tough day

这个月时间过得飞快，因为实在太忙了，带我的主治说，他在这里带教这些年，这个月是有史以来最忙的，病人多也就算了，而且都重，问题一个接着一个，每天早上看实验室结果都是红灯一串串的（如果是不正常的结果，都是用红色标出来的）。所有的决定，会诊，治疗，最后的工作都是落在intern身上去实行，每天一进病房就如上足了发条，不吃不喝也要先完成工作，主治医生或者住院医生问起来为什么这个那个还没做好，我是不能回答因为我要吃饭啊。呵呵。

即使不觉得，但是压力一点点在心中积聚，忙得没有时间去宣泄。

今天早上ICU打电话讨论K女士的病情。她是我在急诊室收的一个病人，肠梗阻，体检发现一个肛门肿块，肠镜确诊是肛门癌，外科让我们确定手术风险，我们做了心脏超声和其他健康检查，病人一般情况很好，于是马上手术了。但是手术以后K女士发作了急性动脉栓塞，深静脉栓塞，横纹肌溶解，急性肾衰竭，在ICU病情不断恶化。每天早上去看她，是最让人心碎的事情。她是一个很可爱的老太太，从来不抱怨，看到我总是脸上绽放出笑容，哪怕插着鼻管，哪怕下肢都已经坏死。

我总是心里带着莫名的愧疚，不知道为什么，也许因为是我把她收进来，把她送上了这条通向深渊的路。我问过主治医生，外科医生，有什么我们那时候可以预防这一切发生，他们都说没有，我们做了一切该做的，病人只是发生了严重的并发症。这样的解释，并不能让我在面对下肢坏疽，奄奄一息的K女士心情更好一点。

ICU说，让我们和家属谈一下，是不是建议放弃治疗，改为no code（就是维持生命治疗，但是不再抢救）。ICU医生说，病人氧气饱和度急剧下降，意识丧失，非常危急了。

和家属谈完以后，家属同意no code了。K女士不会支撑过周末。

回到办公室我们继续讨论病情，主治医生和住院医生若无其事地把话题转移到下一个病人身上，而我的眼眶却慢慢潮湿起来，不知道为什么，只是觉得心里非常难受，一个健康快乐的老太太，两个星期，就这样被彻底改变了生命历程，她看我的眼神，带着微笑，每天早上还总是先问我：how are you today, doc? 我怎能当作什么事情都没发生过。

主治医生发现我神态异样，说are you OK? 我摇摇头，说no, I feel bad about Mrs K,  this case broke my heart. 主治医生说，我们都尽力了，我知道你每天接触她时间最多，建立了感情，感觉很难过，但是作为医生，要明白自己的职业局限，不能太attach。

但是我不知怎么就失去了控制，眼泪不断地落下来，没办法继续下去，我站起来说excuse me，然后走到走廊上，努力让自己平静下来。

回到办公室，住院医生说你还好吧。我说是的，不好意思，继续讨论病情吧。

现在回想起来，不知道为什么当时就失控了，不太professional，主治医生和住院医生肯定觉得怪怪的。可能一方面是无能为力的愧疚，还有就是积蓄已久的压力，终于找到宣泄的途径。

一直到7点做完了事情，明天终于休息了，和好朋友去喝酒了，然后讨论三月份一起去滑雪的计划，好友美酒，让人情酣，开车回来的路上，人有点轻飘飘的，还好没有警察拦我，呵呵。

[茶叶蛋]

我的母亲也是医生，上海各大医院医学院都充斥了她的校友，所以我对你说的深有共鸣。每个医生都是一个普通的人，正常的心，有爱，对生命的脆弱的叹息。妈妈说，人活着就是一口气，下一口没有接上来，一切烟消云散，爱和恨，富和穷，都不见了。有经验的医生对这些见多了后，不是冷漠了，而是锻炼得成熟了，因为，要调整好心情，还有下面的事要做。

[绿豆红茶]

落花医生：
I am so sorry to hear that. Hug...
Please try to have a relaxing weekend :)

[落花飘零]

today i signed Mrs K's death certification.

绿豆红茶，HIT is certainly a concern, we did follow her plt count everyday, no obvious dropping, I don't know what's the exact reason of her LE arterial occlusion, my guess is from massive compression during sugery.

