Tuesday, January 31, 2012

Acute Appendicitis in a 9 year old Child


               I was working in the rural health clinic, thankfully it had been a quiet morning.  I was looking forward to having lunch shortly, seeing that I had only managed to eat a small amount for breakfast, due to my waking up late and rushing out of the door to get to work on time.
                “Sharon, there’s a little 9 year old girl with her mom who just checked in at the front desk.  She’s crying.  Can you please see her before you leave for lunch, please?” pleaded my medical assistant. 
                “Okay, Carla,” I said as I let out a sigh.  “You check her in and I’ll go back and at least eat my sandwich so that my stomach will quit growling.  Agreed?”
                “Agreed, thanks Sharon,” sighed Carla.
                I scurried back to the break room and grabbed my lunch bag out of the refrigerator.  I ate my sandwich so fast, even I was surprised.  I had just eaten the last bite of it when Carla’s head popped around the corner of the door.
                “She’s ready for you, Sharon.  She’s in room two.”
                “Thanks, Carla.”
                I put the rest of my lunch back in the refrigerator and walked down the hall to exam room two.  I knocked on the door and went into see an upset little girl.  I was thinking she probably had a painful ear infection or strep throat.  But what she had, I was definitely not expecting. 
                “Hi, I’m Sharon.  And your chart here says that you’re Melody, is that right?”
                 Melody, sitting uncomfortably on the exam table, nodded her head ‘yes.’
                I immediately noticed that she was in real pain and this wasn’t just an ear infection, she was wiggling around trying to find a comfortable way to sit without pain.  She also had a white chalky look to her face. 
                “Melody, would it help if you laid down on the table?”
                She nodded, ‘yes’ and slowly laid down on her back.
                I turned to her mom and asked her what had happened during the last day or so to bring this pain on.
                “Melody didn’t eat a whole lot yesterday.  She went to school and they called me around lunch and said that she was complaining of being tired and had fallen asleep.  I went and picked her up and brought her home.  She took a nap and when she got up she said that she just didn’t feel well.  She didn’t eat anything for dinner last night, she just wanted some watered down 7-up and that was it.  I noticed that she started running a low grade fever last night.  She went to bed early.  I was woken up around midnight when I heard her in the bathroom throwing up.  She threw up a couple of times, just yellow fluid mostly.  She told me that her stomach hurt, but nothing else.  I thought she probably just had the flu seeing that it was going around her school.  So I let her go back to bed and she woke up this morning with a fever of 101 F.  So after I got her brother off to school, I finally got her dressed and came over here.”

Patients who could have acute appendicitis acquire it due to blockage of it’s small opening into the intestine or from undigested food or other foreign matter that gets caught in it.  It is the most common condition in children requiring emergency abdominal surgery. 

