in my training.
I also learned that mitral valve prolapse cases are very common and usually not a serious issue.
Angina review: substernal, 2-3 minutes, worsens after exercise/work, not sharp pain, tightened chest pain.
Also looked up indications for AS valve replacement: the most important = symptomatic AS because there's a high risk for sudden death and survival rate is low after symptoms occur.
Coumarin is given to A. fib patients to prevent emboli but no anticoagulant is usu. given to taiwanese patients
There was an 87 yo patient aho had pneumonia, didn't want surgery for valvular replacement but still is doing well despite mitral valve stenosis, mural thrombus attached to IAS, mitral regurg, pulm HTN, RHD, severe MS/MVA, and on Manitor anticoagulation. Sometimes, all the indications point to surgery, but in this case, her choice of not having a surgery has worked out fine. Is it luck or are patients better at knowing what's best for them?
Day 3: in OPC
CAD - broad spectrum, sometimes there is no symptom; control contribution factors (cholesterol, blood sugar, blood pressure) is important; choices of drugs to control these factors are also important
A patient's daughter came in to get medication and for consultation for her parent. I don't know if a consent form or identification is required in the U.S for this case
I saw an RBBB ECG. This makes me appreciate Dr. Lopes' 12-lead ECG lecture.
The govt. insurance wants to stop paying for medication once patient reaches target goal for his/her cholesterol and LDL levels. But patient should still maintain medication to help stabilize lipid levels. Dilemma!
Pacemaker syndrome - AV dyssynchronization
I don't know if this was mentioned in class or I was dosing off and missed this detail, but a small amplitude in R wave means not too many viable myocytes. Sometimes in COPD patient, too much air between electrodes and heart can also give low amplitude R waves.
I saw an 103 yo female patient with infected ulceration wound + gangrene changes on 2nd, 3rd and 5th toes of Rt foot. She has peripheral arterial occlusion and calcification of valves. 103 yo!
We ran into some issues with patient's compliance. there were patients who were very compliant, taking medications on schedule and keeping at-home blood pressure chart, while there are patients who were not compliant at all. Even with patient education and family support, these patients still do not recognize the severity of their disease or the importance of controlling contributing factors. What else can a doctor do for patients who are not very cooperative?
On friday, i had some time to shadow Dr. Ting again. He removed the screws put in for a patient with spondylolithesis. The patient complained of back pain caused by the rubbing of the metal plate so removal of the screws might alleviate the pain. I got to take out a screw myself and it was hard to remove. Required a lot of strength!
On day 2, I learned about the 4 degrees of valve regurgitation: 1. mild mitral regurgitation <20% 2. moderate mitral regurgitatioin 20-40% 3. moderate to severe mitral regurgitation 40-60% 4. severe mitral regurgitation >60%.
Dr. Chen - chief of Cardiology, told me that the ability to tell the grading of valve defect is experience-dependent. Therefore, ECHO is done by cardiologist and not by a technician. I learned about the mosaic current (red/blue mix together. When there is a mosaic pattern, it indicates very high velocity of blood flow --> regurgitation. I kept seeing the mosaic current, but sometimes it turned out to be normal. That just means that I have a long way to go in my training.
I also learned that mitral valve prolapse cases are very common and usually not a serious issue.
Angina review: substernal, 2-3 minutes, worsens after exercise/work, not sharp pain, tightened chest pain.
Also looked up indications for AS valve replacement: the most important = symptomatic AS because there's a high risk for sudden death and survival rate is low after symptoms occur.
Coumarin is given to A. fib patients to prevent emboli but no anticoagulant is usu. given to taiwanese patients
There was an 87 yo patient aho had pneumonia, didn't want surgery for valvular replacement but still is doing well despite mitral valve stenosis, mural thrombus attached to IAS, mitral regurg, pulm HTN, RHD, severe MS/MVA, and on Manitor anticoagulation. Sometimes, all the indications point to surgery, but in this case, her choice of not having a surgery has worked out fine. Is it luck or are patients better at knowing what's best for them?
Day 3: in OPC
CAD - broad spectrum, sometimes there is no symptom; control contribution factors (cholesterol, blood sugar, blood pressure) is important; choices of drugs to control these factors are also important
A patient's daughter came in to get medication and for consultation for her parent. I don't know if a consent form or identification is required in the U.S for this case
I saw an RBBB ECG. This makes me appreciate Dr. Lopes' 12-lead ECG lecture.
The govt. insurance wants to stop paying for medication once patient reaches target goal for his/her cholesterol and LDL levels. But patient should still maintain medication to help stabilize lipid levels. Dilemma!
