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醫學生日記2016年6月28日- 五個規則和兩個故事
阿山 （龐靜譯）二零一六年六月二十八日
現在我在婦科腫瘤部門的見習已經結束幾個星期了，但是一直拖延寫這段見習。那隻是一周的見習，但對我這個醫學院的學生來說，至今為止，卻是最有收獲的一周。醫生讓我們這些未來的醫生一定要記住五個規則。我要記錄兩個故事來強調這五個規則的重要性。
- 任何一個女人抱怨幾個月的肚子脹，總覺得飽飽的，沒有胃口 --- 你必須考慮卵巢癌。
- 任何一個女人停經之後陰道出血 --- 除非證明不是，應該是子宮癌。
- 任何一個女人抱怨性交之後出血 --- 除非證明不是，應該是子宮頸癌。
- 任何一個女人抱怨外陰部癢 --- 除非證明不是，是外陰部癌。
- 不要依賴圖象分析師，一定要自己親自看圖象。
這些規則是有關每一種癌症的第一症狀。但是除了子宮癌，這些癌症的診斷都很晚，因為病人自己不告訴醫生這些症狀，還因為醫生們也不問。或者醫生根本不考慮這些症狀與癌症相關。所以，除了子宮癌，所有這些癌症的結果都很慘。說到子宮癌，最保守的或最能忍的病患在停經後出血都會馬上跟醫生說。所以子宮癌發現得比較早，治愈率很高。
故事 1 --- 子宮頸癌
說到婦女的癌症，乳腺癌是全世界婦女的第一殺手。子宮頸癌第二。但是，在美國，子宮頸癌已經下降，卵巢癌現在是美國婦女的第二殺手。為什麽？自從美國要求婦女定期做塗抹檢查，子宮頸癌下降了70%。我們去看一個子宮頸癌的病人之前，主治醫說她相信在她活的日子裏，世界上的子宮頸癌一定能消除。
我們去看一個病人。她就是痛苦的定義。隻要用聽診器輕輕碰她一下，都會引起她痛苦的嗥叫，疼痛使她在自己輪椅周圍的活動都很難。她女兒一直不想讓她的外孫女看到這個情景。子宮頸癌已經擴散到她的肺部和腦子。現在的化療隻是一種無奈的努力，想延長她的生命，減輕腫瘤的痛苦。但是大家都明白癌症一定會殺了她。
我們去看另一個子宮頸癌的病人。她比較年輕，不像上一個病人，沒有子女。她非常想要孩子。她很幸運，她的子宮頸癌發現比較早。但是，最徹底的治療就是摘除生育器官。醫生跟她進行了一次很艱難的談話。她可以選擇盡快的生孩子，但必須知道這同時也給了那種很凶險的癌一個再生的機會，造成她的死亡；另一個選擇就是徹底治療，她永遠不可能再生孩子了。
看過這些病人之後，醫生講了一通非常挫折感的氣話。她並不是對我或任何人生氣。她就是在醫生辦公室裏簡單地罵人、發泄。99%的子宮頸癌是人體病毒（HPV）引起的，同樣的病毒引起生殖器疣。現在已經有了HPV的疫苗。她怒氣衝衝地說：“我們可以消除子宮頸癌，但是美國人對於任何有關性交的事情就是這麽蠢。真可惡！我很遺憾我的話讓你們在場的人不舒服。其實我才不在乎。” 她說的是事實。理論上說，如果用了疫苗，美國人幾乎可以完全避免子宮頸癌。但是，現在隻有30%的青少年用了這種疫苗。為什麽？很多家長認為HPV是性交傳染。讓孩子用疫苗就等於鼓勵孩子無所顧忌的性交。所以他們不讓孩子用這個疫苗。想一想，這些孩子長大成人之後，有了正常的性生活，接觸了HPV，再考慮使用疫苗就太晚了。然後，就是因為這些家長對性交的排斥，造成了新一批的子宮頸癌患者。
我可以明白醫生為什麽這麽有挫折感，這麽憤怒。
故事 2 --- 卵巢癌
卵巢癌很可怕。它幾乎就是不可避免的死亡。而且，如同子宮頸癌，它可以發生在年老或年輕的女人身上。五年的生存率是25%。在這25%幸存者中，80%將會再發癌症，最終死於癌症。
我在婦科癌症中心那個星期跟了一個病人。我初見她時，她幾乎沒有知覺，非常嚴重的智能下降 - 她不記得她是誰，她在哪。她非常的衰弱，營養不良。她基本上是皮，骨頭，和膨脹很大的肚子。她怎麽到了這個份上？
卵巢癌是潛伏性的。它產生的唯一症狀就是它的大小。首先，一個婦女可能覺得有些肚脹，很容易飽。多數人覺得這很正常，隨著年紀增長，飯量越來越少。當腫瘤長大時會壓迫腸道，她們的食欲就會減少。再者，這個婦女把這個症狀當成了正常的老年化，覺得能減輕體重也不錯。在這種癌的發展過程中很少疼痛或不舒服。我們在急診室見了一個病人，她的腫瘤已經長到西瓜那麽大，她失了30磅體重，她從來沒有覺得一點疼痛。我的病人，她開始意識到自己生病了是因為她吃的越來越少，喝的越來越少，體重越來越輕。但是，她非常害怕生病給家裏造成負擔，所以她就忍著，指望著哪一天這病不治而愈。後來，有一天，這個腫瘤終於長大到把她的腸道完全堵塞了。她吃喝任何東西都會馬上吐出來。她已經失重很多，現在很快地嚴重脫水，失去了知覺。她的智力功能隨之迅速下降。這樣了，她才來到醫院。
她的病太重了。醫生們已經和家屬談了生命終結，而且預計她就死在醫院。並不僅僅因為卵巢腫瘤完全壓住了腸道，而且癌細胞已經擴散到肺部。她可能永遠不能吃東西，就得靠輸營養液。她失去太多體重，病得太重，基本上無法承受手術了。營養液也不太可能使她恢複到可以承受化療（順便說一句，從醫學角度，通過腸道的喂食總比營養液強。）。總之，這個病人正在死去。
