醫學生日記2016年3月16日-風風火火

醫學生日記2016年3月16日-風風火火

阿山 （龐靜譯）(原文存在譯文之後）

我今天在兒童耳鼻喉科臨床學習。一天都很忙，我記了幾件事。

 上午6:00-9:00: 嘴唇修複

 每個科室每周都有一個報告會。全科室的人聚會兩個小時，大家一起聽一個專選課題的報告。對於這個課題，多數醫生、住院醫、和學生可能沒有機會獲得第一手資料。報告的目的就是教大家，並且明確指出這個課題的重點。

 耳鼻喉科的報告會定在7:00。我一個小時前就到了。我的指導醫生事先給了我一個預習的單子。我得用這一個小時趕緊讀一讀關於頭和脖子的先天畸形方麵的東西。七點鍾，兩個醫生一起做了嘴唇修複的報告。對我震動最大的一點是，雖然醫生們治療的是創傷是癌症，但是病患們能記住的，一輩子都抹不掉的是他們嘴唇上的傷疤。一個變了形的嘴，或者一個明顯的疤痕，很可能會很不幸地改變病人的一生。從這個角度，我們可以看清醫療和整容的交集點，及共同的重要性。

 上午9:00-10:30 天使綜合症

 我很幸運。我的指導醫生讓我先獨自看病人，然後向他報告我的發現，討論治療方案，最後我們一起去與病人談。這是一個很專門的領域，兒童耳鼻喉專科醫生從醫學院畢業之後還要有將近十年的專科培訓。

 我的第一個病人是一個生了天使綜合症的小女孩。這是一個先天性疾病，會導致智障，但是生了這個病的孩子們的一個重要症狀是他們特別的快樂和友好。因為生了這種病的孩子看上去都像很好玩的娃娃，這種病也曾經被稱為快樂寵物綜合症。這個女孩的病曆很複雜。她經常生病，但是今天還好，很開心地跟一個陌生人（就是我）玩。跟她的父母談了一下，我覺得她的存在實在奇怪。她經常地生各種各樣的病，那些病的任何一種都會使我們正常人的生活很可悲。她呢，隻是因為基因的錯誤，生了這麽多的怪病，她還是照樣活著，而且她知道的唯一狀態就是快樂。

 上午10:30-11:45 甲狀腺切除

 今天的門診比較輕鬆，但是頭和脖頸癌症中心需要人手，所以把我借去了。一個甲狀腺切除手術需要幫手。到了手術室，他們讓我拿著牽引器，抻開脖子上的刀口，如此，手術醫生可以仔細地切除甲狀腺的腺體。甲狀腺周圍有很多重要的神經和血管，手術醫生必須非常小心不能碰壞那些神經和血管。我必須站在那兒，拉開那些皮。手術醫生說這就是醫生們每天的鍛煉。

 上午11:45-下午1:00 急診喉頭鏡

 住院醫學長把我從甲狀腺手術室叫出來，接著進了另一個手術室。他們正準備從門診部去吃午飯時得到呼喚，一個兩歲男孩剛剛沒了呼吸。前幾個小時見他還呼吸順暢，但是一下子他就不能呼吸了。我的指導醫生和住院醫馬上從門診部跑到手術室，準備緊急手術。

 這個男孩有一個移植的心髒，所以用了抗排斥藥物。醫療的正麵結果是他有了一個心髒。但負麵結果是他非常容易感染。當醫生把光鏡放到他喉嚨處時，那裏完全被一層灰色蓋住了。指導醫生說那是黴菌和壞死組織的混合物。那些粘泥狀的東西堵住了他的氣管。手術過程就是刮掉這些泥狀物質，讓空氣可以穿過他的嗓子。

 下午1:00-5:00 希阿利畸形

 由於急診手術，我們下午門診晚了，還有上午的病人在候診。我們迅速回到門診部。根據我前兩天的經驗，我們兒童耳鼻喉科根本沒有午餐時間。我抓了兩塊披薩，一邊走一邊吃。在見每個病人的間隙，我也抓空咬一口。以前總在電視上看醫生無法坐下來吃東西的笑話，今天輪到我了，兩塊披薩，一會咬一口，前々後々用了三個小時才吃光。

 下午主要是正常門診：小孩的扁桃體肥大，小孩睡覺打呼嚕，夜間突然停止呼吸，還有很嚴重的過敏。值得一提的是一個孩子由於母親懷孕期間的複雜狀況造成他出生就有頭顱骨-腦子變形，（稱為希阿利畸形）。他使我想起我科研導師曾經教過我。他說，做為一個醫生，如果用各種病症的術語去考慮這些孩子們是容易的。“哦，想々他有這個病那個病，他現在這樣已經很好了。” 但這並不是一個病人的生活。現實中，“他會拿他自己和正常的孩子去比，所以我們要盡最大的努力讓他們感覺到自己和正常人一樣的健康。”

 下午5:00-7:00 氣管狹窄症

 門診之後，又去看了要求谘詢的病人。通常，一天會收到一到兩個病人要求谘詢的呼喚。今天，我們看了七個要求谘詢的病人。其中六個出生不足兩個星期。這七個都有先天性缺陷。

其中五個都在新生兒特護病房。我記得一個神經科專家做過一個統計，新生兒特護病房的嬰兒是我們所能見到的病得最重的病人，但是他們當中的百分之八十都能完全康複回家。現代醫學是神奇的，病嬰們可以神奇地複原，茁壯成長。

有一個嬰兒先天性氣道陝窄，這造成了她呼吸困難。由於她的母親失明，她的治療比較麻煩。最簡單的治療方法就是切開氣管，然後嬰兒就可以回家了。但如果這樣，殘廢的母親就會失去嬰兒的監護權。我們明天要給嬰兒手術，選擇其它方法為她治療。我會把她的詳細情況在另一篇中寫出來。

原文

March 16, 2016 – Rapid Fire Cases 

I’m on the Pediatric Otolaryngology service today. It’s a very busy service and here are some quick cases to frame and illustrate the day.

