牛年来咯

牛年来咯！

今天好忙。因为大多数外乡华人都请假去了。因为早上的外诊还是一如往常的客似云来。因为下午忽然来了几个房室传导阻断的病人，让我们紧急放置临时心跳节律器。（其实今天是我第一次自己放置哦！有好好先生的N专科医生的监督和指导，真好！）

最开心的当然是赶得及回家吃团圆火锅和寄上这一篇祝福了。祝大家体壮如牛，快快乐乐！

高帽

“医生，你怎么这样年轻？我看，你有没有二十岁呀？不对，你们大学毕业，至少都有二十四岁吧？”

你的意思是我看起来没有什么经验，还是不够稳重吗？哼哼... ...

“我最多是看起来年轻吧了，我的年纪，要的话，三四个孩子都已经有了。”

才不让你知道我的年纪呢！

“不对，你怎么这样漂亮，我还没有见过这样漂亮的医生哟！看到你，我的病都好了一半！”

哇，这一句中听。呃，还好那一些比我漂亮的同事、护士和药剂师都不在，嘿嘿。（暗爽）

高帽人人爱戴，我又岂能例外？所以，接下来... ...

“医生，我的妈妈生病，只是感冒，要登记看百科很麻烦，可以顺便拿一些咳嗽药水什么的吗？”

“可以。可以。咳嗽药水、伤风、发烧的都有。”

“加一些维他命ｃ可以吗？”

“没问题。没问题。”

“可以给一天的病假吗？”

“当然。当然。”

XP  XP  XP

见鬼

这个周五的值班，是个惊奇/险连连的一天，从昨天八点由紧急插管开始，到今天早上心脏复苏结束，把心脏监护病房、重症加护病房等都填满了。（周六工作的同事，原谅向来洪星高照的我做一次病房毒药，哦，除非有人快速痊愈或升上天堂，要不然可没有留下任何空间给今天病危的病人了。）

话说我一早踏入心脏监护病房，就听到氧气高速从口罩外泻的淅淅声还有护士的吆喝声。什么样的开场呀？看起来这一天的值班不怎么乐观了。我丢下背包小跑过去。三位护士阿姨正努力的压制一个神志不清的少妇，企图放置静脉点滴。

“安娣，安娣，不要挣扎，不要挣扎，张开眼睛，你听得到我吗？”用喊的没效，我大力的压向她的胸口，她紧闭着眼睛，毫无意识的挥动四肢，显然仍没有什么知觉。奇怪，她是怎么一回事？血压和血氧饱和度都不错，也没有中风的迹象。无论如何，先给镇静剂，插管维护呼吸道了再说。

“咦，心电图怎么显示新室频脉？准备电击！... ... 呃，怎么不到一分钟又恢复正常了？”

“哎，你不知道，从昨晚进院到现在，这已经是第四次新室频脉了，心脏专科医生昨晚已经检查过她，也开始了抗心律不整药物。她每一次都是这样的，不到一分钟就恢复正常，都没来得及电击去频的。总算插管了，真是松了一口气。”护士阿姨这样告诉我。

“她怎么了？”病人的丈夫看到我走出来，就拉着我问。“是不是起搏器的电池不够了？”

我翻了翻病情纪录。她，戴了心脏起搏器十年了，原本预约在下个月到槟岛中央医院检查起博器的电池强度。

“对不起，我知道你很心急，在我回答你的问题之前，你能不能先告诉我她之前的病历？”

听他侃侃道来，原来，十年前，她也是类似的症状，投诉偶尔见到奇怪的影子，然后就会心跳加速和头晕。后来装了起搏器，十年以来一切还算安好。前几天，她开始呓语，说又见鬼了，心跳加速的问题又回来了。他担心旧戏重演，所以赶快带她来医院。

是见鬼了所以心律不整？不，应该说是心律不整（脑氧不足？）造成见鬼的现象吧？无论如何，应了“病人是最好的老师”这句话，“见鬼”原来可以是心律不整的征兆之一！(@_@;)

经皮心包穿刺置管

在youtube搜寻到这一个。如果你有兴趣。

另一个不幸的故事

那时候，新医院刚启用不久，而我，还在实习阶段。

他，喘着气，被推入心脏监护病房。我趋向前，他虽然气喘，仍可以断断续续的说话。才问了简短的病历，B专科医生就出现在我背后。

“刚从急症室上来的吗？”

“是的，老板。他是xxx，抽烟，但不沾酒或毒品，是七个孩子的父亲，今天早上打扫庭院的时候忽然觉得气喘，呼吸困难... ...”