                I turned to Melody and asked, “Okay, Melody, where in your tummy does it hurt?”
                Melody pointed to her right lower quadrant of her abdomen.
                “Okay, Melody is that where it hurt last night when you told your mom that your stomach hurt?”
                Melody nodded, ‘yes.’
                I quickly looked at the vital signs Carla had taken and noticed that her fever was 101.4 F.  Her pulse was a little on the high side. 
                “Melody, when was the last time you had anything to drink?”
                Melody answered in an almost inaudible voice, “this morning.”
                I turned back to her mom and asked some more questions.
                “Is she on any medications for asthma, or allergies or anything?”
                “No, she doesn’t take anything.”
                “Is she allergic to any medications?”
                “No.”
                “What’s the family history?”
                “I have high blood pressure, her father has type 2 diabetes.  Her grandparents have some heart problems.   That’s it.”
                “Okay, great.  Let me do her physical and then I’m going to send her across the street to the county hospital’s lab to get some labwork done.  But I can tell you right now that she doesn’t have the flu.  I think she has appendicitis.  If the labwork shows what I think it will, then she’s going to need to be seen by a general surgeon to have her appendix taken out. “
                With my saying that, Melody’s eyes enlarged and she gave me this pained look on her face. 
                I looked Melody directly in the eyes.  “Melody, I think you have a little tiny piece of your intestine that is causing you a major problem right now.  If I’m right, then it can be taken care of very easily.  The doctor that I’ll send you to will put you to sleep and then he’ll make a lttle incision with his instrument in your lower abdomen right where it hurts, snag this little piece of intestine, what we call an appendix and remove it from your abdomen.  You’ll then wake up and feel so much better.  Do you understand that?”
                Melody  nodded ‘yes’.
                “Okay then, Melody, I need to feel your tummy  and listen to your chest.  I’ll try real hard to not hurt, but if it does you have to tell me, agreed?” I asked her.
                Through her ever increasing watery eyes, Melody nodded, ‘yes.’
                I took out my stethoscope and put the end piece on her chest wall to listen. I had her roll over so I could listen to her back side.  I then listened to her heart sounds.  Everything was normal.  I gently put the end of my stethoscope on her abdominal wall and listened.  It was unusally quiet.  Taking the stethoscope end piece out of my ears, I wrapped it back around my neck. 
                “Okay punkin, now I need you tell me when it hurts as I feel all around your abdomen.  I’ll be gentle as possible.”
                As I felt her abdomen, first away from where it hurt and then started moving my hand over her right lower quadrant she was becoming more apprenhensive.  I knew then, that if I tried to palpate where it hurt she would not trust me to finish the needed exam.  So I changed tactics a little bit.  I put my hands down by my side and asked her a question.
                “Melody, I want you to use one of your fingers and I want you to put that finger right where the pain hurts the worst.”
                With a tear running down the side of her face, Melody moved her right hand and used her second finger to touch her lower right abdomen just above her hip bone, almost midline.  She was pointing right at McBurney’s point, the anatomical spot where the appendix lies.
                “Okay, punkin, you can put your hand back down.  I won’t touch where you pointed your finger.  I’m going to send you across the street to the county hospital’s lab to get some tests done and once you’ve done that you can come back in this room and lie down.  So I’ll give the lab slip to your mom and the two of you can walk across the street.  I’ll see you again once I get the lab results back.”
                With that I gave her mom the lab slip.  The two of them left the room, Melody walking very gingerly and slowly.   I quickly went back into the breakroom and grabbed the rest of my lunch and ate it while Melody was across the street at the hospital’s lab.

Patients who have acute appendicitis will generally present with nausea, vomiting, anorexia, abdominal pain, fever, right lower quadrant pain, and sometimes diarrhea or constipation. Patients can also have guarding of their abdomen due to the pain and/or rebound tenderness (this is where you press down with your hands and then let up suddenly, if it hurts, then this is considered rebound tenderness). 

As a part of the physical examincation you can have the child hop on one foot, if this elicits pain in their abdomen, it is considered a positive sign. You can also internally rotate their right leg (i.e. turn the leg towards the midline), if this elicits pain then it is considered positive. 

If a patient is suspected of having acute appendicitis the amount of lab work/radiology tests you need depends upon the age of the patient.  If they are a child or adolescent you typically only need to acquire a complete blood count (which should show an elevated neutrophil count).  Neutrophils are a form of white blood cells and they fight off bacterial infections.  You should also acquire an urinalysis to make sure that the problem is not coming from a urinary tract infection.  If the child does not have the typical findings for appendicitis, then it is advisable to acquire an abdominal ultrasound or CT study of the abdomen to ascertain the status of their appendix (is it inflammed vs. does it look normal in size).

Some pediatricians and surgeons will use what is called a pediatric appendicitis score.  The patient is given 1 point for their physical exam findings, laboratory findings and/or radiology test results.  If the patient has a score of 7 or above then they are considered at high probability of having acute appendicitis. 

If the patient is an adult then you also typically need to acquire a CT scan of their pelvis after you have made sure that if it is a female patient they are not pregnant. 