婦科腫瘤醫生對此很不爽。她說：“我就想試試，解決她的問題。” 腸阻可以通過手術改道，讓食物進入好腸子的部份，而不是阻塞的部份。婦科腫瘤醫生堅持說“我要帶她進手術室。我不知道這是對是錯，但是至少我們不是袖手旁觀她的死亡。” 麻醉醫生對她的提議不感冒。大家都在勸阻她。病人死在手術台上的幾率大於50%。 盡管病人在手術中活下來，還有一個更大的可能是病人成了植物人永遠醒不過來了。
婦科腫瘤醫生憑她自己的直覺，堅信一定可以通過手術解決病人的問題。她說服了病人和家屬進行手術，很誠實地說明了她的不確定性以及手術失敗的危險性。她承認在做這個決定時她是憑著自己的直覺，她無法向眾人證明她可以治愈這個病人。
她把病人帶進了手術室。之前她仔細看了病人的CT圖像。這就夠了。她切開肚子，找了一段好腸道，直接連到皮膚上。她沒有浪費時間檢查腹部，或者找到腫瘤試圖切除。前麵看過的圖像已經告訴她什麽能做什麽不能做。總之，這個手術用了半個小時。麻醉醫生成功地叫醒了病人，撥出了喉管。
第二天很奇妙。病人有了知覺。我們給她喝可樂，她也沒吐。病人喝出了是可樂，說她生病這幾個月來這是感覺最好的一次。他們甚至扶她站起來了，走到了椅子處。醫生冒了這麽大的風險，現在見成效了。整個醫療團隊，病人和家屬都知道卵巢癌最後會致病人於死地。但是，在她生命的尾聲能夠吃喝，能強壯到可以回家，和家人在一起，能把她的生命延長幾個月，這就是最重要最偉大的醫療成功。
原文
Journal 20160628
Tuesday, June 28, 2016 – 5 Rules and 2 Stories
I have finished my Gynecology Oncology rotation for several weeks now, but have been delayed writing about it. It was only a one-week rotation, but it has been one of the most profound experiences of medical school for me so far. The doctor left us students with 5 important rules for all future doctors to remember. I will recap two stories that will emphasize the importance of those rules.
1. Any woman that complains of several months of abdominal bloating, feeling full all the time, and losing her appetite – you have to consider ovarian cancer.
2. Any woman that has vaginal bleeding after menopause – it is uterine cancer until proven otherwise.
3. Any woman that complains of routine bleeding after sex – it is cervical cancer until proven otherwise.
4. Any woman that complains of vulvar itching – it is vulvar cancer until proven otherwise.
5. Do not rely on the radiologist, always look at your own imaging
These rules are related to the number one symptom of each cancer, and are fairly unique to each cancer. However, other than uterine cancer, all of these cancers are diagnosed very late, either because the patient does not bring up the symptoms, the doctor does not ask, or the doctor does not think about these symptoms in relation to cancer. Thus, all of these cancers, except uterine, have miserable outcomes. Regarding uterine cancer, even the most reserved conservative and tolerant patient will immediately complain to their doctor if they have bleeding after menopause, hence uterine cancer is discovered early and survival is very good.
