医学生日记2016年3月16日-风风火火

阿山 （庞静译）(原文存在译文之后）

我今天在儿童耳鼻喉科临床学习。一天都很忙，我记了几件事。

 上午6:00-9:00: 嘴唇修复

 每个科室每周都有一个报告会。全科室的人聚会两个小时，大家一起听一个专选课题的报告。对于这个课题，多数医生、住院医、和学生可能没有机会获得第一手资料。报告的目的就是教大家，并且明确指出这个课题的重点。

 耳鼻喉科的报告会定在7:00。我一个小时前就到了。我的指导医生事先给了我一个预习的单子。我得用这一个小时赶紧读一读关于头和脖子的先天畸形方面的东西。七点钟，两个医生一起做了嘴唇修复的报告。对我震动最大的一点是，虽然医生们治疗的是创伤是癌症，但是病患们能记住的，一辈子都抹不掉的是他们嘴唇上的伤疤。一个变了形的嘴，或者一个明显的疤痕，很可能会很不幸地改变病人的一生。从这个角度，我们可以看清医疗和整容的交集点，及共同的重要性。

 上午9:00-10:30 天使综合症

 我很幸运。我的指导医生让我先独自看病人，然后向他报告我的发现，讨论治疗方案，最后我们一起去与病人谈。这是一个很专门的领域，儿童耳鼻喉专科医生从医学院毕业之后还要有将近十年的专科培训。

 我的第一个病人是一个生了天使综合症的小女孩。这是一个先天性疾病，会导致智障，但是生了这个病的孩子们的一个重要症状是他们特别的快乐和友好。因为生了这种病的孩子看上去都像很好玩的娃娃，这种病也曾经被称为快乐宠物综合症。这个女孩的病历很复杂。她经常生病，但是今天还好，很开心地跟一个陌生人（就是我）玩。跟她的父母谈了一下，我觉得她的存在实在奇怪。她经常地生各种各样的病，那些病的任何一种都会使我们正常人的生活很可悲。她呢，只是因为基因的错误，生了这么多的怪病，她还是照样活着，而且她知道的唯一状态就是快乐。

 上午10:30-11:45 甲状腺切除

 今天的门诊比较轻松，但是头和脖颈癌症中心需要人手，所以把我借去了。一个甲状腺切除手术需要帮手。到了手术室，他们让我拿着牵引器，抻开脖子上的刀口，如此，手术医生可以仔细地切除甲状腺的腺体。甲状腺周围有很多重要的神经和血管，手术医生必须非常小心不能碰坏那些神经和血管。我必须站在那儿，拉开那些皮。手术医生说这就是医生们每天的锻炼。

 上午11:45-下午1:00 急诊喉头镜

 住院医学长把我从甲状腺手术室叫出来，接着进了另一个手术室。他们正准备从门诊部去吃午饭时得到呼唤，一个两岁男孩刚刚没了呼吸。前几个小时见他还呼吸顺畅，但是一下子他就不能呼吸了。我的指导医生和住院医马上从门诊部跑到手术室，准备紧急手术。

 这个男孩有一个移植的心脏，所以用了抗排斥药物。医疗的正面结果是他有了一个心脏。但负面结果是他非常容易感染。当医生把光镜放到他喉咙处时，那里完全被一层灰色盖住了。指导医生说那是霉菌和坏死组织的混合物。那些粘泥状的东西堵住了他的气管。手术过程就是刮掉这些泥状物质，让空气可以穿过他的嗓子。

 下午1:00-5:00 希阿利畸形

 由于急诊手术，我们下午门诊晚了，还有上午的病人在候诊。我们迅速回到门诊部。根据我前两天的经验，我们儿童耳鼻喉科根本没有午餐时间。我抓了两块披萨，一边走一边吃。在见每个病人的间隙，我也抓空咬一口。以前总在电视上看医生无法坐下来吃东西的笑话，今天轮到我了，两块披萨，一会咬一口，前々后々用了三个小时才吃光。

 下午主要是正常门诊：小孩的扁桃体肥大，小孩睡觉打呼噜，夜间突然停止呼吸，还有很严重的过敏。值得一提的是一个孩子由于母亲怀孕期间的复杂状况造成他出生就有头颅骨-脑子变形，（称为希阿利畸形）。他使我想起我科研导师曾经教过我。他说，做为一个医生，如果用各种病症的术语去考虑这些孩子们是容易的。“哦，想々他有这个病那个病，他现在这样已经很好了。” 但这并不是一个病人的生活。现实中，“他会拿他自己和正常的孩子去比，所以我们要尽最大的努力让他们感觉到自己和正常人一样的健康。”

 下午5:00-7:00 气管狭窄症

 门诊之后，又去看了要求咨询的病人。通常，一天会收到一到两个病人要求咨询的呼唤。今天，我们看了七个要求咨询的病人。其中六个出生不足两个星期。这七个都有先天性缺陷。

其中五个都在新生儿特护病房。我记得一个神经科专家做过一个统计，新生儿特护病房的婴儿是我们所能见到的病得最重的病人，但是他们当中的百分之八十都能完全康复回家。现代医学是神奇的，病婴们可以神奇地复原，茁壮成长。

有一个婴儿先天性气道陕窄，这造成了她呼吸困难。由于她的母亲失明，她的治疗比较麻烦。最简单的治疗方法就是切开气管，然后婴儿就可以回家了。但如果这样，残废的母亲就会失去婴儿的监护权。我们明天要给婴儿手术，选择其它方法为她治疗。我会把她的详细情况在另一篇中写出来。

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.