Week #1..so far

Disclaimer: this post is all about eye and hospital stuff. If you've no interest in eye jargon or how a Chinese hospital is run, wait for my next post :)

First of all, I'm on rotation at the Eye and ENT Hospital of Fudan University. The facility is separate from the medical university. There are other eye hospital/clinics in Shanghai, but I'm pretty sure this is considered the best one in the city. People come from neighboring cities to see the doctors here. As I expected, the hospital is somewhat of a zoo. But it's actually a very organized zoo, somewhat akin to a themepark I guess. You stand in a line for a very long time, the exam portion is over before you know it, people argue over line-cutting, and there's also snacks available for purchase. I don't fully understand the structure of healthcare here in the PRC and maybe this just underscores my lack of awareness, but I thought for a communist country everyone is supposed to have equal access and equal coverage. However, still when it comes down to it, if one can't afford surgery here you're just screwed it seems. Just yesterday I saw a 10-year-old with congenital glaucoma in his left eye. The eye was so swollen from the high IOP that his cornea was bulging out of the socket. It looked like a large grape--the large korean kind that you have to peel the skin off of. The texture of the cornea looked exactly like grape-flesh. The kid had a trabeculectomy when he was a baby but I'm guessing after that since he was symptomless, the parents probably thought the problem was fixed and 9 years lapsed until the boy had a grape for an eyeball. The doctor said that surgery would yield a 30-40% success rate and that most likely the globe would burst. Even if they were able to make a cut into the eye, upon decreasing the IOP there would be a high chance of serious intraocular hemorrhage. For now the high pressure is squeezing the blood vessels--once you open up that tap, the pressure of all that blocked up blood is going to cause massive bleeding. If the surgery goes badly (60-70% chance) they will obviously enucleate the eye. If the boy doesn't get surgery now, at some later point after he's done growing, he will need to have the eye enucleated (taken out, for you non-eye folk). Jimmy tried to get a picture of the boy but his sister was highly suspicious and didn't let him. I can imagine he's already gotten a lot of flack from his peers so I didn't want to push it. The surgery would cost over $1k USD or 8-10K RMB. My monthly rent is already $400, I can't imagine these people having $1000 of petty cash laying around, especially since it seemed they had traveled a ways to this hospital.

This week Jimmy and I have been rotating through glaucoma and have gotten the chance to shadow some really great doctors. All of the doctors here can speak English, of course, with varying levels of proficiency. One doc, Dr. Cheng, has been really great with explaining things to us in English and letting us look at anything we want. The mornings here start at 7:30am with a staff meeting, grand rounds, and then some quick post-op exams. After that it's been something different everyday. Since there are crazy numbers of patients each day, every exam element is pretty much performed in stations. The patient gets a number, sees the doctor for a quick slit lamp eval, and then the doctor either prescribes some meds or tells them what tests they need to get next. Tonometry, visual field, OCT, GDX, pachs, ultrasound biomicroscopy (UBM), FA, fundus photos are all performed in separate rooms. Patient goes through whatever tests they need (which can take several days because they have to wait in line for each one) and brings the results back to the original doctor for an assessment and plan. Patients here are responsible for their own record keeping--so they have a little booklet for doctor's exam notes and for all their printed test results. Something different from Nova is that they use the Octopus visual field which provide a color printout, in addition to the regular Humphrey VF. They also do the Goldmann perimetry which measures your true peripheral fields. Another cool thing is that since it's a big huge hospital they use UBM a lot to visualize the angle. You can see plateau iris and bowing easily.

70% of glaucoma patients in China have angle closure glaucoma. This makes for very interesting, and often sad, cases. I've seen a couple cases of neovascular glaucoma where probably the best bet is to freeze the ciliary body. For cases detected in the earlier stages, an LPI is pretty much the treatment of choice. If that's not possible it's a trabeculectomy. Dr. Cheng let us play around with the YAG laser and I got to make some LPIs on a piece of paper :) We also get to see any surgeries he performs. Most of the surgical suites are hooked up to 3 flatscreens in the lunch room. Yep, people lunch while some eyeball is being slit open or some neck tumor is being hacked off. It's a little unnerving to watch these surgeries to a backdrop of slurping and lip-smacking. You can see exactly what the doctor sees through his scope, as well as other views of the surgery room ie while a patient is being prepped. Literally less than 30 seconds after a surgery is done, the next patient is being laid out on the table. I assure you this is all done in a very sanitary and up to health codes fashion.

After watching 1 or 2 trabeculectomies, it's all the same...so I was ready for something more exciting. On Wednesday we followed Dr. Cheng to the ER since he was on call. A man came in with a corneal laceratin from some steel thread. When the gauze was rolled back, I could see he also had a vitreous prolapse. Since the ER doesn't have monitors hooked up, Dr. Cheng let us observe table-side as he stitched up this dude's cornea. T'was super cool but the downside is owing to the large number of patients they get each day at the hospital, it's unlikely I'll ever be able to observe that guy post-op cause I'll never find him.

I think that's enough eye mumbo-jumbo for now. Here's something that prompted me to post this update:

I walked past some pho joint and it made me think of you Florida folk...shout out to Judy for inspiring me to write about eye stuff at 12am in the morning ;)