做了一些检查，包括临床心脏超英波后，B医生说，“他这情况是心包腔积液。我们需要刺穿心包腔引流积液才行。”

“经皮心包穿刺置管？”我说这话的当儿应该是双眼发着亮光的吧！

“你没有看过吗？”

“学生时代只看过一次。”

“这个嘛！很简单、很简单！”

“很简单？不危险吗？”

“对呀！他的心包腔内积液很多，做穿刺插管不是问题。这个是实习医生也可以轻易做到的。”

“真的吗？我也可以吗？”

“可以啊！虽然好些正式医生都没有做过这个手续，其实一点也不难。”

“可以教我吗？”我急切的问，带着一点点期待和小小的兴奋，对随后的悲剧没有一丁点的预感。

“当然可以，不过，这一次还是我示范给你看，下一次你才自己动手。你现在先让他签了做经皮心包穿刺置管的同意书。”

“好啊！好啊！”

我拿了同意书，简单的向他解释了我们将要进行穿刺心包的原因和程序。

“医生，这个，危险吗？”

“坦白说，有一定的危险，不过，今天我们的专科医生将会亲自动手，应该还好吧！”

他用双手向前撑着身体，大口的呼吸，在喘气之间说：“我喘到要死，看起来我也别无选择，你们要做，就快一些吧！”

我笑了笑，看着他在同意书上潦草的签下自己的名字。

差不多一个小时后，一切器材准备就绪，病房里聚集了另外几位想要观摩和学习的学长，B医生开始动手了。

“首先，先在胸口抹上消毒药水。让消毒药水风干。”

“注射麻药。把超音波推过来，再次确认心包腔积液位置。”

“针头放在腹部上方，朝着左肩，往上四十五度，就这样一刺，同时抽出液体... ...”

心电图上一阵混乱，继而成为一条直线。他，发了几秒癫痫后，再也不动了。B医生抽出手上的穿刺置管，“快，心肺复苏！”

我跳到了病床上，拼命的按摩心脏。

一下、两下、三下... ...　心电图随着我的动作摇晃了几下... ...

一回合、两回合、三回合... ...　无视于我们的努力，心电图仍是一条没有波动的直线... ...　随着手下的身体渐渐失去体温，我的手也渐渐僵硬起来。

他死了。宣布死亡时间：下午三时三十分。我悄悄的检查过穿刺置管中的液体，血红色，但并不凝结成硬块。（意味着当时并没有刺穿心脏错抽出真正的血液。）

一直到今天，我还记得他的妻子那个惊愕的表情和随后的号啕大哭，还记得自己告诉他“虽然有一定的危险性，但是应该还好”（其实很后悔那样说，是不是应该说非常危险，九死一生？），还记得他在我面前艰难而潦草的签下同意书，还记得那一种别无选择的无奈。

然而，当时宣布的死亡原因是什么？是什么原因造成突发性的心包腔积液？这一切，仿佛也已不再重要。

美丽的总结

如果你是那位倒霉的医生，自责愧疚的当儿，你会：

主动承认错误	16 (69%)
保持沉默	6 (26%)
另寻借口打死不认	1 (4%)

阿伯早上还有说有笑，当晚却在医院逝世了。如果你是他的儿子，你会：

心有不甘的提出诉讼/投诉	4 (19%)
虽然没有实际行动，实则怨恨在心	2 (9%)
人谁无过，不过是一时错手，让一切成为过去	8 (38%)
情愿不知道真相	7 (33%)

任何研究总得作一下分析和报告的。

这个小小的部落民意调查，分析就不必了。总结吗？来这里逛逛的部落客还是诚实、善良和宽容的多。(*^.^)

 

因为要把结果插在新故事之前，日期稍稍倒退了一下。　(~.^)

