Touro California College of Osteopathic Medicine at TIHTC, Taipei Hospital Summer 2016 Where is Taiwan? Taiwan International Healthcare Training Center LOCATION: Taiwan International Healthcare Training Center (TIHTC) at the Taipei Hospital, Ministry of Health and Welfare, Taiwan, R.O.C.
ADDRESS: No. 127, Siyuan Rd, Xinzhuang District, New Taipei City, Taiwan 242
WEBSITE: ptph.gov.tw
2016 COHORT: Benfie Liu, Edwin Liu, Emily Young, Felicia Han, Joe Mak, Steven Lee, Tim Nieh, and Vivian Wan Available Rotations (and more)
Cardiology Pediatrics Orthopedic Surgery
Pulmonology Internal Medicine Heme/Oncology
Nephrology Radiology Infectious Diseases
PM&R Neurology Ob/Gyn
Emergency Medicine Traditional Chinese Dermatology Medicine Internal Medicine Urology General Surgery GI, Ophthalmology Hematology/Oncology 血液學/肿瘤學
● Reviewing anemias ● Reviewing different cancer medications and their side effects ○ Chemotherapy sessions and medication administration ● Shadowing during outpatient and seeing a variety of cancers. Hematology/Oncology remarks
● Chemo drugs are so expensive! But Taiwan’s healthcare system still pays for treatment for a set length of time ● Expensive treatments can get approved, but they take a long time. ● Apparently DNRs are commonplace and hospice care is viewed favorably ● It is difficult caring for patients, especially when they do not have family and the hospital has a responsibility of caring for them. At the same time, they need to be cautious of their spending per patient. Cardiology 心臟科
● Echocardiograms ○ Infective Endocarditis on 2 valves ○ Mitral and aortic valve stenosis ○ Hypertrophy ○ Congestive Heart Failure ○ Measuring ejection fraction Cardiology remarks
● Dr. Chen said, "Your patient is your greatest teacher."
○ By knowing your patient medically and personally, you can treat them in a way that not only improves their condition, but also improves their life significantly.
● "You only see what you know, so you must know what you see."
○ It is very important to understand your diagnostic tools and the results they give you. Emergency Medicine 急診科 ● There are many automobile and moped accidents in Taiwan! ● Cardiac Arrest Resuscitation with Thumper Machine ● Suturing, lacerations, and fractures from motor accidents. ● Lots of X-ray and CT scan reading practice ● Seeing teamwork with nurses, EMTs, police, and physicians. Emergency Medicine remarks ● Impressed by how emergency medicine doctors, nurses, and other personnel work as a team to treat patients ● X-rays are done very quickly!! ● When it gets busy, it gets really busy. ● “Radiation-therapy” for patients, especially parents ○ Pros & Cons of health care system in Taiwan. ● Interesting how ER is split into surgical and internal medicine in Taiwan. Pulmonology 肺科
● Lots of pneumonia, COPD
○ Lots of practice with reading chest X-rays ● Ultrasound-guided thoracocentesis ● Pigtail Catheter Insertion for Pneumothorax ● Shadowed Respiratory Therapist ● VATS Decortication ● VATS Pneumothorax repair Pulmonology remarks
● Learned a lot from the knowledge and clinical experience of the physicians in the pulmonology department! Grateful for their willingness to teach and impressed by their genuine care for their patients. ● Great review and expansion of pulmonary pathology and the differential presentations learned in class. ● Pulmonology has a balance of both clinical problem solving and procedural work. ● Common pulmonology cases: ○ COPD ○ Pneumonia (community acquired pneumonia, aspiration pneumonia, bronchopneumonia, lobar pneumonia) ○ TB / MDR-TB ○ Pleural effusion ○ Empyema ○ Asthma Pediatrics 兒科
● NICU ● Rounding pediatric inpatient wards ● Busy outpatient clinics ● Learned of the critical importance of the physical exam in pediatrics ● Routine child health/growth development exam (e.g. newborn range of motion, infant speech development, BMI) ● Newborn vaccinations ● Examples of pediatric cases: common cold (viral, bacterial), acute otitis media, croup, acute bronchiolitis, pneumonia, newborn jaundice General Surgery 一般外科