Pacemaker syndrome - AV dyssynchronization
I don't know if this was mentioned in class or I was dosing off and missed this detail, but a small amplitude in R wave means not too many viable myocytes. Sometimes in COPD patient, too much air between electrodes and heart can also give low amplitude R waves.
I saw an 103 yo female patient with infected ulceration wound + gangrene changes on 2nd, 3rd and 5th toes of Rt foot. She has peripheral arterial occlusion and calcification of valves. 103 yo!
We ran into some issues with patient's compliance. there were patients who were very compliant, taking medications on schedule and keeping at-home blood pressure chart, while there are patients who were not compliant at all. Even with patient education and family support, these patients still do not recognize the severity of their disease or the importance of controlling contributing factors. What else can a doctor do for patients who are not very cooperative?
On friday, i had some time to shadow Dr. Ting again. He removed the screws put in for a patient with spondylolithesis. The patient complained of back pain caused by the rubbing of the metal plate so removal of the screws might alleviate the pain. I got to take out a screw myself and it was hard to remove. Required a lot of strength!
TCM Rotation Day 1&2 (June 27-28, 2011)
June 27, 2011
Our first day of traditional Chinese medicine (TCM) rotation started with observing Dr. Yen-Yi Ho, the director of TCM department of the hospital. This morning he had about sixty patients, and more than one-third were here for acupuncture. While I was still wondering if he can finish all these patients in time, he showed me how he could make it possible. Since he knows all of his patients really well (to the degree that he can make fun of them without offending them), he can spends less than five minutes on each patient without sacrificing quality of visit (such as patient-doctor interactions). He also used his time wisely so that he can finish multiple jobs in one time. For example, Dr. Ho used the acupuncture time as his “break” from sitting in front of table. Before the “break”, the nurse would have the patients who need acupuncture sit in chairs or lie on beds. Then Dr. Ho would walk between the chairs and beds to put the needles on rapidly. Since patients getting acupuncture need to have needles on for thirty minutes, Dr. Ho would get back to work and have the nurse take out the needles later. Through observing behind Dr. Ho, I got the idea about how to make outpatient visit more efficiently without sacrificing its quality. In the afternoon, Karen and I met and shadowed Dr. Chien-An Chen. We had a discussion about what’s OMM and what we want to learn from TCM, and he suggested that acupuncture would be a good topic to learn. He originally planned to give us an introduction of ten most common used acupuncture points. But since we needed to leave early for the case presentation, that lecture would be given next time.
June 28, 2011
In the morning, Karen and I reported to Dr. Shu-Ling Hsieh, the TCM physician who is specialized in weight loss. Her weight loss clinic only takes those with BMI >24.1 for male and BMI> 22 for female. According to Dr. Hsieh, the most important thing to make weight loss possible is diet control. And the herbal medicines and acupuncture she uses in the clinic is just to assist the change in diet habit easier. Since our bodies can absorb the calorie faster from carbohydrate than proteins or fat, her diet education to patients focuses on low-carb diet. Her patients are required not to have anything fried or sweet. They are told to eat mainly vegetables (not including the ones with a lot of starch like potato), fruits (no too sweet ones), and proteins (no too fatty or salty ones). Since a lot of Taiwanese people get used to have dishes with rice, she also suggests them to have dishes with soup instead. One of her patients she had today actually reported losing 17 kg in two months. This makes thinking maybe I can use what I just learned from Dr. Hsieh to help my family members and I lose weight. In the afternoon, we met Dr. Ho again in outpatient clinic. Today he still had a lot of patients visiting him for acupuncture. We observed him performing acupuncture on patients rapidly. And he is so experienced to acupuncture that he can use only palpation to find each acupuncture point precisely.
World travel of the human body--kidney, liver, heart, brain back to kidney!
7-8am, 9-12pm—extremely interesting nephrology case and ward rounds
Dr. Chen (chief nephrologist) told me yesterday about a complex and interesting case yesterday Dr. Shiu briefed me on the case and showed me how to access electronic medical records for the patients. He said that I could go to the hospital at anytime to study the patient’s records. I was so excited and felt very privileged. Because our group celebrated and had lots of fun at Shuling night market last night, I rose early this morning and headed to the hospital to study the case.
58 yo female with DM, HTN was admitted on 6/21 for progressive muscle weakness and subsequent fall. She has arrhythmia s/p pacemaker placement, regularly followed up at Taiwan Hospital. She had a left AV shunt placed a month ago to prepare for hemodialysis. She has had oliguria without edema in extremities since 2 months ago. 10 days ago, she developed poor appetite due to post-prandial nausea. In the past 3 days, she developed progressive muscle weakness, culminating to a fall today. She displayed no consciousness change, fever, or abdominal pain.