世界的另一端

当我在这一端小鼻子小眼睛的想要放手，看看别人在怎么奋斗？

乱感动的。可我没有给他们电邮。○(-_-)○

——————————————————————

金毛，这是给你翻译的：

（其实超过一半是用网上的翻译器帮忙弄的，嘿嘿。┌(^_^)┘?└(^_^)┐）

随时待命 

苏丹中部早上十时，天气已经起泡热点。我们几乎窒息在的小诊所房间。这里有一个窗口，没有风扇，还有无数的疟疾患者。 

一名年轻的女子走进来，即使天气那么热，她还是把自己从头到脚包裹在服装和围巾里。她盯着地面，喃喃地以阿拉伯文说她的故事。她的3个月大的婴儿生病。他出生与众不同 ，一只眼睛失明，头太小，但很好吃，而且哭声高吭。起初，他的鼻子突起的桥梁看起来没有什么。但，随后，它开始增高，到现在让他不能够进食。 

我们向她要求检查婴儿。她把手伸进她用褶皱的衣服制作的一个捆绑包和围巾。然后那个软件包开始咳嗽起来。我们起先看到了一个膨，好像第二头那像从婴儿的脸突出来，从额头到鼻孔的皮肤紧紧地伸张着。它是如此的大，把他的鼻孔挤压到让他窒息。年轻的母亲把孩子放在她的胸前。他无法呼吸。他用力的吸，哽咽，然后哭了。

 

汤姆卡泰纳医生抬起头来告诉婴儿的母亲： “对不起” ，他说的是阿拉伯语。 “你需要去喀土穆。 ” 

她没有回应。她挣扎着以母乳喂养她的孩子。喀土穆在数百英里之外。我们知道她没有钱，也没有交通工具。但是，我们也知道我们看到的是一个突出的大脑和流体，从婴儿头骨的一个洞里钻出来。这个洞的修复工作属于儿科神经外科医生，而不是我们这两个家庭医生。

 

后来，她回复了卡泰纳。 “请帮帮忙” ，她说。婴儿尖叫着。 

我和卡泰纳母亲慈善医院一起工作了五周。母亲慈善医院位于苏丹偏远的努巴山区，荒野到只有通过联合国飞机才能运送粮食。这是一个只有80张病床的医院，为经历了50年的内战的天主教人口服务。这也是苏丹中部唯一外科医院。母亲慈善医院开幕于2008年3月，只有一个固定的医师：卡泰纳。他来自美国，在非洲工作了10年，首先在肯尼亚，现在苏丹。他受训于家庭医学（在美国）和普通外科（在肯尼亚）。他是医院的医疗主任。也是唯一一个申请工作的人。他在医院开幕前一周抵达当地。 

“这是一场噩梦” ，他告诉我。 “我们只有7天做准备。一边做一边学。我们当中没有一个人有设立一家医院的经验。 ” 

他叙述数百名患者同时出现在开幕式。第二天又有数百人前来。他们有疟疾和肺炎，有人受伤，有人休克。有人在分娩失败后几天前来，通常带着一名死亡了的婴儿，夹在阴道之间。他们在任何时间前来，在最热的时间和最干燥的一年，步行了几个星期才抵达医院。然后耐心的等待医生看病，挤满了医院的院子。 只需要支付15苏丹镑，病得最重的人也可以入院。有些人呆了几个月才康复。他们拥挤在医院的病房里，混乱的蚊帐里，静脉点滴杆，哭泣的婴儿，狗，压迫人的热气和没有洗澡的体臭之中。

 
那几个月卡泰纳病倒了。他患上疟疾两次。他下降了50磅。然而，他一直没有离开过医院。外科病症每天紧急抵达，往往在夜间。卡泰纳工作在一个孤立的地区，没有城市或政府首脑，附近也没有其他医生。他管理的这所医院依靠太阳能发电，抽水，与坑式厕所，小仓库的用品只有每年两次的货运飞机从内罗毕补充。一切是有限的，都不能浪费。卡泰纳运用他的药物，缝合用品，和身体的有限的能量去应付绝大多数的需要。这几乎打跨了他，但他的努力终究得到了回报。我到达的时候，人群仍然很多，但医院运行良好。 

我到达的第一天，看到一个麻风病人，两个肺结核和五十个疟疾 。我们除去了一个无法小便的病人的前列腺。我们让脑膜炎的婴儿入院，她的头部上方的隆起，胀得紧紧的。在未来的几个星期内，我终于看到了在美国常见的疾病：糖尿病，高血压，中风。我还看到肠道寄生虫，填充了眼球的脓，饥饿，和一个被山羊的粪便戳了鼻子的女孩（当地停止鼻血的办法） 。 

