2015.04.15 希波克拉底式的笨拙。我当医生的第一天

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HEALTH
Hippocratic Oaf: My First Day as a Doctor
I was technically a real physician the moment I walked through the hospital doors, but I quickly realized that medical school had left me woefully unprepared.

By Matt McCarthy

Regis Duvignau/Reuters
APRIL 15, 2015
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Seeing a new patient wheeled into the cardiac care unit, I leapt up from my seat.

“Easy,” said the physician next to me. He placed a hand on my shoulder and guided me back into my chair like a trainer gentling an unsteady colt. “Give the nurses a few minutes to do their thing.” He spoke softly and bore a surprising resemblance to a Charles in Charge-era Scott Baio, all black hair and good-natured smiles. “The nurses are going to do a lot more for him tonight than you and I are.”

I nodded and eased back into my seat. “Okay,” I said to Baio as I straightened my scrub top. I was anxious. I was excited. I’d just chugged a large iced coffee and could hardly sit still.

In medical school, I had moved through  rotations in surgery, neurology, psychiatry, radiology, internal medicine, pediatrics, and finally, obstetrics, where a young Jamaican woman let me deliver her child on my first day. She insisted on giving birth on her hands and knees, her back arched like that of a cat as the baby slowly emerged. An amused midwife later said that I had looked like a nervous quarterback, receiving a snap in slow motion.

As graduation approached, choosing a specialty had proved to be difficult. Ultimately I had settled on internal medicine because it was the broadest field, the one that might allow me to feel like a jack-of-all-trades. But tonight was my debut in the big show, a 30-hour shift taking care of critically ill patients and responding effectively to anyone who might roll through the door.

An amused midwife later said that I had looked like a nervous quarterback, receiving a snap in slow motion.
“We’ve got a few minutes,” Baio continued, “and I know this is your first night in the hospital. So let’s go over a few things.”


“Great!” I replied. Our orientation leaders, a peppy group of second- and third-year residents, had instructed us to exude a demented degree of enthusiasm at all times, which wasn’t difficult now that my blood was more caffeine than hemoglobin.

“Just relax,” he said, “and take a look around.”

Together we scanned the fluorescent room, an enclosed space the size of a tennis court containing critically ill patients and nurses bustling between them. The perimeter, painted a regrettable shade of yellow, housed the patients in glass cubicles, while the center, where we were sitting, was mission control, filled with chairs, tables, and computers. “It’s just you and me tonight,” Baio said, whipping his stethoscope back and forth around his neck. “And 18 of the sickest patients in the hospital.”

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Every night an intern and a second-year resident presided over the CCU. Tonight was our turn, as it would be every fourth night for the next month. All of the patients in the unit were on ventilators except one, a large Hispanic man who was riding a stationary bicycle and watching Judge Judy in his room. “These patients are receiving some of the most complex and sophisticated therapies in the world.” Baio reached for a bagel that was sitting on a platter nearby. “Patients get referred to the cardiac-care unit when hope is lost or after something devastating happens. Balloon pumps, ventricular assist devices, transplanted hearts, you name it.”

Until a few days ago, I had never set foot in a cardiac-care unit. Nothing about the setup looked terribly familiar. I continued to study the room, trying to decode the symphony of incessant beeps and alarms and wondering what each of them meant. It felt like I was sitting in the middle of a giant equation with infinite variables.

“These patients should all be dead,” Baio went on. “Almost every one of them is kept alive by an artificial method. And every day they’re going to try to die on us. But we’re going to keep them alive.” He paused for effect. “And that’s cool.”

"Almost every one of them is kept alive by an artificial method. And every day they’re going to try to die on us."
It was cool. In college, I had studied molecular biophysics and briefly flirted with the idea of going to graduate school in that subject, using my degree to solve the structure of molecules that were too small to be seen under a microscope. But the field lost me when a professor, a young crystallographer, introduced the importance of imaginary numbers in biophysics. Try as I might, I just couldn’t wrap my head around that quixotic concept. I wanted to translate science into something more concrete, more tactile, to seek a profession where I could touch and see and feel. So I changed course and pursued medicine. And thus far, it had seemed like a wise decision. Nothing about this moment with Baio seemed imaginary. Quite the contrary, it felt excessively real.


Baio wiped off the bagel crumbs on his scrubs and leaned in close to me. “We have to work as a team. Everything is teamwork. So I need to know what you’re able to do. The more you can do, the more time I have to think about the patients. So rather than listing the shit you can’t do, tell me what you can do.”