[菁子]

医生的心也是肉做的。我觉得从医的人有颗同情心会不知不觉在查房的时候流露出这一点。病人的心总需要人慰籍，医生热情的微笑和安慰会让他们觉得很温暖，也有利于病情恢复呀。但是别太苦自己，不能心太软。
我以前在国内管过的一个病人，是个运动员，但是有先心，做的是预防性的手术，结果麻醉过后就再也没有醒来。这个病例也折磨了我很久，尤其是当我想起她的阳光般的上高中的儿子坐在她病床边和她说笑的样子，我就想“要是她没来医院就好了”。经常有谋事在人成事在天的感觉。
以自己的能力做到最好，对得起良心，就好啦。

[绿豆红茶]

落花医生：
I have been reading your blog for a long time and I really admire your hard work :)

I don't know if you watch the TV show "Grey's Anatomy". One of the interns, Dr. Izzie Stevens has told the chief that she is both a compassionate person and a surgen, and that both are essential in defining who she is as a human being. She and other real surgens I know, including my mom, have taught me that it is the compassion you feel for your patients that makes you a better doctor.

I know too little about Ms K's condition to make a guess here, but may I ask two questions:
Did doctors administer unfractionated heparin, or low molecular weight heparin for her surgery? What happens to her platelet count? I just thought her symptom looks similar to one of the thrombotic disorder--heparin induced thrombocytopenia (HIT). HIT typically develops 4-14 days after the administration of heparin, and with the auto-immune type (type II), clot formation is mainly arterial and rich in platelets, while thrombotic events are mostly in the lower limbs, skin lesions and necrosis may also occur at the site of the heparin infusion.

Again, I do not know the genetic background and family history of that lady. If this sounds irrelavant, or the information comes too late, then forget about it :)

Have a good night.

[小马999]

狮王说的好像很对，专业水平高！另外，是不是有些凝血因子突变的病人 under stress 时，就特容易出现血栓，高凝血状态。落花妹妹能不能给我们从专业方面分析一下？端个板凳我先在前排占个座。

[江湖中人]

落花，很羡慕你的认真。从当初的我不喜欢做医生，到现在我再次选择从医，都是喜于有这种能帮助他人的成就感。但这也是最难的， 特别是我们还必须无奈的要去面对很多痛苦的现实。很多医生也因为这个，放弃了这个职业。我们也许是要去找到一个平衡点吧，这样我们才能生存下来。（很喜欢无锡妹妹的高见）

[狮王传说]

好久没来了，落花又有进步呀。

你这个病例，应该是有教训要吸取的。

首先，作为医生，你表现的不职业。内心的感受是对的，但工作时候哭出来，不应
该。会影响其他医生和病人的心情。医生是个残酷的职业，好的医生感情要细腻，
但不可脆弱，情感是不可外露的。但压力之大，外人难以想象，所以工作后自己减
压，是关键。

其次，肛门癌手术，不外乎切除和造瘘。如果有直肠吻合器的话，手术不是很麻烦
的。你说的并发症，和下肢血运有关，我怀疑术中伤及下肢血管，要不然不会肌肉
坏死的。如果是由小血管栓塞开始逐渐发展的，那么术后小剂量抗凝做的不好，术
后护理观察不仔细。这个教训，要外科医生来找了，和你们无关。

[小马999]

酒后驾驶,开个罚单---再考一遍step1,2,3...哈哈

[angelboy]

A recent study researched the overall quality in almost 5,000 non-federal U.S.hospitals. Interesting findings showed that on average, 28% overall lower inhospital risk-adjusted mortality associated with the 16 procedures and diagnoses, and 5% overall lower complications associated with the 10 procedures experienced by Medicare patients at Distinguished Hospitals for Clinical Excellence compared to all other hospitals.

Do the search and see where your hospital stand, our one is not within the top 5% although it was listed on the top 10 ranked by another annual publication.


source: http://www.healthgrades.com/media/dms/pdf/HospitalQualityClinicalExcellenceStudy2007.pdf

[流氓免]

physician ah, 牛！~
加个油，呵呵呵

[lucky_tomatohead]

为了在你的BLOG留言,特地注册了个笔名

一直在关注你的博客,也一直想写些什么.
你的文字很打动人.你可能是一个平凡的人,但是你也可能有颗不平凡的心,因为你这样的不平凡,你才能够打动到别人.

我几次看你的博客,眼眶都会湿润.尤其是和父母分别入关的那篇,和我的感受竟然如此相似,我也是从入关开始一直到上飞机都没有停止留泪.我曾经很自信自己是个很坚强的人.在出国前每次回家乡看父母,回到上海都要忍不住大哭一场,那些时候都没有想象过一下将来出国会是什么样子.

我不是医生,我也不是学医科的.因为你,因为你的博客,我可以更真实地看到人的生老病死,生离死别.说白衣天使这样的话可能俗了点.但是真的很敬佩你不懈的努力,能够在美国成为一个医生本来就不是一般人可以做得到的.我相信也因为此,你可以获得别人得不到的同等生命中的价值.