                About 45 minutes later, Melody and her mom walked back into the clinic and Melody proceeded to slowly crawl back up on the exam room table and laid down.  About 30 minutes later the hospital lab called me with Melody’s stat lab results.
                The lab results confirmed what I thought they would.  Her urinalysis was normal, and her complete blood count showed a high total white blood cell count with a high neutrophil count (neutrophils are used to fight off bacterial infections).  So these lab values confirmed what I thought, Melody had appendicitis. 
                I walked back into the exam room and advised Melody and her mom that she would need surgery.  I called the emergency room next door at the county hospital and asked who was the general surgeon on call.  They asked why, I advised them of Melody’s condition.  The emergency room registered nurse said she would immediately put in a page for Dr. Thomas.  I asked her to call me back when he had replied.   About five minutes later I received a call back and the county hospital advised me that Dr. Thomas had called and he was on his way in to see Melody and to send her over.
                I walked back into the exam room and advised Melody and her mom that Dr. Thomas was on his way in.  Melody sat up and slowly starting to get down off of the exam table.  She again walked slowly and gingerly down the hallway towards the front door.  She was followed by her mom.  They moved slowly back across the street and walked into the emergency room. 
                About an hour later, Dr. Thomas called me and advised me that Melody did indeed have appendicitis and he was taking her to the operating room as soon as they could get her an intravenous dose of pre-op antibiotics.  He thanked me for working her up and he expected her to do just fine, he didn’t think her appendix had ruptured.
                A day and a half later I walked into the rural health clinic and was given a telephone note from Carla.  The note was from Melody’s mom.  It basically said, ‘thank you, Melody is going home this morning.’  I was glad that she had done so well and would soon be back to her normal self. 

Typical treatment for acute appendicitis consists of:
prompt general surgery consult
intravenous antibiotics
intravenous fluids for hydration
pain control
surgery: usually can be done with a laprascope (1 inch incision) to remove the inflammed appendix
hospital discharge generally within 24-36 hours



Again, thanks for reading.  I solicit your comments and feedback.  –sharon

Tuesday, January 17, 2012

I'd love to hear your comments!

I've been writing this blog for a little over a year now.  In that time frame I've written patient stories that run the gamut from pediatrics to geriatrics, from primary care to oncology (cancer).  I've written about relationships, families, books I've read, and people I've meet. 

Now what I'd love to hear from you my readers is what have your learned, what have you liked, what would you like to read more of, how do you want me to change my writing style (if you do)?  How can I help you through this blog learn more about your own personal health or the health of your family members? 

Please send me your comments once you've been able to think about my questions above and I'll do my best to help you learn about your own health issues.  I love to write and teach, so please tell me what you'd like to learn.

Again, thanks for reading my blog and I wish you a great new year of 2012!  --sharon

Thursday, January 12, 2012

A Clinic Nurse

I was working in my usual clinic seeing patients who had various diagnosis’ related to their liver, generally some sort of hepatitis (inflammation of the liver).  As I exited one of the patient’s rooms, Meg, one of the clinic RNs asked me to come and see her after I had finished seeing all of my scheduled patients. 
I told Meg I would come and find her in about two hours, after my clinic was finished.  She told me that would be fine.
After I finished my morning clinic, I went to find Meg.  I enjoyed working around Meg, she was a very good clinic nurse and went out of her way to help the other nurses.  I also enjoyed seeing her newest pictures of her newborn baby boy who was about 9 weeks old.  She had just recently returned from her maternity leave.  She was so happy to have finally been able to have a child at the age of 35. 
“Meg, I’m free of my clinic patients now.  What did you need?”
“You’re very good at what you do, so I need you to see me.  I don’t want to go and see my OB/Gyn about this, he’s across town.  I’m having pain right here.”  With that she put her hand over her upper right quadrant of her abdomen. 
“Okay, well then let’s go into one of the empty exam rooms and I’ll take a look.”
Meg walked somewhat gingerly into one of the empty exam rooms and I followed behind her.  I closed the exam door and sat down on the exam room stool. 
“Okay, what’s going on?”
“I started having discomfort and now it just hurts over my upper right quardrant.  It started to bother me about a week ago, I noticed that the pain would start up after I would eat some fatty foods.  But now this morning the pain hasn’t gone away and it just hurts constantly.  I don’t want to eat anything, I don’t have any appetitie since this morning, but I’m trying to stay hydrated. “
“Okay, are you having any fevers, vomiting or diarrhea?”
“No, none of those, although I might have felt a little warm this morning.”
“Alright, well what medications are you on right now?”
“I’m still taking my prenatal vitamin and a calcium supplement.”
“Okay, what about medication allergies?”
“None.”
“Anything in your family history?”
“Both of my parents are still alive, my dad has some hypertension, my mom has type 2 diabetes.  That’s it.”
“And your medical history is your previous pregnancy, anything else?”
“No, nothing.  I’m just trying to lose this pregnancy weight I put on, but that’s it.” 
“Okay, well then let me exam you and then I’ll call and try to get your abdominal ultrasound scheduled for this afternoon.”
“Thanks.”