My mind went blank. Or more accurately, I searched it and found it was blank. “Well …” I glanced at the sedated patient before us. He was on a ventilator and had a half-dozen tubes in his neck, arms, and groin, almost all of which pulsed with medications I’d never heard of. As a medical student, I had been exposed to all sorts of patients. But all of those encounters had involved walking, talking, reasonably well-functioning individuals. Lying there, inert and blanched of all color, the patient before me seemed well beyond the reach of my limited powers. If he needed his appendix out or his face stitched together, I was his man. But intensive cardiac care? The learning curve in medicine was so unforgivably steep.

Finally Baio broke the silence. “All right,” he said, “I’ll start. Can you draw blood?”

“No.”


“Can you put in an IV?”

“No.”

“Can you put in a nasogastric tube?”

If he asked me to recite a journal article, I could’ve put on quite a show. But I hadn’t learned much of the practical business of keeping people alive.
“I can try.”

“Ha. That’s a no. Ever done a paracentesis?”


“I’d love to learn.”

He smiled. “Did you actually go to medical school?” Even I had to wonder. If Baio had been asking me to recite pages from a journal article on kidney chemistry or coagulation cascades, I could’ve put on quite a show. But I hadn’t learned much of the practical business of keeping people alive. In fact, I had been allowed to skip the CCU month of my med-school training at Massachusetts General Hospital so I could learn tropical medicine in Indonesia. Who had talked me into that?

“I graduated from Harvard earlier this month.”

“Oh, I know you went to Haaahvaahd,” Baio said with exaggerated fake reverence. “But do you know how to order medications?”

A bright spot. “Some!” I practically beamed.

“Do you know how to write a note?”

“Yes.” The moment I said it I realized just how paltry a contribution it would seem to him. Baio must have seen my face drop.


“That will actually be a big help,” he said. “Examine every patient and write a note on them for the chart. That will save me time. You need to be concise yet precise.”

I grabbed my small notebook and scribbled examine everyone/write notes.

“And listen,” he said while chewing on the stale bagel, “if I want a sandwich tonight, go to the cafeteria to get me a sandwich. And if I ask for a coffee when you return and give me that sandwich, do you know what you should do?”

“Head to Starbucks.”

“Correct.”

One of the nurses tapped me on the shoulder and asked me to order a blood thinner for a patient, but Baio cut her off. “Dr. McCarthy is not yet a functioning member of society,” he told her before putting in the order himself. I watched over his shoulder as he typed away.

"If you keep me well fed and caffeinated, I will be happy. And if I’m happy, I will feel inspired to teach you a thing or two."
After finishing with the order, Baio turned and looked me up and down while grabbing another bagel. “You may be thinking, Why is this guy an asshole?”


I shook my head.

“Well, I’m not an asshole.” He returned to the computer. “I’m stuck in this enclosed unit for the next 20-something hours. I can’t leave. The only way I can step outside of this unit is if a cardiac arrest is called over the intercom and I have to go bring someone back to life.”

“Got it.”

“And if that happens, you’re alone in here. It’s just you. All alone. And them,” he said, spinning his hand once around his head. “Now, if you keep me well fed and caffeinated, I will be happy. And if I’m happy, I will feel inspired to teach you a thing or two about how to actually be a doctor.”

And that was the truth of it. Baio, one year my senior, would essentially be teaching me how to be a physician. It was hard to believe he had been an intern just last week; the man looked like a sample photo at Supercuts. At Columbia, as at most teaching hospitals, interns were paired with second-year residents to manage between 12 and 18 patients, and were provided with varying levels of supervision by attending, board-certified physicians who met with us every morning at 7:30 to discuss our plans for the day. But the guts of the day, the minute-to-minute, I’d spend hooked to Baio.


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“I want nothing more than to keep these patients alive,” I offered, perhaps a touch too earnestly.

He waved his hand at me. “Yeah, yeah. Just show up on time and bust your ass.” This I could do. It was a philosophy a former baseball coach of mine had sworn by. “Looking at you, I’m thinking two things,” Baio said. “One, you kinda look like someone I know. You both look like big ol’ meatballs.”

It was not the first time my admittedly WASP jock appearance had been skewered by a member of the healthcare community. “What’s the other thing?” I asked Baio.

He smiled. “You look terrified.”

“I am.”

“Good. Go examine our new patient.”

This article has been excerpted from Matt McCarthy's book The Real Doctor Will See You Shortly: A Physician's First Year.

Matt McCarthy is a writer and physician based in New York. He writes the Medspin column for Deadspin.




