Week 3, Days 4 and 5: Nephrology and Emergency Medicine

Week 3, Day 4, 6/16/16

After rounding on some of the same patients we saw yesterday, Dr. Lin takes Joe and me through the hemodialysis suite. I heard the Chinese term for dialysis last week for the first time and thought it very appropriate — “shi shen 洗肾” which literally means “wash kidney.” Each session takes about 4 hours, he explains, therefore they have three sessions a day starting at 7:30AM, with capacity for about 23 beds each session. Hemodialysis is one of the two ways patients with chronic kidney failure can take care of the waste products and electrolyte imbalances in their blood. The other method is peritoneal dialysis, which only requires the patient to come into the hospital once a month and gives them more autonomy.

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Source: DocMikeEvans of YouTube

Joe has written a lot about how the hemodialysis machines and process work already, so I would refer to his post about the intricacies of the procedure. The reason why hemodialysis must be monitored carefully by the doctor, nurse, and machine itself, is because it is a delicate balance of moving blood from and to the body at a rate that is tolerable and suitable for the particular patient. Dr. Lin particularly impresses upon us how, even though hemodialysis looks like a peaceful, routine procedure, things can actually go wrong at any moment. Indeed, we see a patient whose blood pressure has been all over the place during her session, currently sitting on something below 100/60 when we visit her. Even though a doctor can take on more patients for more revenue from hemodialysis, they are taking on more risk, especially since it is sometimes hard for families to understand why their loved one suddenly took a turn for the worse when all previous hemodialysis sessions had gone smoothly.

I join Steven for another motor accident filled afternoon in the ER. I am grateful for the chance to again stare at x-rays (which appear on the computer screen within 3 minutes of the doctor sending the patient to radiology — we timed it!) and CT scans to familiarize myself with these imaging modalities. Dr. Jing, our preceptor for the next few hours, lets us try to figure out if there’s anything wrong with each image before pointing out fractures and abnormalities that are imperceptible to our eyes.

One of the more interesting images we see this afternoon is a patient who hasn’t passed stool in a week. His CT scans show a remarkable amount of stool completely distending his colon. Dr. Jing walks us through the transverse slices of the CT scans and teaches us how to recognize where the problem is. There is a bowel obstruction in the sigmoid colon which can be seen because it is followed by a collapsed colon, post obstruction. The obstructing mass will need to be biopsied to determine if it is cancerous, but they will need to go in and empty the bowels first lest they rupture.

We see a chest x-ray with a spontaneous pneumothorax as well (picture below). This patient is a lean and tall male, which we learn is the usual population at high risk for these pneumothoraxes due to gravity pulling down on the lungs (so that the pneumothorax appears at the apices). Dr. Jing tells us that the first time it occurs, the patient is given the choice of surgery, which is a wedge resection, or observation. However, the chance for recurrence is 20%, and if this happens, they strongly recommend surgery as the chance for another pneumothorax is 50%.

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Pneumothorax in apex of left lung.

Lastly, another interesting x-ray we see is that of a little girl. We are amazed by the amount of space between each phalange bone and at the way there is basically nothing in the wrist but a few budding carpal bones. The fact that there is so much space, Dr. Jing explains, is why it is rather difficult for children to break bones in their hands.

There are some differences between the ER here in Taiwan and in the US. As Benfie mentioned, there is a division between internal medicine and surgery in the Taiwan ER — at least here at Taipei Hospital — while I haven’t ever encountered this kind of organization in the US. Complete speculation, but perhaps the existence of the surgical division might be due to the volume of motor accidents, which we have clearly seen a plethora of, that these hospitals receive, which usually are taken care of with a good amount of povidone-iodine and stitches. This article shows the higher traffic death (deaths, not injuries, but I’m thinking there’s a correlation between the two) rate in Taiwan in comparison to other countries. Furthermore, I haven’t spent too much time in ERs in the US, but I feel like I hear a lot about cases of small illnesses of people without insurance appearing in the American ER. Here in Taiwan, with universal healthcare, patients are free to choose from all the doctors in the country, and can go to, for example, the Ob/Gyn without a referral from their primary physician. Therefore, I wonder, if that is why I don’t see too many “small illnesses” in the ER, though it is also probably because I spend all my time in the surgical division rather than the internal medicine division. All speculation, so would appreciate comments it you know more, dear reader?

Another a side note, I once again marvel at the way the Taiwanese (and other foreign countries for sure) must operate in a bilingual medical system. There is an instance where they are trying to account for a mosquito clamp and are arguing about how to write it down on the receipt. “But if you write it in English they won’t understand downstairs!” They settle on a direct translation of “mosquito clamp” and call it a day. We complain so much as American medical students about unpronounceable drug names and hard-to-remember procedures and body parts, but they must be doubly hard to pronounce and remember for those for whom English is a second language.

Week 3, Day 5, 6/17/16
Joe and I round with Drs. Lin and Chen again on the same patients. It’s a change of pace from the primarily outpatient work I’ve observed in Ob/Gyn and the ER. I can see how a relationship building with a patient, or more likely in Nephrology the patients’ families since the patients are often not in a clear state of mind, is a big part of an internist’s skill set. We visit again the 56 year old female former lawyer whose family has decided to tell the doctor that they don’t want any unnecessarily invasive procedures, such as a lumbar puncture. They will wait to see how the anti-fungal medication for her Candida-caused UTI will pan out.

Today, we are also taken to the renal ultrasonography room where Dr. Lin sees five patients. Renal ultrasounds are taken posteriorly in the costovertebral angle with both a long and short axis view, then anteriorly from basically the most lateral edge of the costal margin. He finishes off with viewing the bladder. We learn to compare the renal parenchyma with the liver on the right anterior view; the kidney should be more hypoechoic than the liver. We also see what Dr. Lin believes to be an angiomyolipoma (associated with tuberous sclerosis!) which appears as an echoically homogenous lesion. Other things he checks are the length of the kidney, checks to see that the renal capsule and bladder walls are smooth, if the renal calyces are blunted, and the renal blood flow via Doppler.

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Kidney ultrasound, long axis.

We are told that the afternoon will be all outpatient work so are let off for the day. ‘Til next week when I start Infectious Disease!

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