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。○(-_-)○

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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。

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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.