Story 1 – Cervical Cancer
Of the “woman cancers”, breast cancer is the number one killer of women worldwide. Worldwide, cervical cancer is the number two. However, in the U.S. cervical cancer rates have fallen and ovarian cancer is now the number two “woman cancer” killer. Why is that? Since the U.S. instituted regular pap smear screening for women, the cervical cancer rate in the U.S. has fallen by 70%. My attending physician said right before we went in to see a cervical cancer patient, she fully believes that the world is capable of eliminating cervical cancer in her lifetime.
We go in to see the patient. She is the definition of a miserable mess. Even lightly touching her with the stethoscope causes her to howl and scream in pain. In all her pain, she can barely move within her confines of the wheelchair. Her daughter is trying to shield her granddaughters’ from her misery. The cervical cancer has spread to her lungs and brain. The chemotherapy she gets now is a desperate attempt to prolong her life and reduce her tumor burden, with the acknowledgement that this cancer will kill her.
We go in to see another cervical cancer patient. She is younger, no children or grandchildren like the above patient. She desperately wants to have children. She is luckier, her cervical cancer has been caught early. However, definitive treatment is the removal of her reproductive organs. The doctor has a tough conversation with her. She has the option of trying to have a child very soon and knowing that that will give this very aggressive cancer the opportunity to invade and become her death sentence, or treat the cancer and know she will never bear her own children.
After we these patients, the doctor has a very frustrated and angry conversation. She’s not angry specifically at me or anybody, she’s simply ranting and venting in the physician workroom. 99% of cervical cancer is caused by human papillomavirus (HPV), the same virus that causes genital warts. There is now a vaccine for HPV. She huffs “We could eliminate cervical cancer, but America has to be so goddamn fucking stupid about anything related to sex. Fuck that. I would say I’m fucking sorry to those of you in the room offended by my swearing, but I don’t fucking care”. What she says is true, America could almost completely eliminate future cervical cancer with this vaccine in theory, however, the current vaccination rate in children is only 30%. Why? A lot parents believe that since HPV is a sexually transmitted infection, vaccinating their children will somehow encourage their children to be more sexually reckless. A lot of parents even refuse to think about their children having sex in their future adult lives, so they refuse to consider the vaccine in their childhood. Well, once those children become adults and become sexually active and become exposed to HPV, it will be too late for the vaccine, and a new generation of cervical cancer patients will be created because some parents did not like the idea of sex.
I could see how the doctor would be extremely angry and frustrated too.
Story 2 – Ovarian cancer
Ovarian cancer is terrifying. It is almost inevitable ably a death sentence. Again, like cervical cancer, it can affect both old and young women. The 5-year survival rate is only 25%. And of those 25% survivors, 80% will have cancer recurrence that will ultimately kill them.
For my week on GynOnc, I followed one inpatient. When I met her, she was barely conscious and had severely declining mental status – she couldn’t remember who she was or where she was. She was extremely frail and malnourished, she was essentially skin, bones, and a big bloated belly. How did she get to this point?
Ovarian cancer is insidious. The only symptoms it creates are related to its size. First, a woman might feel she’s getting a bit bloated and getting full a bit easier. Most will think this is a fairly normal part of aging and start eating a bit less. As their tumors get larger and press on their bowels a bit more, they start losing their appetite. Again, the women think it might just be a natural part of aging, and perfect, they’ve started losing a bit of weight. There is rarely any pain or unbearable discomfort in this process. One patient we saw in the Emergency Department had a tumor the size of a watermelon and a 30lb weight loss and never experienced any pain. For my patient, she started realizing she was sick as she was eating and drinking less and less and losing more and more weight. However, she was terrified to be a medical burden or concern for her family, so she just kept bearing with and hoping it would get better on its own. Then one day, the tumor had finally reached a size that it completely closed off her bowels. Anything she ate or drank she quickly vomited. She had already lost a significant amount of weight and rapidly became extremely dehydrated and lost consciousness. Her mental function quickly declined after that. All of that finally brought her to the hospital.
