tough day

這個月時間過得飛快，因為實在太忙了，帶我的主治說，他在這裏帶教這些年，這個月是有史以來最忙的，病人多也就算了，而且都重，問題一個接著一個，每天早上看實驗室結果都是紅燈一串串的（如果是不正常的結果，都是用紅色標出來的）。所有的決定，會診，治療，最後的工作都是落在intern身上去實行，每天一進病房就如上足了發條，不吃不喝也要先完成工作，主治醫生或者住院醫生問起來為什麽這個那個還沒做好，我是不能回答因為我要吃飯啊。嗬嗬。

即使不覺得，但是壓力一點點在心中積聚，忙得沒有時間去宣泄。

今天早上ICU打電話討論K女士的病情。她是我在急診室收的一個病人，腸梗阻，體檢發現一個肛門腫塊，腸鏡確診是肛門癌，外科讓我們確定手術風險，我們做了心髒超聲和其他健康檢查，病人一般情況很好，於是馬上手術了。但是手術以後K女士發作了急性動脈栓塞，深靜脈栓塞，橫紋肌溶解，急性腎衰竭，在ICU病情不斷惡化。每天早上去看她，是最讓人心碎的事情。她是一個很可愛的老太太，從來不抱怨，看到我總是臉上綻放出笑容，哪怕插著鼻管，哪怕下肢都已經壞死。

我總是心裏帶著莫名的愧疚，不知道為什麽，也許因為是我把她收進來，把她送上了這條通向深淵的路。我問過主治醫生，外科醫生，有什麽我們那時候可以預防這一切發生，他們都說沒有，我們做了一切該做的，病人隻是發生了嚴重的並發症。這樣的解釋，並不能讓我在麵對下肢壞疽，奄奄一息的K女士心情更好一點。

ICU說，讓我們和家屬談一下，是不是建議放棄治療，改為no code（就是維持生命治療，但是不再搶救）。ICU醫生說，病人氧氣飽和度急劇下降，意識喪失，非常危急了。

和家屬談完以後，家屬同意no code了。K女士不會支撐過周末。

回到辦公室我們繼續討論病情，主治醫生和住院醫生若無其事地把話題轉移到下一個病人身上，而我的眼眶卻慢慢潮濕起來，不知道為什麽，隻是覺得心裏非常難受，一個健康快樂的老太太，兩個星期，就這樣被徹底改變了生命曆程，她看我的眼神，帶著微笑，每天早上還總是先問我：how are you today, doc? 我怎能當作什麽事情都沒發生過。

主治醫生發現我神態異樣，說are you OK? 我搖搖頭，說no, I feel bad about Mrs K,  this case broke my heart. 主治醫生說，我們都盡力了，我知道你每天接觸她時間最多，建立了感情，感覺很難過，但是作為醫生，要明白自己的職業局限，不能太attach。

但是我不知怎麽就失去了控製，眼淚不斷地落下來，沒辦法繼續下去，我站起來說excuse me，然後走到走廊上，努力讓自己平靜下來。

回到辦公室，住院醫生說你還好吧。我說是的，不好意思，繼續討論病情吧。

現在回想起來，不知道為什麽當時就失控了，不太professional，主治醫生和住院醫生肯定覺得怪怪的。可能一方麵是無能為力的愧疚，還有就是積蓄已久的壓力，終於找到宣泄的途徑。

一直到7點做完了事情，明天終於休息了，和好朋友去喝酒了，然後討論三月份一起去滑雪的計劃，好友美酒，讓人情酣，開車回來的路上，人有點輕飄飄的，還好沒有警察攔我，嗬嗬。

[茶葉蛋]

我的母親也是醫生，上海各大醫院醫學院都充斥了她的校友，所以我對你說的深有共鳴。每個醫生都是一個普通的人，正常的心，有愛，對生命的脆弱的歎息。媽媽說，人活著就是一口氣，下一口沒有接上來，一切煙消雲散，愛和恨，富和窮，都不見了。有經驗的醫生對這些見多了後，不是冷漠了，而是鍛煉得成熟了，因為，要調整好心情，還有下麵的事要做。

[綠豆紅茶]

落花醫生：
I am so sorry to hear that. Hug...
Please try to have a relaxing weekend :)

[落花飄零]

today i signed Mrs K's death certification.

綠豆紅茶，HIT is certainly a concern, we did follow her plt count everyday, no obvious dropping, I don't know what's the exact reason of her LE arterial occlusion, my guess is from massive compression during sugery.