我们做了很多单手术：紧急剖腹产手术时，我们把早产儿绑在了母亲的乳房上让他获得温暖以维持生命，异位妊娠破裂，许多泌尿系统的手术，一些肠道手术，甲状腺手术。我们截去腿和手指。有时候，一项手术中，苍蝇沾在外露肠或肌肉之上。麻醉技术师必须在房间里追逐苍蝇，试图杀死它。 

我很快就厌倦了饮用白开水和热茶;吃扁豆和米饭的晚餐;工作，有时一整天,有时一整夜，当我有空闲时间，也无处可去。最难忍受的，是热气，我在闷热蚊帐下的摇篮里梦想着啤酒。 

病人似乎也只是容忍着我们。他们相信我们并不比信赖种族灭绝的喀土穆政府多。他们需要帮助，并接受我们的照顾。没有含泪道谢，甚至没有笑容;只是阴沉的沉默。当我们向家庭成员要求献血时，他们断然的拒绝，有的甚至昏了过去。患者没有清洗他们的伤口，所以迅速受到感染。他们无处不吐口水。护士助手，也努巴，对他们咆哮,好像他们是一些生病的动物一样，偶尔还打他们的头部。获得病历几乎是不可能的，甚至当4个护士助手高喊着阿拉伯语，他们的唯一反应也只是打一下舌头。

 

这家医院的实验室设有五个或六个基本测试，包括血液抹片疟疾和血红蛋白的贫血症。止痛药的药房配药，三个抗生素，一些化疗药物，还有很多抗疟药物。卡泰纳带着一个便携式超声机，是检查身体内部的唯一途径，因为我们没有X射线。

 
第三个星期，我完全理解母亲慈善医院的局限性，但我也看到卡泰纳奇迹，他每天做的事情，在祖国(美国)需要一个专家小组来完成。我以为他可以处理几乎天底下所有的东西。直到那个婴儿的出现吓倒了我们。我从没有预想卡泰纳可以解决任何神经外科的案件,正如我不以为他会尝试心脏搭桥。 

但是，婴儿挨饿着。没有人能够给与帮助。卡泰纳犹豫着，思考着。他把超声波放在那个脑膨上面，它看起来像是充满了液体，没有太大的大脑。“我们将看我们能做些什么，”他答应了婴儿的母亲。 

那天晚上，我们在互联网上研究，通过可以用卫星上网的笔记本电脑。这医院有没有电话或电子邮件，但它有互联网。我们发现了一份文件，说明16宗脑膨案件的处理手法。大多数好像固定疝气那样，不必切入头骨，只需切开囊，把它绑起来，割掉，再修补头部的漏洞。任何大脑中的囊，通常都可切除。但最后一个步骤是个麻烦。要如何修复和防止再次发生脑膨？如何防止修补处泻漏？ 

我们从互联网上学到，大多数神经外科医师使用的植骨是从头骨，肋骨，或髋关节取来的。我们的孩子微小而畸形。卡泰纳不太愿意取骨：采取了一根肋骨，可能使肺穿孔;剃小头骨，可能会削太深而创建另一个洞，或造成大脑周围有出血现象。婴儿的臀部也可能没有太多骨。卡泰纳决定把重点放在切除脑膨，并希望有足够的材料修补缺陷。 

我们向孩子的母亲解释手术的风险：在行动中死亡，渗漏，受感染。期待她也许能够理解。 “让上帝做决定， ”她说。她来到手术室门口把她的儿子交给我们。 

在麻醉技师试图使孩子沉睡。他一开始时使用天然气，但将口罩并不适用于的巨大肿瘤之上。婴儿尖叫，撒尿，并严厉反抗他，努力要把我们赶走。技师把镇静剂推入静脉，然后迅速试图插管，但他不能把管插进去，而我们也没有人可以做得到。我们尝试了一个小时，孩子仍然不断的醒来尖叫。最后，我们只好放弃。让技师往他的静脉注射药物，希望他不会突然在手术中过程中停止呼吸。 

我推开胚囊上的皮肤。感觉就像触摸脑脊液和空气之间的唯一隔阂。卡泰纳小心的切割和去皮，暴露了装着水的脑膜。它破裂了。透明液体涌出，囊倒塌了。卡泰纳快速的工作，腾出组织，在婴儿的头骨中寻找漏洞。由于囊倒塌，我们看到了囊中的大脑碎片，看起来萎缩和苍白。 