6:00am – 9:00am: Lip Reconstruction

Every medical service has weekly “Grand Rounds”. Grand Rounds are where everybody in the department comes together for 2 hours to listen to somebody present on a chosen topic. The purpose is to teach all faculty, residents, and students about topics they maybe haven’t been exposed to, and to highlight important issues in the field. 

The Otolaryngology (ENT) Grand Rounds was scheduled to start at 7:00am. I arrived an hour early because my attending physician had given me a list of topics he wanted me to study. Today, I used this hour to cram in my reading about head and neck birth deformities. Starting at 7:00, two doctors presented the topic of lip reconstruction. One of the main points that stuck with me is that even though the surgeons are treating the patients for cancer or trauma, what the patients are going to remember, and live with forever, is the scar on their lips and mouth. Having a disfigured mouth or facial scarring will forever, and likely adversely, change a patient’s life. This is a point where we see the intersection and importance of medical and cosmetic concerns. 

9:00am – 10:30am: Angelman Syndrome

I’m very lucky that my attending physician lets me see patients independently, present my findings to him, discuss the plan, and then finally we go as a team, considering this is a fairly specialized field and Pediatric ENT doctors have close to 10 years of training even after graduating medical school. 

My first patient was a little girl with Angelman Syndrome. This is a genetic disorder that results in mental retardation, but the hallmark feature is that the kids are all exceptionally happy and friendly. This disease used to be called Happy Puppet Syndrome, because all the kids just seemed to be happy playful dolls all the time. This girl had a very complicated medical history and was sick quite frequently, but today she was well and completely unperturbed to play with a total stranger (me). Talking with her parents, it just made me think of how strange an existence hers is. She is often very sick with multiple conditions, each one of which one individually make any one of our lives miserable. Yet here she was, with many of them, and because of a genetic mistake, she lives with all these diseases and the only state she knows how to be in is happy. 

10:30am – 11:45am: Total Thyroidectomy

The clinic schedule was fairly light today, and the Head & Neck Oncology service was short on people, so I was loaned out to that service. They needed an extra pair of hands for the total thyroidectomy. My job, in the time I was in the operating room, was to hold the retractors and pull open the incision on the neck so the surgeons could carefully remove the thyroid gland. The thyroid gland is surrounded by many very important nerves and blood vessels, so the surgeons had to take great care not to damage any of those structures. I just had to stand still and keep pulling back on the skin. The surgeon described these procedures as physical workouts for everybody involved. 

11:45am – 1:00pm: Emergency laryngoscopy

My resident grabbed/rescued me from the thyroidectomy and pulled me into another operating room. They were about to go on lunch break from clinic when they got called about a 2 year-old boy that had just stopped breathing. He seemed to have a few hours earlier, but he very quickly stopped being able to breathe. My attending physician and resident had raced over from clinic and prepped for emergency surgery. 

The boy had a transplanted heart, so he was taking immunosuppresants. The plus side of the medication, it allowed him to have a heart. The down side, he was more susceptible to infections. When the doctor put the scope down his throat, it was entirely covered in a layer of gray. He explained that it was a mixture of fungus and dead tissue. All of the gunk had clogged up his airways. The procedure was to scrape out all of the gunk so air could get through his throat again. 

1:00pm – 5:00pm: Chiari malformation

Because of the emergency surgery, we were late for afternoon clinic, and there were still patients from the morning that needed to be seen. We quickly returned to clinic, and from my first 2 days, I knew there was actually no lunchtime in Pediatric ENT. I grabbed 2 slices of pizza and ate while I was walking back to the clinic. In between each patient encounter, I would take a quick bite and get moving to see the next patient. I frequently saw jokes on TV about doctors never being able to sit down and eat. At least I got 2 slices of pizza today… and it took me a span of 3 hours to be able to eat those 2 slices. 

The afternoon was mainly normal clinic visits: kids with big tonsils, kids who snored, kids who stopped breathing at night, kids with really bad allergies. One notable kid was born due to a complicated pregnancy and had a skull-brain deformity (Chiari malformation). He just made me remember what my research mentor had once taught me. As doctors, its easy for us to think of kids in terms of the conditions, such as “oh, considering that he has such and such condition, he is doing really well”. However, that is not the life the patient lives. Instead, “he will be comparing himself to other normal kids, and therefore we have to do our best to make him feel as healthy and normal as we can”. 

5:00pm – 7:00pm: Subglottic stenosis

After clinic, we visited the consults we had been called on. Normally, I was told that there is usually only one or two consult patient encounters per day. Today, we had to see 7 patients. 6 of them were less than 2 weeks old. All 7 had complex birth deformities. 

5 of them were in the neonatal ICU. I remember one statistic quoted by a neonatologist. The babies in the NICU were amongst the sickest patients we would ever see, but 80% of them would make full recoveries and go home. Modern medicine is amazing, and babies have wondrous ability to bounce back and thrive. 

One baby was born with congenital narrowing of her airways, which made it very difficult for her to breathe. Her treatment was complicated by the fact that her mother was legally blind. The easiest treatment, a tracheotomy, would have allowed the baby to go home. But also, the mother would have lost custody due to her own handicap. We are going to surgery with the baby tomorrow and determining what alternatives we can do to open her airway. I’ll very likely write more about her again in a separate case journal.