[菁子]

醫生的心也是肉做的。我覺得從醫的人有顆同情心會不知不覺在查房的時候流露出這一點。病人的心總需要人慰籍，醫生熱情的微笑和安慰會讓他們覺得很溫暖，也有利於病情恢複呀。但是別太苦自己，不能心太軟。
我以前在國內管過的一個病人，是個運動員，但是有先心，做的是預防性的手術，結果麻醉過後就再也沒有醒來。這個病例也折磨了我很久，尤其是當我想起她的陽光般的上高中的兒子坐在她病床邊和她說笑的樣子，我就想“要是她沒來醫院就好了”。經常有謀事在人成事在天的感覺。
以自己的能力做到最好，對得起良心，就好啦。

[綠豆紅茶]

落花醫生：
I have been reading your blog for a long time and I really admire your hard work :)

I don't know if you watch the TV show "Grey's Anatomy". One of the interns, Dr. Izzie Stevens has told the chief that she is both a compassionate person and a surgen, and that both are essential in defining who she is as a human being. She and other real surgens I know, including my mom, have taught me that it is the compassion you feel for your patients that makes you a better doctor.

I know too little about Ms K's condition to make a guess here, but may I ask two questions:
Did doctors administer unfractionated heparin, or low molecular weight heparin for her surgery? What happens to her platelet count? I just thought her symptom looks similar to one of the thrombotic disorder--heparin induced thrombocytopenia (HIT). HIT typically develops 4-14 days after the administration of heparin, and with the auto-immune type (type II), clot formation is mainly arterial and rich in platelets, while thrombotic events are mostly in the lower limbs, skin lesions and necrosis may also occur at the site of the heparin infusion.

Again, I do not know the genetic background and family history of that lady. If this sounds irrelavant, or the information comes too late, then forget about it :)

Have a good night.

[小馬999]

獅王說的好像很對，專業水平高！另外，是不是有些凝血因子突變的病人 under stress 時，就特容易出現血栓，高凝血狀態。落花妹妹能不能給我們從專業方麵分析一下？端個板凳我先在前排占個座。

[江湖中人]

落花，很羨慕你的認真。從當初的我不喜歡做醫生，到現在我再次選擇從醫，都是喜於有這種能幫助他人的成就感。但這也是最難的， 特別是我們還必須無奈的要去麵對很多痛苦的現實。很多醫生也因為這個，放棄了這個職業。我們也許是要去找到一個平衡點吧，這樣我們才能生存下來。（很喜歡無錫妹妹的高見）

[獅王傳說]

好久沒來了，落花又有進步呀。

你這個病例，應該是有教訓要吸取的。

首先，作為醫生，你表現的不職業。內心的感受是對的，但工作時候哭出來，不應
該。會影響其他醫生和病人的心情。醫生是個殘酷的職業，好的醫生感情要細膩，
但不可脆弱，情感是不可外露的。但壓力之大，外人難以想象，所以工作後自己減
壓，是關鍵。

其次，肛門癌手術，不外乎切除和造瘺。如果有直腸吻合器的話，手術不是很麻煩
的。你說的並發症，和下肢血運有關，我懷疑術中傷及下肢血管，要不然不會肌肉
壞死的。如果是由小血管栓塞開始逐漸發展的，那麽術後小劑量抗凝做的不好，術
後護理觀察不仔細。這個教訓，要外科醫生來找了，和你們無關。

[小馬999]

酒後駕駛,開個罰單---再考一遍step1,2,3...哈哈

[angelboy]

A recent study researched the overall quality in almost 5,000 non-federal U.S.hospitals. Interesting findings showed that on average, 28% overall lower inhospital risk-adjusted mortality associated with the 16 procedures and diagnoses, and 5% overall lower complications associated with the 10 procedures experienced by Medicare patients at Distinguished Hospitals for Clinical Excellence compared to all other hospitals.

Do the search and see where your hospital stand, our one is not within the top 5% although it was listed on the top 10 ranked by another annual publication.


source: http://www.healthgrades.com/media/dms/pdf/HospitalQualityClinicalExcellenceStudy2007.pdf

[流氓免]

physician ah, 牛！~
加個油，嗬嗬嗬

[lucky_tomatohead]

為了在你的BLOG留言,特地注冊了個筆名

一直在關注你的博客,也一直想寫些什麽.
你的文字很打動人.你可能是一個平凡的人,但是你也可能有顆不平凡的心,因為你這樣的不平凡,你才能夠打動到別人.

我幾次看你的博客,眼眶都會濕潤.尤其是和父母分別入關的那篇,和我的感受竟然如此相似,我也是從入關開始一直到上飛機都沒有停止留淚.我曾經很自信自己是個很堅強的人.在出國前每次回家鄉看父母,回到上海都要忍不住大哭一場,那些時候都沒有想象過一下將來出國會是什麽樣子.

我不是醫生,我也不是學醫科的.因為你,因為你的博客,我可以更真實地看到人的生老病死,生離死別.說白衣天使這樣的話可能俗了點.但是真的很敬佩你不懈的努力,能夠在美國成為一個醫生本來就不是一般人可以做得到的.我相信也因為此,你可以獲得別人得不到的同等生命中的價值.