祝贺你也祝福你,一直活出自己的精彩.

[wuximm]

I was in your shoes once. I would loss sleep and my appetite over every little disappointment. I was barely survive in my intern year. I had learned to lower my expectations, which was " do no harm to patients, get by and pass each rotation so no need to repeat again, try not to be the weakest intern in my class". I was so busy that I didn't even notice how the other interns were doing. In the end, there were two interns did not get 2nd year contracts renewed and another one had to let go in his 6th months. All three were American graduates. I ranked 2nd at annual in-service exam. Most likely, you are not as weak as you think. What will be worse: kill yourself by pushing self too hard vs repeat intern year? Yesterday, on Pri-med CME conference, I met the guy fired from our program, he is all happy and is currently practicing in Louisiana, I can't trace any past trauma on him at all. Life goes on.

It is OK for a intern to say "I don't know or I am not sure". As a attending myself, I always like those interns who are sincere and trying hard though may have a difficult start and I never fail them. I worried the most are those who know a little and pretend to know it all, make mistakes and always blame on others. You are definitely not one of them, you are fine intern and good physician. Have faith in you. Another point is: medicine is what we do but not who we are. Trying to have fun with other interesting things.

[落花飘零]

thank you guys for the support, i think i am over reacting for this case, every team did their job, just happened to have a very unfortunate outcome.
6hr, i think i need to defense myself and my colleagues a little bit here. there is no malpractice in this case, everything was well done and followed with guideline, if we could do this again, we would still do the same thing. As a matter of fact, the family was giving up, but we are still doing everything we can to see if there is any chance. I don't know how far we will go, maybe tomorrow my attending will give the call.

WUXIMM, thank you for the advice, i think i am exactly this kind of personality you described, and i think most of my colleagues are like me. I care about every feedback from other people, how can I not? my attending has talk with me every two weeks about every improvement after i recieve the feedback. i am struggling with my self esteem everyday, a word can make my day, and a word can ruin my day. this is driving me crazy.

[6hr]

有一种可能性：他们知道有，但是没有告诉你。怕你更伤心。Do you have Mortality & Morbidity Conference month/weekly? When I was in Sir Run Run Shaw Hospital in Hangzhou, we did that, for better doing next time. Learned a lot from that.

We had more terrible experience, In 1994, the 1st year of the hospital, we, a group of not well trained young doctors just like murders in the Hospital. one of my head trauma patient loss life because of GI bleeding, the blood arrived a few minutes after he died. Only if I know more about Cardial Pulmonary Ressusitation. He may well alive now. Another case is a 17 year young girl, trauma, died of spleen(may be more organs) rapture. If the 1st line doctor had more experience. The girl will have a happy life. Fortunately, things changed after Dr. Bryner from California trained us Advanced Trauma Life Support and lots of other things. He has all the characteristics of American surgeons, and furthermore some religious devotion spirit. When he set a goal he never give up.
He trained many good doctors in Sir Run;;and the Hosptal is a good Hospital, famous in Laparoscopy now.
Yes I cried for my head trauma patient. I have more to blame than you.

[流沙随风]

遗憾的是医生不是神。况且，先不说有没有神，即便有，神能做的也就是这些了。

你把爱心写在这里，把你痛苦的经验用在下一个病人身上，K女士定是含笑而去。

[BMW328]

没有人说我来说，为了让这个世界上多一个好医生，大家应该一起来谴责落花酒后驾车的行为

[WEIK2008]

象这样的情况，医生的态度可分为三种：
1.从来没有象姐姐这样想过，没有任何情绪波动，认为医生的职责是按最保险的方式治病，尽力了就好；
2.曾经有过情绪波动，见多了，就漠然处之；
3.象姐姐这样，深切的感受死亡。
姐姐是个性情中人，呵呵

[Dalaoshu]

说不出来什么安慰或者赞美的话了，
我也抱抱可以吗？

:)

[盈袖2006]

这就是我喜欢你的原因.完全明白你的感受.ENJOY THE WEEKEND.

[wuximm]

Observing a lovely lady withering away, you felt the sense of failure and naturely broke down. You only can save those who can be saved. Practicing medicine is indeed very stressful. To heal a person, one must first be a person. There is a limit how much a person can achieve. Most physicians fit the descrpition of obsessive-compulsive personality-want everything to be perfect, set a unrealistic goal and put on lots of stress on themself. During this busy season, I hope you take good care of yourself. "Taking care of yourself is not selfish, but rather it is self-preservation". I hope you set a realistic goal and reduce the need of external validation. It will help you cope with the stress.

[qiqi66]

抱抱...一直很喜欢看你的文章,有很多事情我们都无能为力,只要自己尽力了就好.