最后，他找到了颅骨的缺损。巨大的，超过1英寸宽。嵴骨从顶端刺出，好像大脑从头骨中挤了出来。卡泰纳仔细捆绑了囊，小心的，没有影响到婴儿的脉冲或呼吸。卡泰纳明年以看起来似乎是膜的东西修补颅骨的孔，然后拉下头骨脊，缝合组织周围的缺损。当他完成后，这个洞被看起来像是骨的坚硬东西涵盖着了。卡泰纳接下来缝补皮肤。他把多余的皮肤修剪，并试图使婴儿的鼻子恢复正常形状。 

婴儿不久后醒来，在病房里，和他的母亲在一起。他哭喊，因为饥饿。他被喂食，没有发生呼吸不畅通的问题。他活过了这一晚。第二天早上，修补处也没有泄漏。他仍然活着，活过了几周，才出院回家。 

我离开苏丹的那一天，卡泰纳骑马送我到机场。半途中，一辆卡车介停我们。一个女人躺着，脸色苍白，目光呆滞。又是一个破裂了的宫外孕。卡泰纳伴随她回到医院，我独自去机场。花了将近一个星期才辗转回到家园。 

2011年，苏丹将会票选是否将维持一个国家或分裂为北方和南方。和我谈过天的大多数当地人担心将会发生另一场战争。卡泰纳决定留下来。他打算在苏丹停留许多年，动手术、治疗疟疾、并试图开始产前保健方案。 

病人常常抱怨传统医生消失了。那种可以治疗任何疾病、接生、并缝合伤口的普通医生。我也这样想。可是，在苏丹，我看到了一个训练有素的初级保健医师运行一所大型医院。我尝试想像像卡泰纳这样的医生在美国可以做什么？在这里有无数无法填补的家庭医生空缺，数以百万计的病人没有获得妥当的保健，而最聪明的医学院学生选择专攻皮肤科。我想他会感到震惊，我们有过剩的专家和庞大的保险官僚主义。但是，他将有很多工作。这里急需他。 

他，当然，更被苏丹迫切的需要。他献身于国际医学。怀着极大的热情和希望，他们对山区的苦难，坚持不懈地付出自己。

有兴趣和卡泰纳在苏丹中部工作的医生，请联络Hellen Mwangangi,hellen@doe.co.ke 。首选可以长期服务6个月或以上的医生，但任何帮助，我们将无任欢迎。

————————————————————

噢，原来没有注册看不到原文，我的电脑自动记忆注册名字和密码了，不好意思。

文取自：http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61931-5/fulltext

Always on call

Corry Chapman 

It was ten in the morning in central Sudan and already blistering hot. We nearly suffocated in our tiny clinic room. One window, no fan, and countless patients with malaria.

A young woman entered, wrapped head to toe in a dress and scarf despite the heat. She murmured her story in Arabic, staring at the ground. Her 3-month-old baby was sick. He had been born “different”, blind in one eye, his head too small, but a good eater with a strong cry. The bump on the bridge of his nose had at first seemed like nothing. Then it started to grow, and now he couldn't eat.

We asked to examine the baby. The woman reached into the folds of her dress and produced a bundle wrapped in yet another scarf. The bundle coughed. We saw the mass first, like a second head protruding from the baby's face, skin stretched tight from forehead to nostrils. It was so large that it obliterated the anatomy of his nose. It pressed on his nostrils, squeezing them shut. The mother put the squalling child to her breast. He couldn't breathe. He sucked, choked, cried.

Dr Tom Catena looked up from the baby to the woman. “I'm sorry”, he said in Arabic. “You need to go to Khartoum.”

She didn't respond. She struggled to breastfeed. We knew that she had no money, no transport. Khartoum was hundreds of miles away. But we also knew we were seeing a cephalocele, a protrusion of brain and fluid from a hole in the infant's skull, a hole he'd been born with. Fixing that hole was the job of a paediatric neurosurgeon, not two family medicine doctors.

Finally she looked back at Catena. “Please help”, she said. The baby screamed.

I worked with Catena for 5 weeks at Mother of Mercy Hospital in Sudan, in the remote Nuba Mountains, a wilderness reachable only by UN planes delivering food. It is an 80-bed Catholic hospital that serves a population battered by 50 years of civil war. It is also the only surgical hospital in central Sudan. Mother of Mercy opened in March, 2008, with a permanent physician staff of one: Catena. He is an American doctor who has worked in Africa for a decade, first in Kenya, now Sudan. He trained in family medicine in the USA and in general surgery in Kenya. He is the hospital's medical director and the only one who applied for the job. He arrived on site a week before the hospital opened.

