医学生日记2016年5月2日

阿山 (庞静译）

查房巡诊是第三年实习经历中最重要的部分。每天早上整个团队从一个病房走到另一个病房，检查每个住院病人。整个团队在这个时候了解病人的情况，及这一天要进行的治疗。此外，资深医生也用这个机会进行教学，指出每一个病人治疗的重点。资深医生和初入行的菜鸟们不同的关健在于资深医生有能力根据病人的信息评价病况，进而制定处理方案。通常，现场最资深的医生会问最嫩的学生，“你会怎么办？” 多数时候，我们学生的回答，不论是评论病况还是治疗计划，都不正确。然后这个问题就向上一层移，直到有人给出满意的答案，然后资深医生解释其中的道理。

儿童手术团队主要针对6至12岁的病人。因为我刚结束儿童手术这个阶段，我想如果总结一下这一阶段的查房经历应该挺有意思。我只简单介绍一下病人情况，以及我的想法。我不准备讲病况和治疗。我会对病人身份实情加些变化和编改。只要有机会能写下来的时候，我就试着每次讲一两个病人。

病人1

病人1是个十几岁的女孩，先天唐氏综合症，并伴有严重的先天性心脏缺陷。她的智弱程度比较轻，功能基本健全，可以与医护人员沟通，可以说出她哪里痛，或者哪里不舒服，或者一天中的感觉。现在她在医院已经呆了几个月了。刚开始是心脏瓣膜感染，但是没控制好，引起多器官功能衰竭。我们看到她的时候，她已经恢复很多了。但是仍然肾衰竭，需要透析。我们去看她，给她插一个进食管，从肚皮直接插入。当器官衰竭时，她的一些神经受到伤害。结果造成任何东西经过食管时，她肺部感染的机会就很大，从而会引发很危险的肺炎。我们插入食管一点也不复杂，她可以通过这个管子接收所有食物。

评论

我要说这个女孩非常幸运。从医学上来说，当然了，她非常不幸。但是你只要打开她的房门，你就会看到她是怎样的被爱、怎样被照顾的。她已经在医院呆了几个月，从一个房间挪到另一个房间，但是她的房间仍然被装饰得如同家里的卧室：到处悬挂着粉色的蝴蝶和汽球，到处都摆着绒毛动物，墙上贴着照片和卡片。事实上，你几乎看不到医院病房的白色墙壁。她的父母一直陪伴着她。在医院的所有时间，她的父母轮流陪她住在医院，已经几个月了。祖父母们几乎每天都来看她，把她放上轮椅，推着她在医院里到处走。她很幸运因为她家的经济状况比较稳定，他们能在医院花这么多时间，直接参与她的治疗。因为她有足够的智力感知来自家庭的爱，同时还能表达她对家人的爱，与她身边特殊的事情能够互动，这真可谓幸运。总之，尽管她的病况很糟糕，我还是认为她非常幸运。

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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