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医学生日记2016年6月28日- 五个规则和两个故事
阿山 （庞静译）二零一六年六月二十八日
现在我在妇科肿瘤部门的见习已经结束几个星期了，但是一直拖延写这段见习。那只是一周的见习，但对我这个医学院的学生来说，至今为止，却是最有收获的一周。医生让我们这些未来的医生一定要记住五个规则。我要记录两个故事来强调这五个规则的重要性。
- 任何一个女人抱怨几个月的肚子胀，总觉得饱饱的，没有胃口 --- 你必须考虑卵巢癌。
- 任何一个女人停经之后阴道出血 --- 除非证明不是，应该是子宫癌。
- 任何一个女人抱怨性交之后出血 --- 除非证明不是，应该是子宫颈癌。
- 任何一个女人抱怨外阴部痒 --- 除非证明不是，是外阴部癌。
- 不要依赖图象分析师，一定要自己亲自看图象。
这些规则是有关每一种癌症的第一症状。但是除了子宫癌，这些癌症的诊断都很晚，因为病人自己不告诉医生这些症状，还因为医生们也不问。或者医生根本不考虑这些症状与癌症相关。所以，除了子宫癌，所有这些癌症的结果都很惨。说到子宫癌，最保守的或最能忍的病患在停经后出血都会马上跟医生说。所以子宮癌发现得比较早，治愈率很高。
故事 1 --- 子宫颈癌
说到妇女的癌症，乳腺癌是全世界妇女的第一杀手。子宫颈癌第二。但是，在美国，子宫颈癌已经下降，卵巢癌现在是美国妇女的第二杀手。为什么？自从美国要求妇女定期做涂抹检查，子宫颈癌下降了70%。我们去看一个子宮颈癌的病人之前，主治医说她相信在她活的日子里，世界上的子宮颈癌一定能消除。
我们去看一个病人。她就是痛苦的定义。只要用听诊器轻轻碰她一下，都会引起她痛苦的嗥叫，疼痛使她在自己轮椅周围的活动都很难。她女儿一直不想让她的外孙女看到这个情景。子宫颈癌已经扩散到她的肺部和脑子。现在的化疗只是一种无奈的努力，想延长她的生命，减轻肿瘤的痛苦。但是大家都明白癌症一定会杀了她。
我们去看另一个子宮颈癌的病人。她比较年轻，不像上一个病人，没有子女。她非常想要孩子。她很幸运，她的子宮颈癌发现比较早。但是，最彻底的治疗就是摘除生育器官。医生跟她进行了一次很艰难的谈话。她可以选择尽快的生孩子，但必须知道这同时也给了那种很凶险的癌一个再生的机会，造成她的死亡；另一个选择就是彻底治疗，她永远不可能再生孩子了。
看过这些病人之后，医生讲了一通非常挫折感的气话。她并不是对我或任何人生气。她就是在医生办公室里简单地骂人、发泄。99%的子宮颈癌是人体病毒（HPV）引起的，同样的病毒引起生殖器疣。现在已经有了HPV的疫苗。她怒气冲冲地说：“我们可以消除子宫颈癌，但是美国人对于任何有关性交的事情就是这么蠢。真可恶！我很遗憾我的话让你们在场的人不舒服。其实我才不在乎。” 她说的是事实。理论上说，如果用了疫苗，美国人几乎可以完全避免子宫颈癌。但是，现在只有30%的青少年用了这种疫苗。为什么？很多家长认为HPV是性交传染。让孩子用疫苗就等于鼓励孩子无所顾忌的性交。所以他们不让孩子用这个疫苗。想一想，这些孩子长大成人之后，有了正常的性生活，接触了HPV，再考虑使用疫苗就太晚了。然后，就是因为这些家长对性交的排斥，造成了新一批的子宫颈癌患者。
我可以明白医生为什么这么有挫折感，这么愤怒。
故事 2 --- 卵巢癌
卵巢癌很可怕。它几乎就是不可避免的死亡。而且，如同子宫颈癌，它可以发生在年老或年轻的女人身上。五年的生存率是25%。在这25%幸存者中，80%将会再发癌症，最终死于癌症。
我在妇科癌症中心那个星期跟了一个病人。我初见她时，她几乎没有知觉，非常严重的智能下降 - 她不记得她是谁，她在哪。她非常的衰弱，营养不良。她基本上是皮，骨头，和膨胀很大的肚子。她怎么到了这个份上？
卵巢癌是潜伏性的。它产生的唯一症状就是它的大小。首先，一个妇女可能觉得有些肚胀，很容易饱。多数人觉得这很正常，随着年纪增长，饭量越来越少。当肿瘤长大时会压迫肠道，她们的食欲就会减少。再者，这个妇女把这个症状当成了正常的老年化，觉得能减轻体重也不错。在这种癌的发展过程中很少疼痛或不舒服。我们在急诊室见了一个病人，她的肿瘤已经长到西瓜那么大，她失了30磅体重，她从来没有觉得一点疼痛。我的病人，她开始意识到自己生病了是因为她吃的越来越少，喝的越来越少，体重越来越轻。但是，她非常害怕生病给家里造成负担，所以她就忍着，指望着哪一天这病不治而愈。后来，有一天，这个肿瘤终于长大到把她的肠道完全堵塞了。她吃喝任何东西都会马上吐出来。她已经失重很多，现在很快地严重脱水，失去了知觉。她的智力功能随之迅速下降。这样了，她才来到医院。
她的病太重了。医生们已经和家属谈了生命终结，而且预计她就死在医院。并不仅仅因为卵巢肿瘤完全压住了肠道，而且癌细胞已经扩散到肺部。她可能永远不能吃东西，就得靠输营养液。她失去太多体重，病得太重，基本上无法承受手术了。营养液也不太可能使她恢复到可以承受化疗（顺便说一句，从医学角度，通过肠道的喂食总比营养液强。）。总之，这个病人正在死去。