“It was a nightmare”, he told me. “We had 7 days to get the place going. We learned as we went. None of us had set up a hospital before.”

He recounted how hundreds of patients showed up on opening day. Hundreds more came the next day, and the next. They presented with malaria and pneumonia, with injuries, and in shock. They came after days of failed labour, usually with a baby dead and wedged in the birth canal. They arrived at all hours, in the hottest and driest time of the year, often walking weeks to reach the hospital. They waited hours to be seen, overflowing the hospital's courtyard. For 15 Sudanese pounds (about US$7), the sickest people were admitted and paid nothing more. Some stayed for months, recuperating from major surgery or waiting for a bone to mend. They crowded the wards of the hospital, a chaos of mosquito nets, intravenous poles, wailing babies, skulking dogs, oppressive heat, and the stench of unwashed bodies.

Those first months took a toll on Catena. He got malaria twice. He dropped 50 pounds. He never left the compound. Surgical emergencies arrived daily, often nightly. Catena worked in an isolated region with no cities or government and no other doctors nearby. He managed a hospital that relied on solar power, pumped water, and pit latrines, its small storehouse of supplies replenished only twice a year by cargo plane from Nairobi. Everything was limited, nothing could be wasted. Catena stretched his drugs, suture, and physical energy as far as they could go to treat overwhelming need. It nearly broke him, but the effort paid off. By the time I arrived, the crowds were still large but manageable and the hospital ran well.

On my first day there I saw one patient with leprosy, two with tuberculosis, and 50 with malaria. We removed a man's prostate because he could not urinate. We admitted a baby with meningitis, the top of her head bulging and tense. Over the next few weeks, I saw diseases that I see in the USA: diabetes, hypertension, stroke. I also saw bowel parasites, pus-filled eyeballs, starvation, and goat faeces poked up a girl's nose to stop a nosebleed (a local remedy).

We operated a lot: an emergency caesarean section when we delivered a premature baby and strapped him between his mother's breasts to keep him warm and alive, ruptured ectopic pregnancies, many urological operations, some bowel surgery, a thyroid operation. We amputated legs and fingers. Sometimes during an operation a fly would settle on exposed bowel or muscle. The anaesthesia technician had to chase it around the room, trying to kill it.

I quickly grew tired of drinking only tepid water or hot tea; of lentils and rice for dinner; of working all day and sometimes all night, and then, when I had free time, of having nothing to do and nowhere to go. Most of all it was the heat that got to me, sweltering on my cot under a mosquito net, dreaming of cold beer.

The patients seemed only to tolerate us. They didn't trust us any more than they trusted the genocidal government in Khartoum. They needed help and were resigned to our care. No teary thank yous, no smiles even; just sullen silence. When we asked family members to give blood for an operation, they flatly refused and some even fainted. The patients did not wash their wounds, which promptly became infected. They spat everywhere. The nurse aides, also Nuba, barked at those who were sick like they were animals, occasionally swatting them on the head. Getting a history of a disease or injury was almost impossible, even with four nurse aides shouting Arabic at a patient whose only response was a click of the tongue.

The hospital laboratory did five or six basic tests, including blood smears for malaria and haemoglobin for anaemia. The pharmacy dispensed painkillers, three antibiotics, a few chemotherapeutic drugs, and loads of antimalarials. Catena carried a portable ultrasound machine, his only means of looking inside someone's body since we had no X-rays.

By my third week, I fully appreciated the limitations of Mother of Mercy Hospital, but I had also seen Catena work wonders every day, doing things it would take a team of specialists to accomplish back home. I thought he could handle almost anything. Then the baby with the cephalocele showed up. It intimidated both of us, I think; I know it scared me. I didn't expect Catena to tackle neurosurgery any more than I thought he'd attempt a cardiac bypass.

But the baby was starving. No one else could help. Catena hesitated, thinking. He put the ultrasound to the mass, which mostly looked like it was full of liquid. Not much brain. “We will see what we can do,” he promised the mother.

That night we researched the case on the internet, which came to us via satellite on a laptop. The hospital has no telephone or mail but it does have the internet. We found a paper describing 16 cephalocele repairs. Most had been fixed like hernias, without having to enter the skull. Simply dissect the sac, tie it off, remove it, and patch the hole in the head. Any brain in the pouch was usually scarred and resectable. But the last step was the problem. How do you repair the defect and prevent reoccurrence? How do you prevent leaking?