The gallbladder lies somewhat hidden up underneath the liver on the right side of the abdomen, just below the lower right rib cage.  It’s purpose is to excrete bile into the digestive system when you eat fatty foods.  Bile breaks down the fat and allows your system to absorp it for energy use. 

When people have problems with their gallbladder they can present with pain in their upper right hand quadrant of their abdomen, nausea, vomiting, fevers, sometimes a fast heartbeat, sometimes a positive ‘Murphy’s sign’ which means that they have pain elicited when you press into the midline of the right upper abdominal quadrant while the patient is taking a deep breath.

Patients can also give a history of having pain about one hour after eating a fatty meal.  The gallbladder is being asked to excrete bile and this generally elicits the pain, either from the gallbladder going into spasms or from a gallbladder stone becoming trapped in the bile ducts. 

I did my usual physical exam that I do on new patients, by listening to her chest, heart sounds, had her lay down so that I could do a thorough abdominal exam and then did a quick peripheral exam of her arms and legs.  Meg had a definite ‘Murphy’s sign’ with tenderness to palpation over the midline of her right upper abdominal area.  She was also a little tender over her epigastric area.  She also had some mild rebound tenderness over her right upper abdominal area.  All of this along with her history told me that she most likely had acute cholecystitis, or an inflammed gallbladder that needed to be surgically removed. 
I let Meg sit back up on the exam table and then told her, “Meg I’m going to go call the ultrasound tech downstairs and try to get you into to have an ultrasound done ASAP.  I’ll be right back, hang tight.”
“Okay.”
A few minutes later I walked back into the exam room and told Meg that I had been able to get her scheduled as an overbook in ultrasound within the hour.
“Meanwhile, Meg, I need you to get some blood work drawn, I need a complete blood count, INR, and liver function tests done.  So here is your lab slip, I’ll follow up on these later.  I’ll also call the radiologist and ask him to read your ultrasound after it’s done.  If it shows what I think it will, then I’ll call the surgical service for you and have them see you right away.  You’ll most likely need to have a laproscopic cholecystectomy done.  And the surgical service likes to do these sooner rather than later so that your gallbladder doesn’t become infected and present complications.”
“Thanks, Sharon.  I really appreciate it.”
“Make sure to stay hydrated and don’t eat anything, I’ll call you after I talk to the radiologist.”

Risk factors for having problems with your gallbladder include:
--obesity
--pregnancy
--age
--diabetes
--female
--recent weight loss
--certain drugs
--increased trigylcerides (a part of the lipid panel)

Typical work-up for the gallbladder includes:
--abdominal ultrasound which can show gallbladder wall thickening or swelling
--HIDA scan which is done if the ultrasound is negative, this is a test where dye is injected into the patient’s bloodstream and then as the dye is excreted through the liver into the gallbladder, if the gallbladder is not visualized then this is a positive test
--rarely do we have to order a MR cholangiography (magnetic resonance testing) or a CT scan of the abdomen
--blood work is ordered to ascertain whether the patient is becoming infected from the gallbladder or whether there are other complications occuring such as involvement of the bile ducts with an occluding gallstone, etc.