妇科肿瘤医生对此很不爽。她说：“我就想试试，解决她的问题。” 肠阻可以通过手术改道，让食物进入好肠子的部份，而不是阻塞的部份。妇科肿瘤医生坚持说“我要带她进手术室。我不知道这是对是错，但是至少我们不是袖手旁观她的死亡。” 麻醉医生对她的提议不感冒。大家都在劝阻她。病人死在手术台上的几率大于50%。 尽管病人在手术中活下来，还有一个更大的可能是病人成了植物人永远醒不过来了。
妇科肿瘤医生凭她自己的直觉，坚信一定可以通过手术解决病人的问题。她说服了病人和家属进行手术，很诚实地说明了她的不确定性以及手术失败的危险性。她承认在做这个决定时她是凭着自己的直觉，她无法向众人证明她可以治愈这个病人。
她把病人带进了手术室。之前她仔细看了病人的CT图像。这就够了。她切开肚子，找了一段好肠道，直接连到皮肤上。她没有浪费时间检查腹部，或者找到肿瘤试图切除。前面看过的图像已经告诉她什么能做什么不能做。总之，这个手术用了半个小时。麻醉医生成功地叫醒了病人，拨出了喉管。
第二天很奇妙。病人有了知觉。我们给她喝可乐，她也没吐。病人喝出了是可乐，说她生病这几个月来这是感觉最好的一次。他们甚至扶她站起来了，走到了椅子处。医生冒了这么大的风险，现在见成效了。整个医疗团队，病人和家属都知道卵巢癌最后会致病人于死地。但是，在她生命的尾声能够吃喝，能强壮到可以回家，和家人在一起，能把她的生命延长几个月，这就是最重要最伟大的医疗成功。
原文
Journal 20160628
Tuesday, June 28, 2016 – 5 Rules and 2 Stories
I have finished my Gynecology Oncology rotation for several weeks now, but have been delayed writing about it. It was only a one-week rotation, but it has been one of the most profound experiences of medical school for me so far. The doctor left us students with 5 important rules for all future doctors to remember. I will recap two stories that will emphasize the importance of those rules.
1. Any woman that complains of several months of abdominal bloating, feeling full all the time, and losing her appetite – you have to consider ovarian cancer.
2. Any woman that has vaginal bleeding after menopause – it is uterine cancer until proven otherwise.
3. Any woman that complains of routine bleeding after sex – it is cervical cancer until proven otherwise.
4. Any woman that complains of vulvar itching – it is vulvar cancer until proven otherwise.
5. Do not rely on the radiologist, always look at your own imaging
These rules are related to the number one symptom of each cancer, and are fairly unique to each cancer. However, other than uterine cancer, all of these cancers are diagnosed very late, either because the patient does not bring up the symptoms, the doctor does not ask, or the doctor does not think about these symptoms in relation to cancer. Thus, all of these cancers, except uterine, have miserable outcomes. Regarding uterine cancer, even the most reserved conservative and tolerant patient will immediately complain to their doctor if they have bleeding after menopause, hence uterine cancer is discovered early and survival is very good.