● Hernia repair (pictured to the right) ● Laparoscopic bilateral hernia repair ● Laparoscopic appendectomy ● Laparoscopic cholecystectomy ● Laparoscopic sigmoid colon resection ● Open laparotomy endometriosis removal General Surgery remarks
● Got to see a wider variety of procedures, such as skin grafts, nevus removal, lipoma removal, tracheotomies, fasciotomy, etc that in larger hospitals, other surgical specialties would probably do instead ● It was interesting to see three different specialties (gen surg, ob/gyn, urology) working together on the endometriosis case too ● Gained an understanding of selecting surgical methods/techniques based on short-term outcome, long-term treatment plan, practicality, patient comfort, etc. Nephrology 腎臟科 ● Many UTI cases ● Renal echography (pictured below) ● Reviewed how hemodialysis machines worked ● Research with Dr.Yin-Zheng Chen ○ Thank you to all the Nurses who helped us interview patients. Nephrology remarks
● When treating patients with chronic or end-stage renal disease, it is very important to communicate every part of the treatment plan to them (even the drawbacks) in order to build a long-lasting relationship with them and their families. ● With ESRD, many patients spend much of their time in hemodialysis. They get to know the doctors and nurses very well. ● Since kidneys are responsible for so much (like electrolyte balance, fluid levels, EPO production, etc) nephrology diagnosis can get very complicated Traditional Chinese Medicine
● Acupuncture session with Dr. Chen ○ Learned about meridian lines, qi ○ Learned about different types of acupuncture needle movements -- insertion and extraction from body ○ Learned about training for acupuncturists ○ Observed/experienced treatment of back pain, menstrual cramp pain, and skin clearing treatment Infectious Disease 感控科
● Gram staining for typing bacteria (pictured to the right) ● Hospital procedures for preventing infection transmission (eg. hand washing, droplet precautions, etc.) ● Reviewed infectious diseases of many organs of system Infectious Disease remarks
● Dr. Ke’s concern for infection control is contagious (pardon the pun) ○ Impressed by his meticulous work tracking multidrug resistant bacteria in patients in the hospital ○ Handwashing and infection control procedures, such as droplet precautions, really emphasized and drilled into our lessons ● Dr. Ke is an enthusiastic and fantastic teacher, often posing questions and getting me to think about differential diagnoses Ob/Gyn 婦產科 ● Pap Smears every day ● Fetal Ultrasounds ● Adenomyosis and Endometriosis ● Hysterosalpingography (HSG) (picture to the right) ● Amniocentesis ● C section ● Laparoscopic Assisted Vaginal Hysterectomy + total abdominal hysterectomy ● Dermoid cyst removal ○ Case study of endometriosis in bladder with cyclic hematuria Ob/Gyn remarks ● Very fast paced, mostly outpatient work in this hospital ● Impressed by Dr. Lin & Dr. Cao’s concern for each patient, especially considering her wishes to have/not have baby if pregnant and providing treatment plans according to patient’s desire to become pregnant in the future ● C-section was one of the most exciting surgeries I’ve seen; many people in the room and two teams handling the mother and baby at the same time. Neurology 神經內科
● Looked at CT/MRI of stroke patients with Dr. Wu ○ Also looked at MRAs (angiograms) ● Rounded on patients in the morning. ○ Saw many stroke patients and a few Parkinson’s cases ○ Some are actually psych patients with somatoform disorders ● Nerve Conduction Velocity Testing (NCV) ○ Looking at probe placements ○ Viewing action potentials and speeds of nerves ● Electroencephalogram Testing (EEG) ○ Seeing many probes placed on a patient’s scalp ● Carotid duplex ultrasounds ○ Checking cerebrovascular sufficiency Neurology remarks
● Dr. Wu: It takes a lot patience to deal with patients especially when they’ve suffered a stroke or are limited in their mental capabilities. ● Why Neuro? You can diagnose a patient very quickly without expensive labs, imaging, or invasive procedures!
