醫學生日記2016年5月2日

醫學生日記2016年5月2日

阿山 (龐靜譯）

 

查房巡診是第三年實習經曆中最重要的部分。每天早上整個團隊從一個病房走到另一個病房，檢查每個住院病人。整個團隊在這個時候了解病人的情況，及這一天要進行的治療。此外，資深醫生也用這個機會進行教學，指出每一個病人治療的重點。資深醫生和初入行的菜鳥們不同的關健在於資深醫生有能力根據病人的信息評價病況，進而製定處理方案。通常，現場最資深的醫生會問最嫩的學生，“你會怎麽辦？” 多數時候，我們學生的回答，不論是評論病況還是治療計劃，都不正確。然後這個問題就向上一層移，直到有人給出滿意的答案，然後資深醫生解釋其中的道理。

 

兒童手術團隊主要針對6至12歲的病人。因為我剛結束兒童手術這個階段，我想如果總結一下這一階段的查房經曆應該挺有意思。我隻簡單介紹一下病人情況，以及我的想法。我不準備講病況和治療。我會對病人身份實情加些變化和編改。隻要有機會能寫下來的時候，我就試著每次講一兩個病人。

 

病人1

 

病人1是個十幾歲的女孩，先天唐氏綜合症，並伴有嚴重的先天性心髒缺陷。她的智弱程度比較輕，功能基本健全，可以與醫護人員溝通，可以說出她哪裏痛，或者哪裏不舒服，或者一天中的感覺。現在她在醫院已經呆了幾個月了。剛開始是心髒瓣膜感染，但是沒控製好，引起多器官功能衰竭。我們看到她的時候，她已經恢複很多了。但是仍然腎衰竭，需要透析。我們去看她，給她插一個進食管，從肚皮直接插入。當器官衰竭時，她的一些神經受到傷害。結果造成任何東西經過食管時，她肺部感染的機會就很大，從而會引發很危險的肺炎。我們插入食管一點也不複雜，她可以通過這個管子接收所有食物。

 

評論

 

我要說這個女孩非常幸運。從醫學上來說，當然了，她非常不幸。但是你隻要打開她的房門，你就會看到她是怎樣的被愛、怎樣被照顧的。她已經在醫院呆了幾個月，從一個房間挪到另一個房間，但是她的房間仍然被裝飾得如同家裏的臥室：到處懸掛著粉色的蝴蝶和汽球，到處都擺著絨毛動物，牆上貼著照片和卡片。事實上，你幾乎看不到醫院病房的白色牆壁。她的父母一直陪伴著她。在醫院的所有時間，她的父母輪流陪她住在醫院，已經幾個月了。祖父母們幾乎每天都來看她，把她放上輪椅，推著她在醫院裏到處走。她很幸運因為她家的經濟狀況比較穩定，他們能在醫院花這麽多時間，直接參與她的治療。因為她有足夠的智力感知來自家庭的愛，同時還能表達她對家人的愛，與她身邊特殊的事情能夠互動，這真可謂幸運。總之，盡管她的病況很糟糕，我還是認為她非常幸運。

 

原文

 

Rounds are one of the most defining elements of the third year clinical experience. It’s when the entire team walks from room to room every morning, checking on each of the patients on the service. It’s a chance for the entire team to get an update about the patient’s status and what the medical plan is for the day. In addition, the senior physicians will use rounds as an opportunity for teaching, highlighting important information pertaining to the science and medical management of each specific patient. A key difference between a beginning trainee and senior physician is the ability to formulate an assessment and plan based on the information presented. Often, the most senior attending will ask the most junior trainee, “What would you do?” More often than not, we students are not correct in our assessment or plan. And so, the question moves up the hierarchy, until somebody gives a satisfactory response and the attending will then explain the reasoning.

 

On Pediatric Surgery, the team is typically carrying anywhere between 6 to 12 patients. Since I just finished Pediatric Surgery, I think it would be interesting to do a summary rounds exercise here. I’ll present some basic information about the patient and give my assessment and plan, except I won’t be presenting the medical assessment and plan. There will be a twist. Identifying information will be changed. I’ll try to do 1 or 2 patients every few days whenever I get a chance to jot it down.

 

Patient 1

 

Patient 1 is a teenage girl who was born with Down Syndrome and severe associated heart defects. Her mental retardation was relatively mild, she was high-functioning able to have conversations with the medical team, talk about where she had pain, or if she was uncomfortable, or just in general how her day was. She had been in the hospital for several months now. It started as a heart valve infection, but it spiraled out of control and she went into multi-organ failure. By the time we were seeing her, she had recovered a lot already, but her kidneys were still in failure and required dialysis. We were seeing her to place a feeding tube directly from the skin on her belly to her stomach. While she was in organ failure, she suffered some nerve damage. Part of the consequence was when anything went through her esophagus, there was a significant risk it would get into her lungs, causing very dangerous pneumonias. We placed the tube without any complications and she was able to receive full feeds through this tube.

 

Assessment

I actually would say this girl is very lucky. Of course medically, she was terribly unlucky. But you only had to open her room door to see she was dearly beloved and well cared for. She had been in the hospital for months and moved from room to room, but her hospital room was still decorated like a home bedroom: pink butterflies and balloons hanging everywhere, dozens of stuffed animals stacked on every surface, pictures and cards taped up to the walls. In fact, you could barely notice the hospital room walls were white. She was never without her parents. They took turns staying with her at all times in the hospital, even several months into her stay. Grandparents came to visit almost every day and take her on her wheelchair and stroll through the hospital. She is very lucky in that her family is financially stable enough that they’re able to spend so much time in the hospital and be directly involved her care. She’s also lucky that she was born with enough mental capacity to know her family loved her, and be able to express to them that she loved them too, and be able to interact with all the brightness that her family surrounds her with. So overall, even though her medical course was a disaster, I would still consider her comparatively very lucky.

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