Story 1 – Cervical Cancer
Of the “woman cancers”, breast cancer is the number one killer of women worldwide. Worldwide, cervical cancer is the number two. However, in the U.S. cervical cancer rates have fallen and ovarian cancer is now the number two “woman cancer” killer. Why is that? Since the U.S. instituted regular pap smear screening for women, the cervical cancer rate in the U.S. has fallen by 70%. My attending physician said right before we went in to see a cervical cancer patient, she fully believes that the world is capable of eliminating cervical cancer in her lifetime.
We go in to see the patient. She is the definition of a miserable mess. Even lightly touching her with the stethoscope causes her to howl and scream in pain. In all her pain, she can barely move within her confines of the wheelchair. Her daughter is trying to shield her granddaughters’ from her misery. The cervical cancer has spread to her lungs and brain. The chemotherapy she gets now is a desperate attempt to prolong her life and reduce her tumor burden, with the acknowledgement that this cancer will kill her.
We go in to see another cervical cancer patient. She is younger, no children or grandchildren like the above patient. She desperately wants to have children. She is luckier, her cervical cancer has been caught early. However, definitive treatment is the removal of her reproductive organs. The doctor has a tough conversation with her. She has the option of trying to have a child very soon and knowing that that will give this very aggressive cancer the opportunity to invade and become her death sentence, or treat the cancer and know she will never bear her own children.
After we these patients, the doctor has a very frustrated and angry conversation. She’s not angry specifically at me or anybody, she’s simply ranting and venting in the physician workroom. 99% of cervical cancer is caused by human papillomavirus (HPV), the same virus that causes genital warts. There is now a vaccine for HPV. She huffs “We could eliminate cervical cancer, but America has to be so goddamn fucking stupid about anything related to sex. Fuck that. I would say I’m fucking sorry to those of you in the room offended by my swearing, but I don’t fucking care”. What she says is true, America could almost completely eliminate future cervical cancer with this vaccine in theory, however, the current vaccination rate in children is only 30%. Why? A lot parents believe that since HPV is a sexually transmitted infection, vaccinating their children will somehow encourage their children to be more sexually reckless. A lot of parents even refuse to think about their children having sex in their future adult lives, so they refuse to consider the vaccine in their childhood. Well, once those children become adults and become sexually active and become exposed to HPV, it will be too late for the vaccine, and a new generation of cervical cancer patients will be created because some parents did not like the idea of sex.
I could see how the doctor would be extremely angry and frustrated too.
Story 2 – Ovarian cancer
Ovarian cancer is terrifying. It is almost inevitable ably a death sentence. Again, like cervical cancer, it can affect both old and young women. The 5-year survival rate is only 25%. And of those 25% survivors, 80% will have cancer recurrence that will ultimately kill them.
For my week on GynOnc, I followed one inpatient. When I met her, she was barely conscious and had severely declining mental status – she couldn’t remember who she was or where she was. She was extremely frail and malnourished, she was essentially skin, bones, and a big bloated belly. How did she get to this point?
Ovarian cancer is insidious. The only symptoms it creates are related to its size. First, a woman might feel she’s getting a bit bloated and getting full a bit easier. Most will think this is a fairly normal part of aging and start eating a bit less. As their tumors get larger and press on their bowels a bit more, they start losing their appetite. Again, the women think it might just be a natural part of aging, and perfect, they’ve started losing a bit of weight. There is rarely any pain or unbearable discomfort in this process. One patient we saw in the Emergency Department had a tumor the size of a watermelon and a 30lb weight loss and never experienced any pain. For my patient, she started realizing she was sick as she was eating and drinking less and less and losing more and more weight. However, she was terrified to be a medical burden or concern for her family, so she just kept bearing with and hoping it would get better on its own. Then one day, the tumor had finally reached a size that it completely closed off her bowels. Anything she ate or drank she quickly vomited. She had already lost a significant amount of weight and rapidly became extremely dehydrated and lost consciousness. Her mental function quickly declined after that. All of that finally brought her to the hospital.