After we these patients, the doctor has a very frustrated and angry conversation. She’s not angry specifically at me or anybody, she’s simply ranting and venting in the physician workroom. 99% of cervical cancer is caused by human papillomavirus (HPV), the same virus that causes genital warts. There is now a vaccine for HPV. She huffs “We could eliminate cervical cancer, but America has to be so goddamn fucking stupid about anything related to sex. Fuck that. I would say I’m fucking sorry to those of you in the room offended by my swearing, but I don’t fucking care”. What she says is true, America could almost completely eliminate future cervical cancer with this vaccine in theory, however, the current vaccination rate in children is only 30%. Why? A lot parents believe that since HPV is a sexually transmitted infection, vaccinating their children will somehow encourage their children to be more sexually reckless. A lot of parents even refuse to think about their children having sex in their future adult lives, so they refuse to consider the vaccine in their childhood. Well, once those children become adults and become sexually active and become exposed to HPV, it will be too late for the vaccine, and a new generation of cervical cancer patients will be created because some parents did not like the idea of sex.
I could see how the doctor would be extremely angry and frustrated too.
Story 2 – Ovarian cancer
Ovarian cancer is terrifying. It is almost inevitably a death sentence. Again, like cervical cancer, it can affect both old and young women. The 5-year survival rate is only 25%. And of those 25% survivors, 80% will have cancer recurrence that will ultimately kill them.
For my week on GynOnc, I followed one inpatient. When I met her, she was barely conscious and had severely declining mental status – she couldn’t remember who she was or where she was. She was extremely frail and malnourished, she was essentially skin, bones, and a big bloated belly. How did she get to this point?
Ovarian cancer is insidious. The only symptoms it creates are related to its size. First, a woman might feel she’s getting a bit bloated and getting full a bit easier. Most will think this is a fairly normal part of aging and start eating a bit less. As their tumors get larger and press on their bowels a bit more, they start losing their appetite. Again, the women think it might just be a natural part of aging, and perfect, they’ve started losing a bit of weight. There is rarely any pain or unbearable discomfort in this process. One patient we saw in the Emergency Department had a tumor the size of a watermelon and a 30lb weight loss and never experienced any pain. For my patient, she started realizing she was sick as she was eating and drinking less and less and losing more and more weight. However, she was terrified to be a medical burden or concern for her family, so she just kept bearing with and hoping it would get better on its own. Then one day, the tumor had finally reached a size that it completely closed off her bowels. Anything she ate or drank she quickly vomited. She had already lost a significant amount of weight and rapidly became extremely dehydrated and lost consciousness. Her mental function quickly declined after that. All of that finally brought her to the hospital.
She was extremely sick. The medical team had a conversation with the family about the end of life, with the expectation that she would very likely die this hospital stay. Not only had the ovarian cancer completely compressed her bowels, it had already spread to her lungs. She was likely to never be able to eat again and would rely on IV nutrition. She had lost too much weight and was simply too sick to survive surgery. The IV nutrition was not ideal to get her recovered to a state where chemotherapy would be possible. (Side note, in medicine, feeding through the gut is always more preferable compared to IV nutrition). To summarize, this patient was actively dying.
The GynOnc doctor wasn’t happy with the state of things. She simply said, “I want to try to fix her”. Bowel obstructions can be bypassed surgically, by looping up the good end to allow the contents to exit through the skin instead of hitting the obstructed point. The GynOnc doctor insisted “I want to take her to the operating room. I don’t know if it’s the right decision, but it beats sitting and watching her die”. Anesthesia was not happy with that idea. They kept trying to dissuade her. The patient had a greater than 50% chance of dying on the operating table. Even if she did survive the surgery, there was an even greater chance she would never be extubated or wake up.
The GynOnc doctor believed in her gut instinct in that she could do something surgically to fix the patient, and she convinced the patient and family to proceed with surgery, all while being very honest and realistic about her own doubts and the high chances of failure and death. She admitted to everybody involved in the decision making, she had no evidence that she could make this patient better other than her own gut instinct.
She took this patient to the operating room. Beforehand, she had thoroughly reviewed the limited CT imaging that had been done on the patient. This was enough. She made her cuts and grabbed the good loop of bowel and brought it up to the skin. She didn’t waste any time inspecting inside the abdomen or trying to find tumor she could resect. Looking at the prior imaging was enough to tell her what she could and couldn’t do. All in all, the surgery took about half an hour. Anesthesia was able to successfully wake the patient up and extubate her.
The next day was wondrous. The patient was conscious. We were able to give her a coke without her vomiting it up. The patient claimed the taste of coke was one of the happiest feelings she had had in several months. They were even able to help her stand up and move to a chair for a bit. This giant risk the doctor took was paying tremendous dividends. The medical team, patient, and family all knew this ovarian cancer was going to kill the patient. But, being able to eat and drink at the end of her life, regaining enough strength to go home and be with her family, being able to prolong her life by several months, those were great and important medical achievements in itself.