Later that afternoon, I placed a call to the radiologist reading ultrasounds.  I told him what was going on with Meg and he pulled up her ultrasound. 
After he quickly looked at Meg’s ultrasound, he said, “Sharon, you can calll Meg and tell her she needs to see the surgeon, she’s got a positive ‘Murphy’s sign’ on her ultrasound and several large gallstones in her gallbladder.”
I told the radiologist, thanks for his help and put in a call to Meg.
“Meg, your ultrasound is positive for a problem with your gallbladder, where do you want to have your surgery done?”
“I’ll have it done here, that way my insurance will pay 100% of the costs, so you can refer me to the surgical clinic on the first floor.”
“Alright, well then let me page them and see whether they can get you in tomorrow to be seen.  I’ll call you back.”
“Thanks.”
I hung up the phone and paged the surgical service on call.  Dr. Brooks returned the call, he was a third year surgical resident.  I explained to him what was going on with Meg and her ultrasound results.  He told me that he would call me back in about 10 minutes as soon as he ran the case by the attending. 
Twenty minutes later, Dr. Brooks was back on the phone with me. 
“Sharon, Dr. Kessler, my attending took a look at Meg’s ultrasound report and he says based on it being a positive study, we don’t need to see her in clinic.  We also saw her labwork that was done.  We can just do her as a direct admit through day surgery.  Call her back and tell her that we have her scheduled on Friday for her lap cholecystectomy, she needs to be in day surgery clinic checking in at 6 am.  She should be able to go home Saturday morning.  Anesthesia can see her in day surgery clinic prior to the procedure and one of our surgical interns can do her pre-op history and physical then.  Make sure she doesn’t eat or drink anything from midnight on prior to her scheduled surgery.  Any questions?”
“Nope, I think that covers it, thanks much for your help.  I’ll call Meg and tell her what to expect.”
I placed a call to Meg who was still in clinic trying to get some work done.  I told her what the surgical resident had said to me and relayed the pre-op instructions. 

Treatment for acutely inflammed gallbladders (cholecystitis) is for the patient to have either a laproscopic cholecystectomy (removal of the gallbladder through a small opening in the abdominal wall) or an open cholecystectomy where the patient has about a 4-6” incision over their right upper abdomen.  Generally the surgical services will try to do a laproscopic cholecystectomy if at all possible.  This leads to a shorter recovery period. 

IV antibiotics can also be used just prior to and after the surgery if the surgical service feels they are removing an infected gallbladder.  But not all patients need antibiotics, seeing that less than half (46%)  of patients with acute cholecystitis have a positive surgical culture. 

“Thanks for your help, Sharon.  I’m still nauseated, so I don’t think I’m going to be eating anything anyway between now and 36 hours from now on Friday morning.  I’ll go let Pat (her nursing supervisor) know that I’ll be out for a few weeks.  I’ll be glad to get this taken care of, it kind of puts a wrench in my wanting to do anything. “
“Alright, well if you need anything for your nausea, let me know, you can take some Tylenol for the discomfort, that won’t bother your clotting factors for surgery.”
“Okay.”
The next day in clinic, Meg wasn’t feeling too perky, she remained nauseated, but didn’t want to take anything for it.  Around noon, I noticed that Meg had gone home for the rest of the day.  Friday afternoon, Pat came and found me and told me that Meg had her lap cholecystectomy that morning and she had gone up to see her in the recovery room.  She said Meg was comfortable and her nausea was finally gone.  Dr. Brooks had come by and told her that everything had gone very well and they were planning on discharging her home in the morning. 
Four weeks later, Meg was back at work having fully recovered. 

Thursday, January 5, 2012

Keep Your Personal Boundaries Intact

A part of keeping yourself heathy, is keeping your boundaries intact.  This means physical boundaries as well as emotional boundaries.

Keeping yourself healthy emotionally means that you don’t allow others to verbally abuse you, shame you, control you or pull you into a co-dependency relationship.  To be emotionally healthy you need to be involved in encouraging, strengthening relationships with family members and friends.   You need to be around people who will emotionally support you and be your ally when necessary. 