After we these patients, the doctor has a very frustrated and angry conversation. She’s not angry specifically at me or anybody, she’s simply ranting and venting in the physician workroom. 99% of cervical cancer is caused by human papillomavirus (HPV), the same virus that causes genital warts. There is now a vaccine for HPV. She huffs “We could eliminate cervical cancer, but America has to be so goddamn fucking stupid about anything related to sex. Fuck that. I would say I’m fucking sorry to those of you in the room offended by my swearing, but I don’t fucking care”. What she says is true, America could almost completely eliminate future cervical cancer with this vaccine in theory, however, the current vaccination rate in children is only 30%. Why? A lot parents believe that since HPV is a sexually transmitted infection, vaccinating their children will somehow encourage their children to be more sexually reckless. A lot of parents even refuse to think about their children having sex in their future adult lives, so they refuse to consider the vaccine in their childhood. Well, once those children become adults and become sexually active and become exposed to HPV, it will be too late for the vaccine, and a new generation of cervical cancer patients will be created because some parents did not like the idea of sex.
I could see how the doctor would be extremely angry and frustrated too.
Story 2 – Ovarian cancer
Ovarian cancer is terrifying. It is almost inevitably a death sentence. Again, like cervical cancer, it can affect both old and young women. The 5-year survival rate is only 25%. And of those 25% survivors, 80% will have cancer recurrence that will ultimately kill them.
For my week on GynOnc, I followed one inpatient. When I met her, she was barely conscious and had severely declining mental status – she couldn’t remember who she was or where she was. She was extremely frail and malnourished, she was essentially skin, bones, and a big bloated belly. How did she get to this point?
Ovarian cancer is insidious. The only symptoms it creates are related to its size. First, a woman might feel she’s getting a bit bloated and getting full a bit easier. Most will think this is a fairly normal part of aging and start eating a bit less. As their tumors get larger and press on their bowels a bit more, they start losing their appetite. Again, the women think it might just be a natural part of aging, and perfect, they’ve started losing a bit of weight. There is rarely any pain or unbearable discomfort in this process. One patient we saw in the Emergency Department had a tumor the size of a watermelon and a 30lb weight loss and never experienced any pain. For my patient, she started realizing she was sick as she was eating and drinking less and less and losing more and more weight. However, she was terrified to be a medical burden or concern for her family, so she just kept bearing with and hoping it would get better on its own. Then one day, the tumor had finally reached a size that it completely closed off her bowels. Anything she ate or drank she quickly vomited. She had already lost a significant amount of weight and rapidly became extremely dehydrated and lost consciousness. Her mental function quickly declined after that. All of that finally brought her to the hospital.
She was extremely sick. The medical team had a conversation with the family about the end of life, with the expectation that she would very likely die this hospital stay. Not only had the ovarian cancer completely compressed her bowels, it had already spread to her lungs. She was likely to never be able to eat again and would rely on IV nutrition. She had lost too much weight and was simply too sick to survive surgery. The IV nutrition was not ideal to get her recovered to a state where chemotherapy would be possible. (Side note, in medicine, feeding through the gut is always more preferable compared to IV nutrition). To summarize, this patient was actively dying.
The GynOnc doctor wasn’t happy with the state of things. She simply said, “I want to try to fix her”. Bowel obstructions can be bypassed surgically, by looping up the good end to allow the contents to exit through the skin instead of hitting the obstructed point. The GynOnc doctor insisted “I want to take her to the operating room. I don’t know if it’s the right decision, but it beats sitting and watching her die”. Anesthesia was not happy with that idea. They kept trying to dissuade her. The patient had a greater than 50% chance of dying on the operating table. Even if she did survive the surgery, there was an even greater chance she would never be extubated or wake up.
The GynOnc doctor believed in her gut instinct in that she could do something surgically to fix the patient, and she convinced the patient and family to proceed with surgery, all while being very honest and realistic about her own doubts and the high chances of failure and death. She admitted to everybody involved in the decision making, she had no evidence that she could make this patient better other than her own gut instinct.
She took this patient to the operating room. Beforehand, she had thoroughly reviewed the limited CT imaging that had been done on the patient. This was enough. She made her cuts and grabbed the good loop of bowel and brought it up to the skin. She didn’t waste any time inspecting inside the abdomen or trying to find tumor she could resect. Looking at the prior imaging was enough to tell her what she could and couldn’t do. All in all, the surgery took about half an hour. Anesthesia was able to successfully wake the patient up and extubate her.
The next day was wondrous. The patient was conscious. We were able to give her a coke without her vomiting it up. The patient claimed the taste of coke was one of the happiest feelings she had had in several months. They were even able to help her stand up and move to a chair for a bit. This giant risk the doctor took was paying tremendous dividends. The medical team, patient, and family all knew this ovarian cancer was going to kill the patient. But, being able to eat and drink at the end of her life, regaining enough strength to go home and be with her family, being able to prolong her life by several months, those were great and important medical achievements in itself.