祝賀你也祝福你,一直活出自己的精彩.

[wuximm]

I was in your shoes once. I would loss sleep and my appetite over every little disappointment. I was barely survive in my intern year. I had learned to lower my expectations, which was " do no harm to patients, get by and pass each rotation so no need to repeat again, try not to be the weakest intern in my class". I was so busy that I didn't even notice how the other interns were doing. In the end, there were two interns did not get 2nd year contracts renewed and another one had to let go in his 6th months. All three were American graduates. I ranked 2nd at annual in-service exam. Most likely, you are not as weak as you think. What will be worse: kill yourself by pushing self too hard vs repeat intern year? Yesterday, on Pri-med CME conference, I met the guy fired from our program, he is all happy and is currently practicing in Louisiana, I can't trace any past trauma on him at all. Life goes on.

It is OK for a intern to say "I don't know or I am not sure". As a attending myself, I always like those interns who are sincere and trying hard though may have a difficult start and I never fail them. I worried the most are those who know a little and pretend to know it all, make mistakes and always blame on others. You are definitely not one of them, you are fine intern and good physician. Have faith in you. Another point is: medicine is what we do but not who we are. Trying to have fun with other interesting things.

[落花飄零]

thank you guys for the support, i think i am over reacting for this case, every team did their job, just happened to have a very unfortunate outcome.
6hr, i think i need to defense myself and my colleagues a little bit here. there is no malpractice in this case, everything was well done and followed with guideline, if we could do this again, we would still do the same thing. As a matter of fact, the family was giving up, but we are still doing everything we can to see if there is any chance. I don't know how far we will go, maybe tomorrow my attending will give the call.

WUXIMM, thank you for the advice, i think i am exactly this kind of personality you described, and i think most of my colleagues are like me. I care about every feedback from other people, how can I not? my attending has talk with me every two weeks about every improvement after i recieve the feedback. i am struggling with my self esteem everyday, a word can make my day, and a word can ruin my day. this is driving me crazy.

[6hr]

有一種可能性：他們知道有，但是沒有告訴你。怕你更傷心。Do you have Mortality & Morbidity Conference month/weekly? When I was in Sir Run Run Shaw Hospital in Hangzhou, we did that, for better doing next time. Learned a lot from that.

We had more terrible experience, In 1994, the 1st year of the hospital, we, a group of not well trained young doctors just like murders in the Hospital. one of my head trauma patient loss life because of GI bleeding, the blood arrived a few minutes after he died. Only if I know more about Cardial Pulmonary Ressusitation. He may well alive now. Another case is a 17 year young girl, trauma, died of spleen(may be more organs) rapture. If the 1st line doctor had more experience. The girl will have a happy life. Fortunately, things changed after Dr. Bryner from California trained us Advanced Trauma Life Support and lots of other things. He has all the characteristics of American surgeons, and furthermore some religious devotion spirit. When he set a goal he never give up.
He trained many good doctors in Sir Run;;and the Hosptal is a good Hospital, famous in Laparoscopy now.
Yes I cried for my head trauma patient. I have more to blame than you.

[流沙隨風]

遺憾的是醫生不是神。況且，先不說有沒有神，即便有，神能做的也就是這些了。

你把愛心寫在這裏，把你痛苦的經驗用在下一個病人身上，K女士定是含笑而去。

[BMW328]

沒有人說我來說，為了讓這個世界上多一個好醫生，大家應該一起來譴責落花酒後駕車的行為

[WEIK2008]

象這樣的情況，醫生的態度可分為三種：
1.從來沒有象姐姐這樣想過，沒有任何情緒波動，認為醫生的職責是按最保險的方式治病，盡力了就好；
2.曾經有過情緒波動，見多了，就漠然處之；
3.象姐姐這樣，深切的感受死亡。
姐姐是個性情中人，嗬嗬

[Dalaoshu]

說不出來什麽安慰或者讚美的話了，
我也抱抱可以嗎？

:)

[盈袖2006]

這就是我喜歡你的原因.完全明白你的感受.ENJOY THE WEEKEND.

[wuximm]

Observing a lovely lady withering away, you felt the sense of failure and naturely broke down. You only can save those who can be saved. Practicing medicine is indeed very stressful. To heal a person, one must first be a person. There is a limit how much a person can achieve. Most physicians fit the descrpition of obsessive-compulsive personality-want everything to be perfect, set a unrealistic goal and put on lots of stress on themself. During this busy season, I hope you take good care of yourself. "Taking care of yourself is not selfish, but rather it is self-preservation". I hope you set a realistic goal and reduce the need of external validation. It will help you cope with the stress.

[qiqi66]

抱抱...一直很喜歡看你的文章,有很多事情我們都無能為力,隻要自己盡力了就好.