Her vitals signs were normal. Her physical exam had mostly negative findings. One pertinent negative was “no edema in extremities,” which is a possible presentation late stage renal insufficiency. However, her lab values showed severe hyponatremia (112), hypokalemia (2.5), anemia, elevated creatinine and BUN. The last three could be explained by chronic kidney disease (decreased EPO production and glomerular filtration rate.) The severe hyponatremia and hypokalemia were both concerning and intriguing.
So the clinical impressions were:
1. Hyponatremia
2. Hypokalemia, r/o poor appetite
3. CKD S5, uremic symptoms (uremia could have caused poor appetite, vomiting/nausea)
4. Type II DM
5. HTN (probable complication of CKD)
6. Anemia (probable complication of CKD)
Initial treatment plans were
1. KCl supplement
2. F/O stool OB to check source of blood loss if any
3. Prepare for hemodialysis
The patient also received 3% normal saline at decreasing infusion speed to increase her serum Na+ level gradually. Dr. Chen was careful not to increase serum Na+ too drastically to avoid demyelination syndrome. He reasoned the patient likely had chronic instead of acute hyponatremia. If it were acute, the patient would experience very severe symptoms and would be rushed to ER. Since it most likely was chronic hyponatremia, then the CSF would have equilibrated with the serum osmolarity and Na+ concentration. In other words, the CSF Na+ level was also abnormally low at 112 upon admission. So if the serum Na+ was corrected too quickly, the CSF would not be able to equilibrate immediately (due to BBB.) Then the osmotic difference between the CSF and the serum would cause fluid to rush out of the central nervous system, causing demyelination. This indeed was a very good caution.
While the patient’s serum Na+ increased (going towards normal), her consciousness actually deteriorated. So they consulted the neurologist, who suspected that there might have been demyelination syndrome due to over correction. The brain CT showed no definite lesion and the patient’s consciousness continued to improve. When Dr. Chen and I saw her today (6/28) during rounds, she was fully conscious and conversant, asking to go home. It’s inspiring to witness how Dr. Chen’s knowledge and caution help the patient regain her function. During our visit with the patient, Dr. Chen acknowledged the patient’s desire to be discharged. He also explained to her that he was concerned about her AV shunt might developed a thrombus because her left arm was quite swollen. He also let me feel the thrill on the AV shunt and ascultate the extremely loud bruit!!
Foley training discussion with Dr. Shiu
Dr. Shiu ordered Foley training for this patient and explained to me why the protocol was necessary. Foley catheter is a thin sterile tube inserted through urethra into the bladder to drain urine. After using a Foley catheter for a while, patient cannot be taken off of it without training. This is because the bladder gets used to not being distended and sending the message of urgency to the CNS. So if the patient goes off of F C quickly, he or she may not experience urinary urgency even with extreme bladder distension. For the elderly, sometimes their bladders may expand to hold liters of urine without the patient wanting to urinate. More deceiving is the fact that, pass a certain point of distension, urine will leak out of the urethra from the bladder. So patient may appear to urinate without actually emptying his bladder. This is why it’s important to train the bladder and re-establish the urgency signal to the brain. For this patient, Dr. Shiu instructed clamping the catheter every 2 hours so fluid may build up in the bladder, sending the urgency signal to the brain. Once the patient feels the need to urinate, unclamp the catheter to relieve the pressure.
After rounds, Dr. Chen and I discussed the case in details. In our talk, he’s shown me more than I could ever imagine about the intricacy and complexity of nephrology. We covered the following topics:
• Hypokalemia often manifests in Q wave in EGK, while hyperkalemia shows up as elevated T waves.
• Edema, cardiac gallop sounds, lung basal field crackles are all good indicators of fluid status.
• Hyponatremia types/etiology (mindmap)
• Physiologic (appropriate) vs. non-physiologic (inappropriate) ADH release
• Thyroid hormone, cortisol effects on fluid status
• Electrolyte/fluid status correction and central pontine demyelination (demyelination syndrome)
• Metabolic effects on serum electrolyte
• TTKG (trans-membrane tubular potassium gradient)
• Concentration does not equal amount
o To monitor micro-albuminuria, use U_alb/U_creatinine
o To find amount of K+ excreted, use U_K+/U_creatinine
• Complex renal disease (Glomerular AND tubular dysfunction)
o DM glomerulo-sclerosis =>decreased GFR=>lower K+/Na+ filtration
o Tubular dysfunction=>decreased K+/Na+ reabsorption
• Can’t dilute or concentrate urine well
o Combined G/T disease=> various electrolyte profile (hypo, normal, or hyperkalemia, hyponatremia)
• Medication that cause tubular interstitial damage
o Chinese herb, NSAIDS
• Fanconi syndrome: disease of the proximal renal tubules of the kidney in which glucose, amino acids, uric acid, phosphate and bicarbonate are passed into the urine, instead of being reabsorbed.
