Dr Chih-Hung Chang, Nephrologist,
New Hung Yuan Clinic
前長庚腎臟科醫師,分享醫療資訊,用HDF(Hemodiafiltration)、HD(Hemodialysis)、新式延展性血液透析術(HDx)治療尿毒症患者,包含高雄市、苓雅區、鳳山、前鎮、小港、大寮、鳥松等區,也接受國外腎友來台旅遊透析(Travel dialysis)和居護所合作居家醫療服務。
---
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.
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.
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.
---
Jonathan Reisman is an internist and pediatrician at Massachusetts General Hospital, and the president of the World Health and Education Network.
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.
A few weeks ago, a second-year cardiology fellow told me that he had taught a first-year how to pull out a balloon pump. “When we went in the room, the patient said, ‘You’re not learning on me, are you?’ And I had to lie and say: ‘No! He’s done this many times. We’re going to do it together. You get two for the price of one.’ That calmed him down. Then I had to talk the first-year through the entire procedure, pretending like I was explaining it to the patient.”
另外,作者最近要求外科同仁幫忙患者放 left ventricular assist devices (LVADs),這位外科同仁也許因為少做此項術式,對作者說
「Whether my patient wouldn’t be better off being transferred to a hospital that had more experience? “Do we have the best team in place to manage potential complications?」 he asked.
「If it were your father, he said, what would you want?」
#SeptCHEST Second Opinion: The deadly #Ebola outbreak in West Africa is a frightening reminder that a lack of education, outreach, and modern medical facilities can make it more difficult to contain a virus.
醫學界在某些方面,常有些傾向,the lower the better? 例如,飯前血糖,或是膽固醇等,也許有些是受廠商的影響,不斷地下修標準值。每日飲食鈉攝取量,也是。過往,心臟科也是認為食鹽愈少愈好,甚至有些病人飲食都不加鹽的,就是為了防治高血壓 。美國心臟協會的標準是每日平均少於1.5克,世界衛生組織的準則是少於2克,美國食品管理局則建議少於2.3克,而美國成人每日平均鈉的攝取量是3.4克。
黃達夫院長應該是引用這期的NEJM文章,
附上 editorial 供大家參考
Low Sodium Intake — Cardiovascular Health Benefit or Risk?
Suzanne Oparil, M.D.
n engl j med 371;7; august 14, 2014
"The authors suggested that the alternative approach of recommending high quality diets rich in potassium might achieve greater health benefits, including blood-pressure reduction, than aggressive sodium reduction alone."
An ambulance departs Dobbins Air Reserve Base near Interstate 75, Saturday, Aug. 2, 2014, in Marietta, Ga. Officials at Emory University Hospital in Atlanta expect an American that was infected with the Ebola virus to be transported today.(AP Photo/John Bazemore)
The U.S. Centers for Disease Control and Prevention has received "nasty emails" and at least 100 calls from people saying "How dare you bring Ebola into the country!?" CDC Director Dr. Tom Frieden told The Associated Press Saturday.
以下這句話,就是美國國家對自己人民的人道關懷,難怪一堆人拼命想拿到綠卡,這是有道理的,因為國家真的會照顧你,反觀我們呢?
"I hope that our understandable fear of the unfamiliar does not trump our compassion when ill Americans return to the U.S. for care," Frieden said.
地點背景介紹:
1) Emory's isolation unit for infectious diseases, created 12 years ago to handle doctors who get sick at the CDC
2) In 2005, it handled patients with SARS, which unlike Ebola can spread when an infected person coughs or sneezes.
There are experimental treatments, but Brantly had only enough for one person, and insisted that his colleague receive it. His best hope in Africa was the transfusion of blood he received including antibodies from one of his patients, a 14-year-old boy who survived thanks to the doctor.
Children who have a sick family member in the isolation ward eat a prepared meal. While the children have no symptoms, they are being housed in the same areas as those who are exhibiting signs of Ebola infection.
A burial team from the Liberian health department prayed before entering a house to remove the body of a woman suspected of dying of Ebola. Workers wearing protective clothing are retrieving bodies from all over Monrovia, the capital, where the spread of the highly contagious virus has been called catastrophic.
Is Barefoot-Style Running Best? New Studies Cast Doubt
Photo
Minimalist shoes and barefoot running may not be ideal for running. 走路或是跑步時,就會聽到有跑友說,穿五趾鞋或是赤足跑很好之類的,看了以下這文章還是讓我繼續穿著鞋子跑。因為Credit Jodi Hilton for The New York Times
Economy and rate of carbohydrate oxidation during running with rearfoot and forefoot strike patterns.
J Appl Physiol . 2013 Jul 15;115(2):194-201.
Dr. Gruber agrees. “I always recommend that runners run the way that is most natural and comfortable for them,” she says. “Each runner runs a certain way for a reason, likely because of the way they were physically built.
A reminder to get a check-up from the 1920s.Credit Images from the History of Medicine/National Institute of Health
1920年代的醫療海報是推銷人們做「身體理學檢查」,現在呢?是做「256切斷層掃描」
不只是台灣醫界大老說,身體理學檢查愈做愈少,在美國也是遇到同樣的問題。理學檢查是患者和醫師建立關係的第一步,有了身體理學檢查接觸後,患者也比較願意說出心裡話。然而,目前的真實狀況是,最算有檢查也常會不經意地看到隔著衣服聽診的狀況(而不是聽筒直接正確接觸皮膚),這對醫學生而言,和學校教的正規檢查方式不一樣啊。 不是醫師不想幫患者做身體理學檢查,而是在一般的15分鐘門診時間內,有慢性的問題,急性的症狀,抽血報告或是檢查報告要說明,藥物要開立或是調整。而且這些事,全部都要用電腦忙碌地記錄下來,作者稱這些好像是現代醫學交易「modern medical transaction」。