海外実習：Day 4 (Outpatient)

Transplant Clinic and HCC Clinic 

• What I learned

  • I shadowed the "Fresh post" clinic. Those who received the transplant recently (usually about 6 month or so). The transition is fresh post -> monday stable -> stable. 

  • The pharmacist talks with the patient first to go over their meds. Then the doctor and registered nurse go talk with the patient.  

    • In Japan, I do not see many pharmacist being directly involved with the outpatient, so I was kind of surprised.

    • Post transplantation, patient are on steroids, so their glucose level might become high. Fluconazole and tacrolimus have drug interaction and having stable tacrolimus level is important. 

  • Immunosuppressants after transplant -> tacrolimus, cellcept (mycophenolate mofetil), and prednisone. Eventually, tacrolimus only but for the rest of their life. 

  • There was one person in his 30s that got acute liver failure and ended up doing a transplant due to green tea extract usage. 

  • There are some patient who get striction of the the biliary pathway after transplantation and require stenting. Need to do ERCP to check. If that doesn't work you can do surgical fixation (like Roux-en-Y).

  • Unlike most solid cancers, the diagnosis of HCC can be established in patients with cirrhosis based on multiphasic CT or MRI without histological confirmation.

• 印象に残った事

  • In order to the transplant, in addition to the MELD score, the patient needs a "good insight" and supportive family and insurance ( or "under insured"). 

    • MELDスコアもあるが、先生の主観のもと、ある程度「選別」が行われていると感じた。

    • 例え凄く病態が悪い方でも、その方にその認識と改善したいという気持ちがないと、移植には持っていけない。ご遺体から頂いた大切な臓器は大事にしてくれる人の所にいくべきだと感じた。患者さんの病態だけではなく、willingnessも評価するのが大事だと思った。

  • アメリカは保険のカバレッジも考慮する必要がある。よって、恐らくsocial workerの役割も大きいと思う。There was one patient who got the transplant, but the health insurance coverage ended or something along that line. Thus, ran out of the medication and ended up in devastating state. 日本ではあまり考えられない。

感想

• I haven't confirmed it, but I think patient have to leave the hospital fairly quickly after the transplantation. Thus, even if they live 2 hours or so away from the hospital, the patient and the caregiver needs to translocate to a nearby place (like a family house). 恐らくアメリカの病院の平均入院日数は短く（日本だとだいたい2週間以内だけど、アメリカは1週間未満だと思う）、回転率は早いと思う。After the transplant, the patient has to come to the clinic about 2 times a week. After 2~3 months, they can go home and come to clinic from there. When I was looking at the medical records, I noticed how much Emergency Department visits the patient were having. If the problem occurs before the next visit, the patient have to go to the emergency department. Right after the transplantation, there are so many possible problems that can occur and I was just surprised by how early they get released from the hospital.

• 日本で固定臓器の移植は見たことないが、恐らく日本だったらもっと長く病院で見ると思う。入院を継続すると医療費も高くなるから、患者さん自身も早期退院を望んでいるとは思う。でも、外来にしてしまうと患者さんの負担が増えると思う。何かが起こる分からない中、知らない土地に2ヶ月もいるのは不安だと思う。医療者にとっても入院している方が、直ぐに対応できて、安心だとは思う。アメリカの医療形態ではこれがスタンダードなのだろう。日本では実行できないと思う。必ずしも入院をする必要は問題でも不安だから入院したいと、くる患者さんもいる。どっちが良いのかは分からない。