健康
希波克拉底式的笨拙。我当医生的第一天
从技术上讲，当我走进医院大门的那一刻起，我就是一名真正的医生，但我很快意识到，医学院让我毫无准备。

作者：马特-麦卡锡

Regis Duvignau/路透社
2015年4月15日

看到一个新病人被推入心脏护理单元，我从座位上跳了起来。

"放松，"我旁边的医生说。他把一只手放在我的肩膀上，引导我回到椅子上，就像一个训练师在指导一匹不稳定的小马。"给护士们几分钟时间来做他们的工作。" 他说话的声音很轻，与 "查尔斯当家 "时代的斯科特-拜奥惊人地相似，全是黑发和善意的微笑。"护士们今晚要为他做的事比你和我做的多得多。"

我点了点头，缓缓回到座位上。"好的，"我一边整顿我的擦洗上衣，一边对Baio说。我很焦急。我很兴奋。我刚刚喝了一大杯冰咖啡，几乎坐不住了。

在医学院里，我在外科、神经科、精神病科、放射科、内科、儿科和最后的产科轮转，在那里，一位年轻的牙买加妇女让我在第一天为她接生。她坚持用手和膝盖分娩，当婴儿慢慢出来的时候，她的背部像猫一样拱起。一位有趣的助产士后来说，我看起来就像一个紧张的四分卫，在慢动作中接受扣球。

随着毕业的临近，选择一个专业被证明是困难的。最终我选择了内科，因为这是最广泛的领域，可以让我觉得自己是个万能的人。但今晚是我在大舞台上的首次亮相，30个小时的轮班，照顾危重病人，对任何可能进门的人作出有效的反应。

一位有趣的助产士后来说，我看起来像一个紧张的四分卫，在慢动作中接受扣球。
"我们有几分钟的时间，"Baio继续说，"我知道这是你在医院的第一个晚上。所以我们来复习一些东西。"


"太好了！" 我回答道。我们的迎新领导是一群活泼的二年级和三年级住院医生，他们指示我们在任何时候都要散发出疯狂的热情，这并不难，现在我的血液中咖啡因比血红蛋白多。

他说："放轻松，""四处看看"。

我们一起扫视了荧光室，这是一个网球场大小的封闭空间，里面有危重病人和在他们之间忙碌的护士。周边被漆成令人遗憾的黄色，病人被安置在玻璃隔间里，而我们所坐的中心则是任务控制室，摆满了椅子、桌子和电脑。"今晚只有你和我，"Baio说，把他的听诊器在脖子上来回晃动。"还有医院里18个最病态的病人。"

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每天晚上都有一名实习生和一名二年级住院医生主持CCU的工作。今晚轮到我们，接下来的一个月里，每隔四天就会轮到我们。病房里所有的病人都在使用呼吸机，只有一个人例外，他是一个身材高大的西班牙裔男子，正在房间里骑着固定自行车看朱迪法官的节目。"这些病人正在接受世界上最复杂、最尖端的治疗。" 巴奥伸手去拿放在旁边盘子里的一个百吉饼。"当希望破灭或发生破坏性事件后，病人会被转到心脏护理单元。球囊泵、心室辅助装置、移植的心脏，你都知道。"

直到几天前，我还从未踏入过心脏护理室。这里的设置看起来一点也不熟悉。我继续研究这个房间，试图解读不绝于耳的哔哔声和警报的交响乐，并想知道它们每一个都意味着什么。我感觉自己就像坐在一个具有无限变量的巨大方程式中间。

"这些病人应该都已经死了，"巴奥继续说。"几乎每一个人都是通过人工方法维持生命。而且每天他们都会试图在我们身上死去。但我们要让他们活着。" 他停顿了一下，以达到效果。"这很酷。"

"几乎每一个人都是通过人工方法维持生命的。而每天他们都会试图在我们身上死去。"
这很酷。在大学里，我曾学习过分子生物物理学，并曾短暂地萌生过在该学科上研究生的想法，用我的学位来解决那些在显微镜下看不到的太小的分子结构。但是，当一位教授，一位年轻的晶体学家，介绍了虚数在生物物理学中的重要性时，这个领域失去了我。尽管我很努力，但我就是无法理解这个古怪的概念。我想把科学转化为更具体、更有触感的东西，寻求一个我可以触摸、看到和感觉到的职业。所以我改变了方向，追求医学。到目前为止，这似乎是一个明智的决定。与巴奥在一起的这一时刻，没有任何东西是想象出来的。恰恰相反，它感觉非常真实。


贝奥擦掉了他的手术服上的面包屑，靠在我身边。"我们必须作为一个团队工作。一切都是团队合作。所以我需要知道你能做什么。你能做的越多，我就有更多的时间考虑病人的问题。所以与其罗列你不能做的事情，不如告诉我你能做什么。"