To keep yourself healthy physically, not only do you need to address and control any chronic health issue(s) you may have, you also need to exercise and eat right.  But that’s not all.  You also need to keep yourself healthy physically by staying out of volatile scenarios, either at work, or with a family member.  For if you are around volatile people, they can harm you emotionally (through verbal abuse) or through physical assault on you.  Either way you have to deal with the emotional baggage that comes with the incident.  If you don’t deal with the emotional baggage, then you put yourself at risk of having panic attacks, anxiety, high blood pressure, etc in the future.  None of which is in your best interests. 

As an example of the above, I’ll share with you a work scenario that I was involved in and ended up being temporarily victimized by. 

At the time that this episode happened, I had finished writing a NIH (National Institutes of Health) grant and it had been submitted for possible funding.  Nancy was the department service line administrator and hence she was responsible for the financial affairs of the department. 
 
I walked into Nancy’s office, she was sitting at her desk, probably about 20 feet away from me.   I stayed near her open door.   No one was in the outer offices, they had left work for the day. 

My hands were down, clasped together and I was standing in a non-threatening position.  I proceeded to advise Nancy in a very non-threatening mode, that I had come across an error in the NIH grant I had written, and would therefore be withdrawing it from consideration.  With this said, Nancy immediately FLEW out of her chair and came across the room so fast I probably didn’t even have time to take a breath. 

She went from being calm at her desk to being extremely angry in less than 10 seconds.  Rage filled her face as she stood less than 2 inches away from my face and started to scream (literally scream!) at me. 

With her right second finger wagging in front of my nose (almost touching it), and her left hand in a cusped position 1 inch from my neck as though she was getting ready to throttle me, her face red with rage, she informed that I couldn’t do that and if I didn’t immediately leave her office she would call security on me. 

I continued to stand there with my hands down at my side totally confused by how she had acted.  I was in shock over her reaction.  What she had done really scared me. 

When I didn’t immediately leave her office, Nancy then turned around FLEW back to her desk, picked up the phone to call security on me.  Still screaming at me to get out of her office, she proceeding to dial security.  Not knowing what else to do I left her office. 

I went back to my office, sat down, in shock and cried.  I honestly couldn’t believe I had just witnessed Nancy in such a rage.  I tried to contact my physician boss,  but he was in a meeting. 

The next morning I waited for my boss to arrive at work so that I could advise him of what happened.  When he got off the office elevator,  Nancy was by his side. 

He proceeded to come into my office where we discussed what happened.  My boss told me that Nancy had been waiting for him on the 1st floor and was profusely apologetic to him over what she had done.  He told me to wait a few days to see whether Nancy apologized to me.  At the time, he truly believed she would.  He knew that I had not done anything wrong, or made any movement with my body to incite Nancy to have done such a thing.

Nancy never did apologize to me.  She refused.  Little did anyone know or understand that Nancy had a narcissistic personality disorder, which allowed her to have a contemptuous and uncaring attitude towards her work colleagues.  And because submitting a NIH grant cost the hospital I was working for monies, she became enraged at me at what she thought was financial wastage. 

I later found out that I had 30 days after my NIH submission to make any last minute corrections to the grant, which I did.  The grant was eventually rated, and they came back to me and told me they wanted to fund me after I published my research data. 

It wasn’t until 3 years later that Nancy was finally fired.   

Now how can you protect yourself (emotionally and physically) and help heal yourself from such a scenario that I was involved in.  I’ll share with you some of the things that I did to heal myself. 
1)      I shared this incident with my close friends, which allowed me to acquire support from them
2)      I allowed myself time to grieve the incident, to express my emotions and feelings I was going through during and after the episode happened
3)      I expressed my righteous anger towards Nancy’s actions in a safe environment and tried to understand the incident from her point of view
4)      I went and did a long, hard physical exercise session which allowed me to express and vent my emotional energy which was caught up in my physical state
5)      I attempted to report this incident to higher ups in the hospital adminstration seeing that they were compiling a work policy against work place violence
6)      I kept my wits about me and from then on I stayed away from Nancy and was never around her again without someone else in the room with me
7)      I advised other work colleagues of what she had done, so that they were aware of her ability to fly into a rage, so that they would be aware of this potential against them

All of these 7 steps allowed me to stay emotionally healthy and not end up feeling permanently victimized by Nancy.  I remembered who’s fault it was and therefore didn’t cower around her after this incident happened. 

