DOCTORS

Pronouncing the Patient Dead

By DANIELA J. LAMAS, M.D.

 OCTOBER 30, 2014 7:00 AM

CreditGetty Images

Pronouncing the Patient Dead http://nyti.ms/1vjTz7A

作者是胸腔科的fellow，因為他的intern在忙，所以，就換他來宣expire。這是一位32歲，受盡化療痛苦的癌症女病人。病房裡牆上貼滿了這患者之前跑馬拉松為cancer research募款的照片，這病人滿臉欣喜的比著勝利手勢，通過終點線。

作者回憶起他第一次宣病人expire，也是在他intern時，那一次他匆匆忙忙地進入病房，然而老經驗的護理師說，你不用這麼急的，因為病人沒有要去那裡。當時是intern的作者，從沒有宣過expire，只好偷偷地拿出intern survival guide，上面寫「要先表示同理心，你要先說sorry」。然而，聽診病人的心跳是否停止？目視病人胸膛是否有起伏？觸診病人是否有脈動？最後看著時鍾大聲念出時間宣告病人expire，之後再說「I am sorry again」，才離開。之後中外皆然，都是一堆的文書工作。

看到這文章就讓我想起15年前，在高醫當intern時，第一次被護理師叫去宣一位病人的expire，同樣的徬徨。後來在高長當住院醫師時顧加護病房病人，偶爾也需要半夜起來宣expire，那時蓋完醫師章後，用lamy 2000的這支鋼筆簽下自己的名字，這樣的記憶還十分鮮明。

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Daniela Lamas is a pulmonary and critical care fellow at Brigham and Women’s Hospital, Beth Israel Deaconess Medical Center and Massachusetts General Hospital, in Boston.

從黴菌身上學習

SundayReview | OPINION

Learning From Fungi

Of Medicine and Mushrooms

By JONATHAN REISMANOCT. 4, 2014

Photo

Of Medicine and Mushrooms http://nyti.ms/ZeeXSA from NEW YORK TIMES

我是被這文章的標題吸引進來的，霉菌能教我們醫師們什麼？

Defining mushrooms from Encyclopedia of Life
All mushrooms are fungi, but not all fungi are mushrooms. 

作者這位年輕的住院醫師說到一天在醫院的停車場附近樹叢，看到一堆野生的mushrooms，被它們的美麗外觀所吸引，從不了解它們，認為可能吃一小口就可能產生fulminant liver failure（醫學院教的）或是有些品種就是可以吃的 (edible)，逐漸找書來看、上網學習。

在幾個月的學習後，他有一次就挖下了一些他認為可以吃的mushrooms，把它們煮來吃，後來也是沒事，他的信心愈來愈大了。逐漸能辨識的品種愈來愈多。作者說，這學習mushrooms，就像學習人的疾病一樣，從醫學生紙上談兵，到後來實戰經驗在住院病人上學習，做疾病的鑑別診斷。

作者說到他有一次急診值班，一位18個月的嬰兒因為發燒來掛急診，媽媽說，應該是感冒吧，但是作者用觀察mushrooms一樣，仔細看嬰兒，發現有呼吸窘迫，鼻翼凹陷、胸膛肋骨上的肌肉也凹陷，他覺得這不是感冒，經過檢查後，是嚴重肺炎，就送到ICU治療了。

But when I approached the infant to examine him more closely, I noted his nostrils flaring and the muscles between his ribs contracting into subtle channels across his chest with each inhalation. He was working hard to breathe.

Each medical case, like each mushroom, is a diagnostic puzzle. 

當醫師診斷疾病，要看氣候，地區，而會有不同的疾病流行。當一個野外食物專家，也要從當地的氣候，地區，雨量，以及周圍的植物型態來知道附近會有什麼mushrooms（兩者區別的過程真的有點相同）。

LEARNING to diagnose diseases or identify mushrooms also means learning ecology. Just as an experienced forager knows which mushrooms to expect based on region, climate, season and recent rainfall patterns, the sort of tree overhead and forest duff underfoot, a physician understands that diseases have an ecological context of season and geography. Doctors expect Lyme disease in the summer and influenza in the winter, and, as with foraging, knowing what to look for helps us to see it. A fruity whiff in the forest tells of nearby black trumpet mushrooms, which are often smelled before they are seen, just as the slight movements of a child’s nostrils tell of more serious problems hidden inside the lungs.

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Jonathan Reisman is an internist and pediatrician at Massachusetts General Hospital, and the president of the World Health and Education Network.

5個美國CDC可能犯的錯

Ebola: Five ways the CDC got it wrong

By Elizabeth Cohen, Senior Medical Correspondent

October 14, 2014 -- Updated 1655 GMT (0055 HKT)

Ebola: Five ways the CDC got it wrong http://www.cnn.com/2014/10/13/health/ebola-cdc/index.html?sr=sharebar_twitter

看到美國的CDC官員被炮轟有關於ebola的處理不當，5項錯誤，就讓人想到台灣呢？雖然有過SARS的處理經驗，但是，能記取多少？因此分享給大家參考。

Here are five things they say the CDC is getting wrong.

1. The CDC is telling possible Ebola patients to "call a doctor."
找到自己的醫生？不容易，而且，醫生一旦請疑似病例自行就醫，就中間可能散佈更多的感染。最好是用ambulance(119)系統，不然醫院或是急診一旦來了疑似ebola病例，ER有可能因而需要關閉數小時（例如：Massachusetts就曾發生過）

2. The CDC director says any hospital can care for Ebola patients.
事實上，不是所有的醫院都有處理病人和感染物能力的
"not all hospitals are created equally"

3. The CDC didn't encourage the "buddy system" for doctors and nurses.
沒錯，有時候自己無菌操作穿戴方式錯誤，或是被污染了，也不自知，有另一個buddy在旁監督，效果更好。

"buddy," another health care worker, who acts as a safety supervisor, monitoring the worker from the time he puts on the gear until the time he takes it off.

4. CDC didn't encourage doctors to develop Ebola treatment guidelines.
是否插管或是洗腎治療被感染的病人？也許是還沒有正式的治療指引，這需要時間來慢慢建立。
- inserting a breathing tube and giving kidney dialysis -- that were unlikely to help Duncan. He described them as a "desperate measure" to save his life.

5. The CDC put too much trust in protective gear.
照顧過確診ebola患者的醫護人員，也應該被追蹤是否被感染。因為，防護衣不是萬能的，也會有操作不當而自己被感染而不知情的狀況。

Public health experts said that was a misstep, as the CDC should have realized that putting on and taking off protective gear is often done imperfectly and one of the workers might get an infection.

附上這影片說明，防護衣的穿脫也是可能感染途徑之一，真令人心驚。
http://edition.cnn.com/video/data/2.0/video/health/2014/10/14/sgmd-gupta-ebola-suit-demo.cnn.html