Three other patients we visited during rounds.
An 83 yo male presented with change in consciousness. He had no fever or other frank signs. Dr. Chen said 4 ddx we must consider are: sepsis (elderly sometimes don’t mount a strong enough immune response to present fever), medication induced consciousness change, metabolic, and degenerative origin. Patient has suffered dementia and dilution, and he has been on low dose narcotic for his degenerative back pain. Pt’s son brought him to the hospital because he was asleep for long hours and could not wake up for meals. After admission to the hospital, he has been regaining his consciousness, so Dr. Chen discusses with the patient’s son about reducing doses of narcotics and other psychoactive agents.
78 yo patient presented with jaundice due to reaction TB antibiotic treatment and fever. The high bilirubin and low albumin led Dr. Chen to discontinue TB antibiotics temporarily. First urine culture showed Candida; 2nd urine culture showed extended spectrum resistant E. coli. Dr. Chen prescribed Ertapenem, but the patient reacted with seizure. After switching to Myroupenem, the patient has been responding well.
70 yo presented with fever and repeated UTI/leukocytosis. Urine culture showed Klebsiella and ESEL. Dr. Chen prescribed flouroguinolone first and then switched to Ertapenem based on the culture results. Blood culture showed non-resistant E coli, inconsistent with the urine culture. Dr. Chen proposed that perhaps patient had transient bacteremia due to diarrhea (although the Ertapenem would have suppressed the level to less than 10^5.) Dr. Chen emphasized the importance of finding/having an idea of the source of bacteremia. He shared another case to strengthen his point. A DM patient had pyuria and bacteremia but ABD echo had negative findings. Patient continued to spike fever despite of no signs of infection, until CT scan showed a large liver abscess, which explained the bacteremia. Furthermore, U/S detected bilateral hydronephrosis. Dr. Chen said the patient might have a neurogenic, spasmic bladder, so he ordered an intravenous pyelogram to investigate causes of the hydronephrosis. Patient is doing better; fever has subsided with Ertapenem.
8-9am Internal medicine meeting:
ABD pain: incredible differential diagnosis exercise!!!
Dr. Wu was such an incredible teacher. He led us through an exciting journey of differential diagnosis and detective work through a deceivingly simple chief complaint of “abdominal pain.”
Dr. Wu started with the anatomy, which totally confirmed what Dr. Perra recommended us to know well to prepare for all rotation. (I met with Dr. Perra before our trip, and he advised that we needed to know the anatomy well first and foremost.) He said, the origin of epigastric/upper ABD pain could all the structure around this area: pancreas, gall bladder, spleen, stomach (peptic ulcer disease), lung, heart, and even diaphragm. Peptic ulcer disease symptoms often worsen in hunger, so patients usually awake in the middle of the night or early morning in severe pain. PUD patients often have history medication, NSAIDS, steroids use and family history of H. Pylori infection.
He said that inferior wall myocardial infarction could often be referred to epigastric region pain. One must not miss a diagnosis like this. Pleuritis could refer to ABD pain, and the pain would be related to movement and breathing. L diaphragm disease can reflect to epigastric region while R diaphragm may reflect to both shoulders. Gallbladder stone or laceration would be stronger after meals, due to increased peristalsis. GB pain is best described as dull, from anterior to posterior. If gallbladder stone completely obstruct the common bile duct, one should also check the distal biliary bile duct. Blockage of distal biliary bile duct often leads to pancreatitis, which manifests with epigastric pain and elevated serum amylase. Sometimes patients may experience extreme epigastric pain, which subsides with time—this presentation may be explained by an acute obstruction by GB stone, which later passes.
Hepatitis, on the other hand, often does not manifest in referred epigastric pain. This is because there is no nerve in liver parenchyma; nerves run along hepatic vessels. So pain with hepatic origin are usually bloated or swollen in nature; for example, the parenchyma is so inflamed that it starts compressing the peri-vascular nerves. Pain with renal origin may present as ABD pain as well, often due to renal stone. Lastly, one should consider muscle strain and ABD hematoma as ddx for ABD pain.
The resident also noted that the patient had hyperactive bowl sounds. Dr. Wu suggested ileus. The ABD Xray showed slightly more than usual amount of stool. So Dr. Wu brought up a critical point about ABD pain. One should try to gently percuss the ABD to get a sense of the extraneous material: solid (organ enlargement, stool impaction), gas (abscess, pneumobilia), or fluid (ascites). One should pay attention to both the percussion sound and the tactile frequency and vibration.