NCV Study Being Done ----> Radiology 放射科 ● Saw MRI and CTs being performed ○ Differentiated between T1 and T2 contrasts for MRI ○ Observed scans of different modalities of CT ■ Saw the speed of the technicians ○ MRIs are very detailed and have many adjustable parameters ● Looked at Mammograms ○ Need to look at symmetry and past scans for reference ○ May be difficult to view lesions for an inexperienced viewer (like a medical student...) ● Reviewed and diagnosed different CT/MRI images Radiology Remarks
● Wondering why x-rays and CT orders from the ER get filled so quickly? Thank the CT/MRI staff! They’re very efficient in what they do. They are there every day, day and night. ● Radiology in this hospital usually do not do procedures or see patients, but they are vital to other specialties. ● Radiologists need to know a lot of pathology!!! Orthopedic Surgery 骨科
● Schedule was more intense than other departments’, but definitely well worth it. ● Journal/Article review in the morning, surgery until lunch time, outpatient clinic in the afternoon, and 1-1 lectures to finish the day (8am-5pm). ● Open Reduction, Internal Fixation for a variety of fractures, including clavicles, upper and lower extremities, spine, and spine. ● Total Knee Arthroplasty with Dr. Shih Sr., and Total Hip Arthroplasty with Dr. Huang. ● Outpatient Department- diagnostic tests in physical exam, hyaluronic acid knee injections, tons of X-Rays and MRIs. Orthopedic Surgery remarks
● Learned a ton from 1-1 lectures; Development of Nails and Plates History with Dr. Shih, Lumbar Spinal Stenosis and Interventions (spinal fusions) with Dr. Huang, Osteoporosis with Dr. Yang and Dr. Chen, and Basics of Orthopedics with Dr. Zhuang. ● Had a great time shadowing Rex, the PGY-1 in orthopedics department. PM&R ● Learned principles and appliance of kinesio tape ● Got first-hand treatment with different PT modalities such as Transcutaneous Electrical Nerve Stimulation, ShortWave Diathermy, Vertebral Traction, and Interferential Current Treatment. ● Watched PTs treat patients who had Cerebrovascular Accidents, and the challenges ensued in personalizing an optimal rehabilitation course for each patient. ● OPD allowed us to see patients in varying stages of their rehabilitation, and seen how far they’ve come since injury. PM&R remarks
Joe and Edwin are extremely appreciative for Linda and Tom’s personable approach to teaching them principles in Physical Rehabilitation Outside the hospital! Food :)
- Fan Tuan 飯糰 - Din Tai Fung 鼎泰丰 - Hot Pot 火鍋 - Shaved Ice 刨冰 - Hua Shen Bing Qi Ling 花生冰淇淋 - Cong Shu Bing 蔥蔬餅 - Boba 珍珠奶茶 - Fuhang Soy Milk 豆浆 More Food Favorite lunch spot...
$2-3 dollars per meal Shilin Night Market 士林夜市 Elephant mountain 象山 Chiang Kai-shek Memorial Hall 中正紀念堂 Basketball 籃球 Guanshan 關山-RURAL MEDICINE Jiufen 九份 RESEARCH AND OMED
● 3 posters presented at OMED and BIOM 18th Annual International Seminar - September 17 & 18, 2016 in Anaheim, California
● 11 posters presented at the BIOM 17th Seminar ● Global Health Research Abstracts: ○ Student Doctor Michael Lee, OMS III - 1st place in Research Category in 2015 ■ Patients with Six Cannulation Sites for Hemodialysis Correlated with Decreased Occurrence of AV Shunt Thrombosis in Taipei Hospital ○ Comparison Between Fried Frailty Score and Established Prognostic Factors in Predicting Mortality of Hemodialysis Patients in Taiwan ○ Epidemiological study of risk factors and comorbidities in hemodialysis patients at Taipei Hospital in Taiwan: a fixed cohort survey, 2010–2014 ○ Effectiveness of Taipei Hospital’s CKD Education Program on Chronic Kidney Disease Patients’ Renal Failure Outcomes The End & THANK YOU!!!
From Touro California Taiwan Global Health Internship Group 2016:
Benfie Liu, Edwin Liu, Emily Young, Felicia Han, Joe Mak, Steven Lee, Tim Nieh, and Vivian Wan
Feel free to contact any of us with questions!
Our blog: https://globalhealthtaiwan.wordpress.com/