We learned from the internet that most neurosurgeons use bone grafts taken from the skull, rib, or hip. Our baby was tiny and deformed. Catena didn't feel comfortable harvesting bone: take a rib and you might perforate the lung; shave off a little skull and you might go too deep, create another hole, or cause bleeding around the brain. There was probably not much bone in the baby's hips. Catena decided to focus on the resection and hope there was enough material around the defect to make a decent patch.

We explained the risks of surgery to the child's mother:death during the operation, leakage, infection. Maybe she understood. “It's up to God,” she said. She came to the operating room door to hand over her son.

The anaesthesia technician tried to sedate the baby. He started with a gas, but the facemask would not fit over the huge mass. The baby screamed, urinated, and flailed his arms, fighting us off. The technician pushed an intravenous sedative, then quickly tried to intubate him, but the tube would not go in. None of us could do it. We tried for an hour, the baby often waking up and screaming. Finally we gave up. The technician knocked him out with intravenous medicine alone, hoping he wouldn't suddenly stop breathing during the procedure.

I prodded the skin over the sac. It felt like the only barrier between cerebrospinal fluid and room air. Catena carefully incised it and peeled it back, exposing a meninges-like membrane pregnant with fluid. It ruptured. Clear liquid poured out, deflating the sac. Catena worked fast, freeing up tissue, searching for the hole in the baby's skull. As the sac collapsed, we saw fragments of brain inside, which looked shrunken and pale.

Eventually he exposed the cranial defect. It was large, more than an inch wide. A sharp ridge of bone jutted up from the top of it, as though the brain had burst through the skull. Catena carefully tied off the sac, cut and removed it without a change in the baby's pulse or breathing. Catena next tried to patch the hole by stitching together what appeared to be membrane and then pulling down the skull ridge, suturing it to tissue around the defect. When he finished, the hole was covered by bone and what felt like firm tissue. Catena closed the skin next. He trimmed the excess and tried to return a normal shape to the baby's nose.

The baby woke up shortly afterwards, out in the ward with his mother. He cried, hungry. He fed without choking. He lived through the night. The next morning, there was no leak. He was still alive and doing well weeks later, and was discharged home.

The day I left Sudan, Catena rode with me down to the airstrip. Halfway there, a truck coming the other way flagged us down. A woman lay in the back, pale and listless, staring up at nothing. Another ruptured ectopic pregnancy. Catena accompanied her back to the hospital and I caught my plane. It took me nearly a week to get home.

In 2011, Sudan votes on whether it will remain one country or separate into north and south. Most people I talked to there fear another war. Catena is staying. He expects to be in Sudan for years, operating, treating malaria, and trying to start a prenatal-care programme.

My patients often bemoan the disappearance of the traditional doctor, the general practitioner who could treat any ailment, deliver babies, and stitch wounds. I do too. In Sudan, I saw a single well trained primary-care physician run a large hospital. I try to imagine what a doctor like Catena could do in the USA, where family medicine residencies cannot fill their slots, millions go without health care, and the best and brightest medical students want to be dermatologists. I think he would be appalled by our glut of specialists and our huge insurance bureaucracy. But he would have plenty of work. He is sorely needed here.

He is, of course, sorely needed in Sudan too. He is one of those remarkable physicians who dedicate their lives to international medicine. With great passion and hope they pit themselves against mountains of suffering, tirelessly chipping away.

Physicians interested in working with Dr Catena in central Sudan should contact Hellen Mwangangi at hellen@doe.co.ke. Long-term commitments of 6 months or longer are preferred, but any help would be welcome.

不幸的诚实

发生了不幸的错误，难听的话，硬着头皮，还是得说。我请加护病房的护士把家属请进来。

“这位先生，你是陈先生的家属吗？”

“我是他的儿子。我爸爸的情况怎么样了？”

“坦白说，他的情况不怎么好。你可以先告诉我他在病房里，也就是进来加护病房前的情况吗？”

“他今天早上还有说有笑。医生也说其实他今天并没有住院的必要。只不过是来放置静脉留置导管而已，之后就可以回家了。”

“嗯，后来呢？”这一些都在记录之中，不过，仍要向家属确定一下。

“病房里人很多，大家看起来都很忙。我们等了很久，直到傍晚才轮到我爸爸。其实他进去很久，刚刚被推出来时也没怎么样，只是说有一些头晕要休息一下，后来就开始气喘了。”