CT scan can reveal much too. It’s hard to tell in empty stomach if there’s asymmetric wall thickening. But with lumen distention, one can tell if gastric or intestinal lumen has focal thickening, which could indicate neoplasm. With tumor large enough to obstruct GI lumen, distention can be observed proximal to the mass. He also talked about CBD (common bile duct) anatomy further. Adult CBD usually has 7mm diameter, greater than 1cm is considered distention (need to investigate obstruction). One should also compare the sizes of CBD against hepatic portal vein in the same CT slide. If CBD is larger than portal vein, it’s distended with or without exceeding 1cm.
Dr. Wu then elaborated on the branches proximal to CBD, joined from common hepatic duct and cystic (GB) duct. Tracing common hepatic duct back into the liver, there are left and right intra-hepatic ducts. Portal veins run parallel to these branches. Distended biliary tract, including the above branches, can be seen as large hypo-dense area in CT scan. When GB stone is the suspect for CBD distention, one can check serum bilirubin and MRI to confirm.
This was very fun to learn about many of the possible causes of ABD pain and how to analyze backwards from symptoms to etiology.
130-5pm Nephrology outpatient clinic
I made a statistical note this afternoon in Dr. Chen’s clinic. Of the 22 patients he saw today, there were 20 with progressive/chronic renal diseases. 2 cases were UTI’s. The interesting thing was the co-morbidity trend. In the 20 CDK patients, 6 had HTN, 5 had type II diabetes, and 7 had both HTN and t2DM. I want to continue these counts for the rest of the week whenever possible. I also asked Dr. Chen about whether HTN causes CKD. He said that this notion used to be in vogue, but it’s becoming more dubious. Only malignant HTN has been shown to cause nephrosclerosis (pathological proof). The link between essential/isolated HTN with kidney dysfunction is questionable, without pathological proof.
He also said that it would be interesting to look into different specialty’s guidelines for treatment goals. He said that cardiologists pay attention to serum lipid, HTN, serum glucose, etc. Nephrologists heed renal function, and glucose, and HTN, etc. Hepatologists care about HTN, lipid levels in addition to liver functions. So there are overlaps between the specialties but they have slightly different take and priority on each parameter and treatment goal. He said that more and more, cardio-renal should be considered as a unit like cardio-pulmonary has been. For instance in late stage renal disease, one should be cautious with ACE-I usage because it can dilate efferent arterioles and further dampens GFR. ACE-I, in early renal disease, can actually protect against glomerular damage from ultra-filtration. If the patient has reached ESRD, ACE-I can be used at higher amounts if necessary to control HTN because the patient no longer relies on his/her own GFR. This is prime example of how renal health is related to cardiovascular health. As I rotate through the different specialty and present the multi-disciplinary case study, I begin to appreciate how profoundly true the first principle osteopathy (the body is a unit) is.
Dr. Chen (chief nephrologist) told me yesterday about a complex and interesting case yesterday Dr. Shiu briefed me on the case and showed me how to access electronic medical records for the patients. He said that I could go to the hospital at anytime to study the patient’s records. I was so excited and felt very privileged. Because our group celebrated and had lots of fun at Shuling night market last night, I rose early this morning and headed to the hospital to study the case.
58 yo female with DM, HTN was admitted on 6/21 for progressive muscle weakness and subsequent fall. She has arrhythmia s/p pacemaker placement, regularly followed up at Taiwan Hospital. She had a left AV shunt placed a month ago to prepare for hemodialysis. She has had oliguria without edema in extremities since 2 months ago. 10 days ago, she developed poor appetite due to post-prandial nausea. In the past 3 days, she developed progressive muscle weakness, culminating to a fall today. She displayed no consciousness change, fever, or abdominal pain.
Her vitals signs were normal. Her physical exam had mostly negative findings. One pertinent negative was “no edema in extremities,” which is a possible presentation late stage renal insufficiency. However, her lab values showed severe hyponatremia (112), hypokalemia (2.5), anemia, elevated creatinine and BUN. The last three could be explained by chronic kidney disease (decreased EPO production and glomerular filtration rate.) The severe hyponatremia and hypokalemia were both concerning and intriguing.
