雙語·當呼吸化為空氣 我的住院醫(yī)生同事杰夫和我一起合作治療創(chuàng)傷

我的住院醫(yī)生同事杰夫和我一起合作治療創(chuàng)傷。每次創(chuàng)傷室那邊有并發(fā)的腦損傷，他就叫我過去，我倆的行動一向很默契。他檢查腹部，然后問我對病人的認知功能有什么判斷?！班?，他要是想，還是可以做參議員的，”有一次我如此回答，“不過只能去個比較小的州了?！苯芊虼笮?，從那時起，一個州的人口就成為我們描述腦損傷嚴重程度的指標。“他是懷俄明還是加利福尼亞？”杰夫這么問，決定給病人制訂什么程度的治療方案?；蛘呶铱赡軙f：“杰夫，我知道他的血壓還很正常，但我要給他做手術，不然他就要從華盛頓變成愛達荷了，你能把他穩(wěn)一穩(wěn)嗎？”
My fellow resident Jeff and I worked traumas to-gether. When he called me down to the trauma bay because of a concurrent head injury, we were always in sync. He’d assess the abdomen, then ask for my prognosis on a patient’s cognitive function. “Well, he could still be a senator,” I once replied, “but only from a small state.” Jeff laughed, and from that moment on, state population became our barometer for head-injury severity. “Is he a Wyoming or a California?”Jeff would ask, trying to determine how intensive his care plan should be. Or I’d say, “Jeff, I know his blood pressure is labile, but I gotta get him to the OR or he’s gonna go from Washing-ton to Idaho—can you get him stabilized?”

一天，我在餐廳吃著常吃的午餐，健怡可樂加冰激凌三明治。突然呼機響了，說馬上要來一個重傷病人。我跑到創(chuàng)傷室，剛把冰激凌三明治藏在一臺電腦后面，急救車就到了，急救員們推著輪床，連珠炮似的交代情況：“二十二歲，男性，摩托車事故，時速四十英里，鼻孔流出液體，疑似腦漿……”
In the cafeteria one day, as I was grabbing my typical lunch—a Diet Coke and an ice cream sandwich—my pager announced an incoming major trauma. I ran to the trauma bay, tucking my ice cream sandwich behind a computer just as the paramedics arrived, pushing the gurney, reciting the details: “Twenty-two-year-old male, motorcycle accident, forty miles per hour, possible brain coming out his nose. . . ”

我立刻開始工作，叫人給我拿了個插管托盤，檢查其他的體征。安全插管之后，我檢查了他身體多處的創(chuàng)傷：臉部淤青，皮肉擦傷，瞳孔放大。我們給他注射了很多甘露醇，減輕腦腫脹，急急忙忙地推他去照片子：顱骨碎裂，活動性大出血。我心里已經在規(guī)劃開顱手術了，該怎么鉆開顱骨，把血抽出來。他的血壓突然下降了。我們又迅速把他推回創(chuàng)傷室。創(chuàng)傷團隊的其他人剛剛趕到，他的心跳就停止了。在他周圍，各種各樣旋風般的行動迅速進行：很多導管插入他的股動脈，深入他的胸腔，靜脈上注射著藥物；與此同時，醫(yī)生的拳頭捶打著他的心臟部位，保持血液流通。三十分鐘后，我們停了手，任他完成死亡的過程。大家都意見一致地低語：腦部受這么重的傷，死了其實更好。
I went straight to work, calling for an intubation tray, assessing his other vital functions. Once he was safely intubated, I surveyed his various injuries: the bruised face, the road rash, the dilated pupils. We pumped him full of mannitol to reduce brain swelling and rushed him to the scanner: a shattered skull, heavy diffuse bleeding. In my mind, I was already planning the scalp incision, how I’d drill the bone, evacuate the blood. His blood pressure suddenly dropped. We rushed him back to the trauma bay, and just as the rest of the trauma team arrived his heart stopped. A whirlwind of activity surrounded him: catheters were slipped into his femoral arteries, tubes shoved deep into his chest, drugs pushed into his IVs, and all the while, fists pounded on his heart to keep the blood flowing. After thirty minutes, we let him finish dying. With that kind of head injury, we all murmured in agreement, death was to be preferred.

我溜出創(chuàng)傷室，他的家人正好被領進去認尸。我突然想起來，我的健怡可樂，我的冰激凌三明治……創(chuàng)傷室又那么悶熱。急診室一個住院醫(yī)生幫我打了掩護，我像個幽靈似的溜了回去，從那個我救不了的病人的尸體前，把冰激凌三明治“救”了出去。
I slipped out of the trauma bay just as the family was brought in to view the body. Then I remembered: my Diet Coke, my ice cream sandwich. . . and the sweltering heat of the trauma bay. With one of the ER residents covering for me, I slipped back in, ghostlike, to save the ice cream sandwich in front of the corpse of the son I could not.

在冰箱里凍了三十分鐘，三明治算是“滿血復活”了。我一邊想，挺好吃的，一邊把卡在牙縫里的巧克力碎屑給弄出來。而死者的家人正在那邊做最后的道別。我在想，短暫的從醫(yī)生涯以來，我的道德觀，是后退了，還是進步了？
Thirty minutes in the freezer resuscitated the sandwich. Pretty tasty, I thought, picking chocolate chips out of my teeth as the family said its last goodbyes. I wondered if, in my brief time as a physician, I had made more moral slides than strides.