“病房里的住院医生有没有向你解释他的情况呢？”

“有啊！不只是他，还有肾科专科医生。他们已经告诉过我发生了什么事，也向我们道歉。说是放置静脉留置管的过程中出了差错，伤了静脉，血积在肺叶中，如果不能及时止血，会有生命危险。”

“是的。”他的冷静出乎我的意料之外，也很让我感到庆幸，不需要面对那一种一发不可收拾的场面。“他们说的没错。你父亲的失血过多，到目前为止我们已经输入了九袋红血球，但情况还是很不稳定，恐怕不太乐观。”

这个时候，Dr. S走入加护病房。

“这位是？”

“是xxx的儿子。陈先生，这位是我们的值班的专科医生。”

“陈先生来的正好。我们需要到会议室里谈一谈。CCC，你也一起过来。”

我们三个人于是走入了加护病房旁宽阔而安静的会议室。

“陈先生，在你父亲身上发生的事，我感到很抱歉。其实放置静脉留置管这一个小手术，我们这里每一天都进行好几单，而且都是在超音波引导之下进行的，从来没有出过像发生在今天发生在你父亲身上这样的事。”

“我明白。我知道这一种事情是很难预料的。在他之前那位放置静脉留置管的老先生都好好的，真不知道轮到我爸爸时怎么会这样。”

“正是。我很高兴你这么明白事理。发生这样的事，真的很不幸。我推想应该是你父亲的血管和其他人不太一样造成的。”

“血管不一样？怎么说呢？”

“你的父亲患上糖尿病十多年了，不是吗？”

“对呀！对呀！”

“糖尿病患者的血管往往比其他人来得细小。”

“那倒是。我父亲平常住院都很难安针放药的。”

“那就对了。用来洗肾的静脉留置管比平常打点滴注射药物的留置管要大得多了。这样一来，当我们把留置管推进他的静脉时，无可避免的就会造成伤害。”

“这么说，不是他们说的那样在放置时发生失误？”

现场忽然安静了几秒。

“呃，这一点很难说，是有这一种可能性，不过，我认为，主要是你父亲的静脉不同于其他人的缘故。”

“... ...”

“无论如何，现在怎么办？他还在流血，不能止血吗？”呼，终于有台阶可以下。

“因为失血过多，引发了并发症，很难止血。我们希望可以靠输入血小板和血清来帮助止血，这样或许可以送入手术室，尝试开刀修复伤口。”

... ...

陈先生离开了之后，

“CCC，刚才是你告诉他这个情况是我们的失误引起的吗？”

“我... ...是的。”

“你太没有经验了。怎么可以那么样说？你知道这可能引起一场诉讼吗？”

“可是... ...可是... ...其实在病房里，我们已经向他们认过错了。”

“你们都太嫩了。CCC，以后你要记住，无论如何，不可以对病人或家属承认这种医疗错误，知道吗？这样做，有损我们的专业形象，后果可以是很严重的。”

长辈的经验之谈真的就错不了吗？诚实真的会招来不幸吗？让我值过了明晚的夜班，下一次，也许再说另一个不幸的诚实故事。

不幸的错误

碰见倒下了的他，地点在加护病房，时间是晚上十时许。

阿伯因糖尿而肾亏，才开始私人医院洗肾一个星期，因为插针处跑位而红肿，不能继续洗肾，只好跑过来中央医院求医。

那是一个不幸的傍晚。我的同事在他的颈项上放置了静脉留置导管后大约一小时，阿伯就开始气喘了。一检查之下，发现他脸色苍白，左胸腔下方积液。紧急放置了胸腔管，新鲜的血液登时涔涔流出（证实了所积之“液”实为血液）。过度失血引发了泛發性血管內血液凝固症。为此，他被转入了加护病房。即使输了很多红血球、血小板、血浆和无数的盐水，他的情况仍然不稳定，修复手术的风险实在太大了。

我的责任则是把这一个不幸的消息告诉他的家人。

“... ...”

发生这样不幸的事，谁也不愿意。病人步行进来，躺着出去，对家属、对医疗人员，都是很大的打击。

承认一个错误需要多大的勇气？承认一个医疗错误，又需要多大的勇气？

如果你的医生向你认错，你会怎么样反应？如果你是我，你会选择怎么婉转相告？