So the clinical impressions were:
1. Hyponatremia
2. Hypokalemia, r/o poor appetite
3. CKD S5, uremic symptoms (uremia could have caused poor appetite, vomiting/nausea)
4. Type II DM
5. HTN (probable complication of CKD)
6. Anemia (probable complication of CKD)
Initial treatment plans were
1. KCl supplement
2. F/O stool OB to check source of blood loss if any
3. Prepare for hemodialysis
The patient also received 3% normal saline at decreasing infusion speed to increase her serum Na+ level gradually. Dr. Chen was careful not to increase serum Na+ too drastically to avoid demyelination syndrome. He reasoned the patient likely had chronic instead of acute hyponatremia. If it were acute, the patient would experience very severe symptoms and would be rushed to ER. Since it most likely was chronic hyponatremia, then the CSF would have equilibrated with the serum osmolarity and Na+ concentration. In other words, the CSF Na+ level was also abnormally low at 112 upon admission. So if the serum Na+ was corrected too quickly, the CSF would not be able to equilibrate immediately (due to BBB.) Then the osmotic difference between the CSF and the serum would cause fluid to rush out of the central nervous system, causing demyelination. This indeed was a very good caution.
While the patient’s serum Na+ increased (going towards normal), her consciousness actually deteriorated. So they consulted the neurologist, who suspected that there might have been demyelination syndrome due to over correction. The brain CT showed no definite lesion and the patient’s consciousness continued to improve. When Dr. Chen and I saw her today (6/28) during rounds, she was fully conscious and conversant, asking to go home. It’s inspiring to witness how Dr. Chen’s knowledge and caution help the patient regain her function. During our visit with the patient, Dr. Chen acknowledged the patient’s desire to be discharged. He also explained to her that he was concerned about her AV shunt might developed a thrombus because her left arm was quite swollen. He also let me feel the thrill on the AV shunt and ascultate the extremely loud bruit!!
Foley training discussion with Dr. Shiu
Dr. Shiu ordered Foley training for this patient and explained to me why the protocol was necessary. Foley catheter is a thin sterile tube inserted through urethra into the bladder to drain urine. After using a Foley catheter for a while, patient cannot be taken off of it without training. This is because the bladder gets used to not being distended and sending the message of urgency to the CNS. So if the patient goes off of F C quickly, he or she may not experience urinary urgency even with extreme bladder distension. For the elderly, sometimes their bladders may expand to hold liters of urine without the patient wanting to urinate. More deceiving is the fact that, pass a certain point of distension, urine will leak out of the urethra from the bladder. So patient may appear to urinate without actually emptying his bladder. This is why it’s important to train the bladder and re-establish the urgency signal to the brain. For this patient, Dr. Shiu instructed clamping the catheter every 2 hours so fluid may build up in the bladder, sending the urgency signal to the brain. Once the patient feels the need to urinate, unclamp the catheter to relieve the pressure.
After rounds, Dr. Chen and I discussed the case in details. In our talk, he’s shown me more than I could ever imagine about the intricacy and complexity of nephrology. We covered the following topics:
• Hypokalemia often manifests in Q wave in EGK, while hyperkalemia shows up as elevated T waves.
• Edema, cardiac gallop sounds, lung basal field crackles are all good indicators of fluid status.
• Hyponatremia types/etiology (mindmap)
• Physiologic (appropriate) vs. non-physiologic (inappropriate) ADH release
• Thyroid hormone, cortisol effects on fluid status
• Electrolyte/fluid status correction and central pontine demyelination (demyelination syndrome)
• Metabolic effects on serum electrolyte
• TTKG (trans-membrane tubular potassium gradient)
• Concentration does not equal amount
o To monitor micro-albuminuria, use U_alb/U_creatinine
o To find amount of K+ excreted, use U_K+/U_creatinine
• Complex renal disease (Glomerular AND tubular dysfunction)
o DM glomerulo-sclerosis =>decreased GFR=>lower K+/Na+ filtration
o Tubular dysfunction=>decreased K+/Na+ reabsorption
• Can’t dilute or concentrate urine well
o Combined G/T disease=> various electrolyte profile (hypo, normal, or hyperkalemia, hyponatremia)
• Medication that cause tubular interstitial damage
o Chinese herb, NSAIDS
• Fanconi syndrome: disease of the proximal renal tubules of the kidney in which glucose, amino acids, uric acid, phosphate and bicarbonate are passed into the urine, instead of being reabsorbed.
Three other patients we visited during rounds.
An 83 yo male presented with change in consciousness. He had no fever or other frank signs. Dr. Chen said 4 ddx we must consider are: sepsis (elderly sometimes don’t mount a strong enough immune response to present fever), medication induced consciousness change, metabolic, and degenerative origin. Patient has suffered dementia and dilution, and he has been on low dose narcotic for his degenerative back pain. Pt’s son brought him to the hospital because he was asleep for long hours and could not wake up for meals. After admission to the hospital, he has been regaining his consciousness, so Dr. Chen discusses with the patient’s son about reducing doses of narcotics and other psychoactive agents.