幾天后，我聽說醫(yī)學院的一個朋友勞里被車撞了，一個神經科醫(yī)生做了手術，試圖救她的命。她昏迷過去，又醒了過來，第二天去世了。我不想再往下聽了。以前聽這種事情，總是一句簡單的“車禍喪生”就不會再去想其他的，現(xiàn)在那樣的日子一去不復返了?，F(xiàn)在聽到一句“車禍喪生”，就像打開了潘多拉的魔盒，各種各樣的畫面一起涌上來：輪床急速向前，創(chuàng)傷室的地上鮮血淋漓，導管插入她的喉嚨，拳頭不斷捶打她的胸腔。我仿佛看見一雙手，我的手，剃著勞里的頭發(fā)，手術刀割開她的頭顱；耳邊有鉆子的嗡嗡聲，骨頭的焦煳味，鉆開時飛揚的微塵，撬開她一小塊頭骨時那裂開的聲音。她的頭發(fā)被剃掉了一半，她的頭部完全被拆解了。她再也無法變成完整的自己了，她的朋友和家人都認不出她了。也許她身上還插了胸管，一條腿上做了牽引……
A few days later, I heard that Laurie, a friend from medical school, had been hit by a car and that a neurosurgeon had performed an operation to try to save her. She’d coded, was revived, and then died the following day. I didn’t want to know more. The days when someone was simply “killed in a car accident” were long gone. Now those words opened a Pandora’s box, out of which emerged all the images: the roll of the gurney, the blood on the trauma bay floor, the tube shoved down her throat, the pounding on her chest. I could see hands, my hands, shaving Laurie’s scalp, the scalpel cutting open her head, could hear the frenzy of the drill and smell the burning bone, its dust whirling, the crack as I pried off a section of her skull. Her hair half shaven, her head deformed. She failed to resemble herself at all; she became a stranger to her friends and family. Maybe there were chest tubes, and a leg was in traction. . .

我沒有詢問細節(jié)。畢竟已經見過太多了。
I didn’t ask for details. I already had too many.

那一刻，我心里突然涌現(xiàn)出自己毫無同情心的一幕又一幕：我對病人萬分擔憂的心情不管不顧，急著勸他們出院；別的事情忙不過來的時候，我忽略病人的痛苦；我觀察病人的病狀，記下來，做出自以為準確的各種診斷，卻并沒有看到深層的病因——后來這些病人總是不斷出現(xiàn)在我的回憶中，滿懷復仇的怒火，不屈不撓。
In that moment, all my occasions of failed empathy came rushing back to me: the times I had pushed discharge over patient’s worries, ignored patients’ pain when other demands pressed. The people whose suffering I saw, noted, and neatly packaged into various diagnoses, the significance of which I failed to recognize—they all returned, vengeful, angry, and inexorable.

我怕自己即將成為托爾斯泰筆下那種很典型的醫(yī)生，沉浸于空洞的形式主義，診斷時只會生搬硬套，完全忽略更大程度上的人性意義。（“醫(yī)生們來看她，有時各人單獨地來，有時大家舉行會診，用法語、德語、拉丁語說很多的話，他們互相批評，按照他們看得出來的病征開出各種各樣的藥方，但是他們當中沒有一個人想到那個簡單的道理，就是他們完全不能夠了解娜塔莎病中的痛苦。”）一位剛被診斷出腦瘤的母親來找我。她很困惑、很恐懼，完全不知所措。當時的我筋疲力盡，全然不把她放在心上。我匆忙地回答了她的問題，向她保證手術一定會很成功，也安慰自己說沒時間詳細地解答她所有的問題。但我為什么沒有抽出時間呢？曾經有個脾氣特別暴躁的獸醫(yī)病人，拒絕眾多醫(yī)生、護士和理療師的勸告，結果，他背上的傷口破裂了，正如我們警告的那樣。我當時在手術室，被叫了出去，幫他縫好裂開的傷口。他痛得嗷嗷大叫，我心想：他活該。
I feared I was on the way to becoming Tolstoy’s stereotype of a doctor, preoccupied with empty formalism, focused on the rote treatment of disease—and utterly missing the larger human significance. (“Doctors came to see her singly and in consultation, talked much in French, German, and Latin, blamed one another, and prescribed a great variety of medicines for all the diseases known to them, but the simple idea never occurred to any of them that they could not know the disease Natasha was suffering from.”) A mother came to me, newly diagnosed with brain cancer. She was confused, scared, overcome by uncertainty. I was exhausted, disconnected. I rushed through her questions, assured her that surgery would be a success, and assured myself that there wasn’t enough time to answer her questions fairly. But why didn’t I make the time? A truculent vet refused the advice and coaxing of doctors, nurses, and physical therapists for weeks; as a result, his back wound broke down, just as we had warned him it would. Called out of the OR, I stitched the dehiscent wound as he yelped in pain, telling myself he’d had it coming.