So if you find yourself in an abusive scenario (either emotionally or physically) which can indeed affect your physical health, remember what I did to address my emotions and remain in control of who I was and not act like a victim from them on out.  In the end, I stayed empowered and healthy. 

Another thing to remember is that if you are a victim of workplace violence, you are not alone.  It is estimated that 10% of all employees have suffered from some sort of workplace violence.  I hope you are not one of them, and if you are that you have been able to recover from it. 

Again, thanks for reading and leaving your comments, I hope you have a great 2012!  --sharon

Chinese Medicine

A few years ago I wrote the following essay after returning from mainland China.  I was one of the medical ambassadors on a People to People trip.  The 2 week time period I spent there was a real eye opener as far as my being able to see the stark differences between Chinese herbal medical care and Western medicine.  I don't think we realize how fortunate we are to have all of the medical advances, technology and diagnostic testing available to us when we become ill, until that is, it is not available. 

So as we look towards this New year, let us be grateful for our medical care, and the medical care of our family members.  Let us all make this year better for ourselves, our family members and our friends by addressing our health issues in a responsible, accountable way.  Then the end result can be that we are all healthier and better for it.

As always, thanks for reading my blog and writing comments.  I appreciate it.  --sharon 


                                    An Outsider’s View on Chinese Medicine

            On October 31st, 5 PA delegates and 2 guests took off from Los Angeles for mainland China.  We had been asked by the People to People Ambassador program to take part in an exchange of ideas/medical training with our Chinese counterparts. 

            We landed in Hong Kong and within a few hours we were deplaning in Beijing to begin the first part of our trip.  The five PA delegates came from across the U.S. (Lois Brown, Pittsburgh, PA; Rosemary Chidester, Malvern, PA; Ellen Namer, NY, NY; delegation leader, Pamela Scott, Williamsburg, WV, and myself, from Denver, CO). 

            We spent 10 days touring China, seeing many of the historic sites such as the Great Wall, Tiananmen Square, Forbidden City (Beijing area); Reed Flute Cave, Li River cruise (Guilin); Yu Yuan Gardens, Jade Buddha Temple, Shanghai Museum, and Old Shanghai, (Shanghai).  Additionally, we partook in many cultural events such as attending the Peking Opera, Shanghai Acrobatics, and watching a performance by the Guilin Ethnic Dancers. 

            But, of course, our main purpose in traveling to China was to see Chinese medicine in action.  We meet with many different Chinese physicians and administrators in the three cities we traveled to: Beijing, Guilin and Shanghai.

            In the process, we learned from our Chinese counterparts, as well as they learned from us.  In many of our meetings we advised them on the training of PAs, and on various ways we are employed.   They in turn, discussed with us how they are trained, medical school, and residency training.  As of 2004, they do not have specialists (as we know them).  This is an area they are investigating and forming their fellowship training programs to met the need.   

            Some of the health care issues in China that surprised me was, first the lack of health insurance.  Only 30% of Chinese nationals have insurance.  The remaining 70%, if they were to get ill, would only have their own available personal monies to pay for it. 

            Another eye-opener for me was the health care facilities themselves.  They ranged from looking like a 1940s Appalachia Mountain region clinic facility up to an early 1990s U.S. urban hospital facility.  For example, the clinic in Guilin was housed in a building which was so dilapidated that the floor of the x-ray machine had large holes in it, and no lead in the walls to prevent radiation seepage.  Laboratory equipment ranged from nearly nothing to an up-to-date laboratory facility with all the latest lab tests available. 

            On our visit to Beijing’s Traditional Chinese Medicine (TCM) Hospital we were shown around an out-patient facility which saw 3,000 patients per day.  All sorts of eastern-type medical practices were performed here from acupuncture;  tuina (a form of chiropratic manipulations);  moxi-poxi (lighting with a match an ½ to 1 oz herbal concoction which is positioned on the end of an acupuncture needle, and then allowed to smoke).  The majority of patients who are given prescriptions go home with a form of herbal medication.  Each day they are to boil water, pour their bag of herbs into it, let it simmer, then drink the ‘hot tea’  during the day, starting the whole process over the following morning. 