78 yo patient presented with jaundice due to reaction TB antibiotic treatment and fever. The high bilirubin and low albumin led Dr. Chen to discontinue TB antibiotics temporarily. First urine culture showed Candida; 2nd urine culture showed extended spectrum resistant E. coli. Dr. Chen prescribed Ertapenem, but the patient reacted with seizure. After switching to Myroupenem, the patient has been responding well.
70 yo presented with fever and repeated UTI/leukocytosis. Urine culture showed Klebsiella and ESEL. Dr. Chen prescribed flouroguinolone first and then switched to Ertapenem based on the culture results. Blood culture showed non-resistant E coli, inconsistent with the urine culture. Dr. Chen proposed that perhaps patient had transient bacteremia due to diarrhea (although the Ertapenem would have suppressed the level to less than 10^5.) Dr. Chen emphasized the importance of finding/having an idea of the source of bacteremia. He shared another case to strengthen his point. A DM patient had pyuria and bacteremia but ABD echo had negative findings. Patient continued to spike fever despite of no signs of infection, until CT scan showed a large liver abscess, which explained the bacteremia. Furthermore, U/S detected bilateral hydronephrosis. Dr. Chen said the patient might have a neurogenic, spasmic bladder, so he ordered an intravenous pyelogram to investigate causes of the hydronephrosis. Patient is doing better; fever has subsided with Ertapenem.
8-9am Internal medicine meeting:
ABD pain: incredible differential diagnosis exercise!!!
Dr. Wu was such an incredible teacher. He led us through an exciting journey of differential diagnosis and detective work through a deceivingly simple chief complaint of “abdominal pain.”
Dr. Wu started with the anatomy, which totally confirmed what Dr. Perra recommended us to know well to prepare for all rotation. (I met with Dr. Perra before our trip, and he advised that we needed to know the anatomy well first and foremost.) He said, the origin of epigastric/upper ABD pain could all the structure around this area: pancreas, gall bladder, spleen, stomach (peptic ulcer disease), lung, heart, and even diaphragm. Peptic ulcer disease symptoms often worsen in hunger, so patients usually awake in the middle of the night or early morning in severe pain. PUD patients often have history medication, NSAIDS, steroids use and family history of H. Pylori infection.
He said that inferior wall myocardial infarction could often be referred to epigastric region pain. One must not miss a diagnosis like this. Pleuritis could refer to ABD pain, and the pain would be related to movement and breathing. L diaphragm disease can reflect to epigastric region while R diaphragm may reflect to both shoulders. Gallbladder stone or laceration would be stronger after meals, due to increased peristalsis. GB pain is best described as dull, from anterior to posterior. If gallbladder stone completely obstruct the common bile duct, one should also check the distal biliary bile duct. Blockage of distal biliary bile duct often leads to pancreatitis, which manifests with epigastric pain and elevated serum amylase. Sometimes patients may experience extreme epigastric pain, which subsides with time—this presentation may be explained by an acute obstruction by GB stone, which later passes.
Hepatitis, on the other hand, often does not manifest in referred epigastric pain. This is because there is no nerve in liver parenchyma; nerves run along hepatic vessels. So pain with hepatic origin are usually bloated or swollen in nature; for example, the parenchyma is so inflamed that it starts compressing the peri-vascular nerves. Pain with renal origin may present as ABD pain as well, often due to renal stone. Lastly, one should consider muscle strain and ABD hematoma as ddx for ABD pain.
The resident also noted that the patient had hyperactive bowl sounds. Dr. Wu suggested ileus. The ABD Xray showed slightly more than usual amount of stool. So Dr. Wu brought up a critical point about ABD pain. One should try to gently percuss the ABD to get a sense of the extraneous material: solid (organ enlargement, stool impaction), gas (abscess, pneumobilia), or fluid (ascites). One should pay attention to both the percussion sound and the tactile frequency and vibration.
CT scan can reveal much too. It’s hard to tell in empty stomach if there’s asymmetric wall thickening. But with lumen distention, one can tell if gastric or intestinal lumen has focal thickening, which could indicate neoplasm. With tumor large enough to obstruct GI lumen, distention can be observed proximal to the mass. He also talked about CBD (common bile duct) anatomy further. Adult CBD usually has 7mm diameter, greater than 1cm is considered distention (need to investigate obstruction). One should also compare the sizes of CBD against hepatic portal vein in the same CT slide. If CBD is larger than portal vein, it’s distended with or without exceeding 1cm.
Dr. Wu then elaborated on the branches proximal to CBD, joined from common hepatic duct and cystic (GB) duct. Tracing common hepatic duct back into the liver, there are left and right intra-hepatic ducts. Portal veins run parallel to these branches. Distended biliary tract, including the above branches, can be seen as large hypo-dense area in CT scan. When GB stone is the suspect for CBD distention, one can check serum bilirubin and MRI to confirm.