我的大脑一片空白。或者更准确地说，我搜索了一下，发现它是空白的。"嗯......" 我瞥了一眼我们面前的镇静病人。他戴着呼吸机，脖子上、胳膊上和腹股沟里插着半打管子，几乎所有的管子都在跳动着我从未听说过的药物。作为一名医学院学生，我曾接触过各种各样的病人。但所有这些接触都涉及到会走路、会说话、功能还算正常的人。躺在那里，毫无生气，脸色苍白，我面前的病人似乎远远超出了我有限的能力范围。如果他需要切除阑尾或缝合他的脸，我就是他的人。但是心脏重症监护？医学的学习曲线是如此不可原谅的陡峭。

最后，贝奥打破了沉默。"好吧，"他说，"我开始吧。你能抽血吗？"

"不会。"


"你能给病人打点滴吗？"

"不能。"

"你能插上鼻胃管吗？"

如果他让我背诵一篇期刊文章，我可以做一场相当精彩的表演。但我还没有学到多少维持人的生命的实际业务。
"我可以试试。"

"哈，这可不行。做过穿刺术吗？"


"我很想学。"

他笑了笑。"你真的上过医学院吗？" 即使是我也不得不怀疑。如果白奥让我背诵一篇关于肾脏化学或凝血级联的期刊文章，我可能会做一场相当精彩的表演。但我并没有学到多少关于维持人的生命的实际业务。事实上，我被允许跳过麻省总医院医学院培训中的CCU月，以便在印度尼西亚学习热带医学。谁说服我这样做的？

"我这个月早些时候从哈佛大学毕业。"

"哦，我知道你去了Haaahvaahd，"Baio用夸张的假敬意说。"但你知道如何订购药物吗？"

一个亮点。"有些！" 我几乎是喜笑颜开。

"你知道怎么写纸条吗？"

"是的。" 当我说出这句话的时候，我意识到这对他来说是多么微不足道的贡献。白奥一定是看到了我的脸色不好。


"这实际上将是一个很大的帮助，"他说。"检查每一个病人，并为他们写下病历上的说明。这将为我节省时间。你需要简明而准确。"

我拿起我的小本子，潦草地检查每个人/写笔记。

"还有，听着，"他一边嚼着陈旧的百吉饼一边说，"如果我今晚想吃三明治，就去食堂给我买个三明治。而如果我在你回来时要求喝咖啡，并把那个三明治给我，你知道你应该怎么做吗？"

"去星巴克。"

"正确。"

一个护士拍了拍我的肩膀，要我为一个病人订购血液稀释剂，但贝奥打断了她。"麦卡锡医生还不是一个正常的社会成员，"他告诉她，然后自己下了订单。我在他的肩膀上看着他打字的样子。

"如果你让我吃饱喝足，我就会很高兴。如果我高兴，我就会觉得有灵感，可以教你一两件事。"
完成订单后，白奥转过身来，上下打量着我，同时拿起另一个百吉饼。"你可能在想，为什么这家伙是个混蛋？"


我摇了摇头。

"嗯，我不是一个混蛋。" 他回到了电脑前。"接下来的20多个小时，我都被困在这个封闭的单元里。我不能离开。我可以走出这个单元的唯一方法是，如果有人通过对讲机呼叫心脏骤停，我必须去把人救活。"

"知道了。"

"如果发生这种情况，你在这里是孤独的。只有你。独自一人。还有他们。"他说，手在头上转了一圈。"现在，如果你让我吃饱喝足，喝足咖啡，我就会很高兴。如果我高兴，我就会觉得有灵感，可以教你一两件关于如何真正成为一名医生的事情。"

这就是它的真相。比我大一岁的巴奥，基本上会教我如何成为一名医生。很难相信他上周还是个实习生；这个人看起来就像超级理发店的一张样本照片。在哥伦比亚大学，和大多数教学医院一样，实习生与第二年的住院医生结成对子，管理12到18个病人，并由主治医生提供不同程度的监督，这些医生每天早上7:30与我们见面，讨论我们当天的计划。但是，一天的主要工作，每分钟的工作，我都会花时间与Baio联系在一起。


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"我只想让这些病人活着，"我提出，也许有点太认真了。

他朝我挥了挥手。"是的，是的。只要你准时出现，并打爆你的屁股。" 这一点我可以做到。这是我的一个前棒球教练发誓的理念。"看着你，我在想两件事，"巴奥说。"第一，你看起来有点像我认识的人。你们俩看起来都像大肉球。"

这不是我第一次承认的WASP运动员的外表被医疗保健社区的成员嘲笑。"另一件事是什么？" 我问贝奥。

他笑了笑。"你看起来很害怕。"

"我是。"

"很好。去检查我们的新病人吧。"

本文节选自马特-麦卡锡的《真正的医生很快就会见到你》一书。一个医生的第一年。

马特-麦卡锡是驻纽约的作家和医生。他为Deadspin撰写了Medspin专栏。