            During our tour of the TCM hospital we were informed that herbal medicine can only treat disease symptoms, it doesn’t treat the disease process.  If a patient were to be hospitalized, then they use western medicine.  For the majority of Chinese patients, they don’t have the monies to pay for western medicine, and hence they use the less expensive herbal formulation. 

            As an example of their lack of monies to treat disease, the Chinese population has a prevalence rate for chronic hepatitis B of 9.7% (per a report from the Beijing government).  This means that 130 million Chinese are infected with this virus.  The medication used to treat and clear this virus from a patient costs approximately $600 per month, and you need to be treated for 11 months.  This kind of medication cost is beyond the reach of all but the richest of Chinese.  For instance, the annual salary of Chinese physicians is $3,000 USD/yr.

            Another thing that surprised me was that Chinese physicians do not do any sort of physical examination on their patients.  I didn’t see an examination table in any of the clinics we visited.  Nor do the physicians wear stethoscopes around their necks.  Basically the process for a patient is that they go in and speak to the physician about what their symptoms are, the physician decides what they need, gives them a prescription and out the door they go. 

            While I was in Shanghai, and meeting with a few of the attendings of the Shanghai Medical School, I asked the Chinese physician responsible for taking care of viral hepatitis patients, whether she would be interested in doing some clinical research in conjunction with the medical school I work for.  She seemed quite interested in pursuing this option.  I went on to tell her of the long-term remission rates we have acquired with chronic hepatitis B and C.  I advised her that I had access to medications for the Chinese patients, and hence they wouldn’t have to be concerned about this cost.

            During my conversation regarding viral hepatitis, I was surprised that my Chinese counterpart didn’t know the prevalence rates in China of two of the diseases she treats (chronic hepatitis B and C).  I had to inform her of the rates as quoted from one of the Beijing government sources.  I would have thought that this sort of information would be one of the first pieces you would learn about a disease you are treating.  But, not so, in China. 

            The other item that took me by surprise was there was a TCM physician sitting next to the physician who treats viral hepatitis, and during our conversation he sat up in his chair, looking proud, declared that he had a 40% remission rate using TCM on his patients who have acute hepatitis A, B or C.  I had to keep my jaw from dropping to the floor, for I knew that if you combined all three acute hepatitis cases together and just gave them symptomatic care for their disease, 70% don’t need anything else, they will totally recover and do just fine.   That made me wonder what kind of herbs he was giving to them, to make them recover at only 57% of the rate that placebo would give you.

            Another parameter of where Chinese medicine is, in comparison to the Western world,  is that they still, to this day, put all infected patients in one hospital, and all other patients in another.  This means that chronic hepatitis and HIV patients, if hospitalized, are put in a hospital separate from other general hospital patients.  This is their idea of infection control.

              Now that I’m back home, I’m grateful that I live in the U.S. and if I were to become ill, have medical facilities and technological advances available to me that 99% of the Chinese do not.  I have at my fingertips, physicians who understand epidemiology of disease, how to appropriately diagnose them, know which medication to prescribe to rid my system of most diseases, for other diseases, control it.  This is in stark contrast to what I saw in China.  It’s no wonder that most Westerners who if they become ill in China, are told to get to Hong Kong.  For the Hong Kong physicians have been trained in the British medical system, and hence treat with Western medicine. 

            China has come a long way (their economy is growing at a rate of 9.8%/year, they are now vaccinating their children under the age of 3 for prevalent childhood diseases including hepatitis B, as well as their overall level of poverty has decreased).  But they still have a long way to come.  They need to develop wastewater treatment plants, increase their electrical capability, as well as have potable drinking water.  Seeing the current situation of medicine in China was an eye-opener for me.  Just give the ‘sleeping giant’ another 10-20 years and don’t be surprised if it truly becomes a world power to be reckoned with.