This was very fun to learn about many of the possible causes of ABD pain and how to analyze backwards from symptoms to etiology.
130-5pm Nephrology outpatient clinic
I made a statistical note this afternoon in Dr. Chen’s clinic. Of the 22 patients he saw today, there were 20 with progressive/chronic renal diseases. 2 cases were UTI’s. The interesting thing was the co-morbidity trend. In the 20 CDK patients, 6 had HTN, 5 had type II diabetes, and 7 had both HTN and t2DM. I want to continue these counts for the rest of the week whenever possible. I also asked Dr. Chen about whether HTN causes CKD. He said that this notion used to be in vogue, but it’s becoming more dubious. Only malignant HTN has been shown to cause nephrosclerosis (pathological proof). The link between essential/isolated HTN with kidney dysfunction is questionable, without pathological proof.
He also said that it would be interesting to look into different specialty’s guidelines for treatment goals. He said that cardiologists pay attention to serum lipid, HTN, serum glucose, etc. Nephrologists heed renal function, and glucose, and HTN, etc. Hepatologists care about HTN, lipid levels in addition to liver functions. So there are overlaps between the specialties but they have slightly different take and priority on each parameter and treatment goal. He said that more and more, cardio-renal should be considered as a unit like cardio-pulmonary has been. For instance in late stage renal disease, one should be cautious with ACE-I usage because it can dilate efferent arterioles and further dampens GFR. ACE-I, in early renal disease, can actually protect against glomerular damage from ultra-filtration. If the patient has reached ESRD, ACE-I can be used at higher amounts if necessary to control HTN because the patient no longer relies on his/her own GFR. This is prime example of how renal health is related to cardiovascular health. As I rotate through the different specialty and present the multi-disciplinary case study, I begin to appreciate how profoundly true the first principle osteopathy (the body is a unit) is.
Week 4 TCM
Chinese medicine is more similar to Osteopathic medicine than I had expected. They both take the whole body approach to medicine and consider the patient as a person and not a disease. They also believe that the body is a unit and that everything affects everything else. So when treating the patient for back pain, you don't necessarily focus on the back because other factors could be playing a role.
At Taipei Hospital, the Chinese medicine department is quite busy. Dr. Ho, the chair of the department, sees about 60 patients for consultations and does about 20 acupuncture treatments in a morning or afternoon clinic session (about 4 hours). He is quite busy, but still manages to crack jokes with the patients. He includes a structural exam with his consultation and does some manipulative treatments with foot stomping and arm flailing. I'm not quite sure what he is doing, but he said he will explain it tomorrow. During his 4 hour clinic session, he sees patients for herbal consultation and does 2 sessions of acupuncture. The tables are all lined up and patients are called in as a group. Curtains separate each of the tables. Dr. Ho goes to each table and puts in whatever needles he thinks are needed and moves directly to the next patient. He somehow remembers each patient and doesn't need to refer back to the charts. A volunteer follows and counts the numbers of needles so that they can be sure to remove them all. After he applies needles to all the patients he goes back to seeing patients for herbal consultations.
The Chinese Medicine department also has a weight loss section. Dr. Hsieh comes in on Tuesday mornings to do acupuncture and consult patients who are trying to lose weight. She has a set of about 30 points that she uses on all her patients. She also gives them dietary instructions that are very similar to a low carb diet. She asks all the patients to eat less sugar, starch, and fat and to eat mostly proteins and produce. One patient came in who was just using the treatments to maintain her weight without dietary change and Dr. Hsieh told her that this treatment is for weight loss and dietary change is necessary. Patients are given the option of acupuncture and also electroacupuncture, which apparently stimulates the points more and creates more change in the body. Another patient that came in today had lost 16 kg in 2 months with this treatment, diet and exercise. This was her last visit for the treatment. This case in extraordinary and most people lose weight more slowly, which is supposed to be healthier. This treatment seems to be quite effective and patients seem to be quite happy. Dr. Hsieh consulted about 10 new patients to start treatment today.
Through research on the NIH website, I have been able to learn about research on acupuncture. Researchers have shown that by stimulating a point on the foot that is good for eyesight, the part of the brain responsible for the eye becomes active. I'm not sure if this phenomena can be explained scientifically yet, but it is quite interesting. It is believed that some hormones or neurotransmitters are released in response to the needle. Researchers have also shown that acupuncture changes resting-state brain activity causing analgesic effects. (All of these can be found at http://nccam.nih.gov/research/results/topics/index.php?title=Traditional_Chinese_Medicine). I am continuing to learn how acupuncture works through continuing education lectures on the National Center for Complementary and Alternative Medicine website.
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