"我就是想让他活下来!"

2016-04-26 殳儆 医学界

导读:医生对治愈的渴望是这个职业最原始的驱动力;零的突破那种欢欣和喜悦,是为了挑战难度的技术突破,也是为了病人的新生。 我是一个ICU医生,一个工作了18年的ICU医生,做成第一例ECMO一直在我的短期计划中。 为什么这么向往做ECMO?因为它就像神奇的兵器倚天剑。处于精力体力巅峰状态的武士一定会向往有机会用它来建功立业,印证自己半生的经验和技艺。 这样繁复的操作

导读:医生对治愈的渴望是这个职业最原始的驱动力;零的突破那种欢欣和喜悦,是为了挑战难度的技术突破,也是为了病人的新生。

我是一个ICU医生,一个工作了18年的ICU医生,做成第一例ECMO一直在我的短期计划中。

为什么这么向往做ECMO?因为它就像神奇的兵器倚天剑。处于精力体力巅峰状态的武士一定会向往有机会用它来建功立业,印证自己半生的经验和技艺。

这样繁复的操作和管理,要在一片空白中做成第一次是不容易的。天上的星太亮,地上的坑太多,一个医生,担负着重要的责任用技术来探险,需要机会,也需要勇气。

我所说的机会最主要是指合适的病人:ECMO是人工的心肺替代,它适合青壮年突发急病,心肺功能崩溃的病人,又必须有充足的经济来源,没有十几二十万人民币的保证,没法上机。

江浙一带,经济发达。通常中青年突发的急症,家庭又有经济能力,家属会非常焦虑,惶急中会发动各种社会关系打招呼,请会诊,商量转院。而疾病的胶着状态会持续几周,在起起伏伏的病情变化中,心志坚定百折不回与医生配合度高的家属并不太多。

所谓勇气,就是医生要面对危重疾病的各种不确定因素,面对每一刻都可能死亡的漫长等待,面对家属的焦虑和纠结。面对各方的期待。

在医患关系非常糟糕的现状下,最明哲保身的做法是劝这样的危重病人转到浙一这样的大医院去。所以一个市级医院的ICU医生想要做成第一例ECMO必须有承担各方压力的心理准备。

我等候那样的机会,已经3年。从负责H7N9抢救的2013年,一直等到我跳槽离开公立医院的那一天。这是横亘在我心里的一件重要的事。时间越久,这桩心事越尖利,在每一次参加大型的学术会议,每一次听别的ICU医生做ECMO交流的时候都会戳痛我,有点死不瞑目的感觉。

离开市一医院那一日,我去库房看望没有拆封的ECMO机器,它仍然盖在塑料布下面静候着,我心里的遗憾难以言表。这个机器,是市里为了抢救危重的H7N9病人拨款100多万买入的。我身为主帅,看着它,心里横亘着那个愿望,却没有机会利剑出鞘一次。跳槽出去以后,能做成的希望恐怕更加渺茫,只能寄希望于我的兄弟们继续努力了。

不过希望就像埋在沙漠里的种子,一有机会立刻会发芽成长。

2016年年初。老张收入的那个早上,我盯着参数已经非常高的呼吸机,心里快速策划着上ECMO的可能:

病人才五十多岁,体格强壮,没有慢性疾病。不慎吸入了大量刺激性气体,肺部损伤非常严重。常规呼吸机已经快支撑不住。以他的年纪和康复能力,正是最适用ECMO的病人。

病人的单位非常关切他的病情,不计代价地支持抢救,有足够经济上的支持。而且病人的家庭结构较为简单,单位领导和病人的亲属非常理解和信任医生。

这是上ECMO非常有利的条件。

困难当然也很多:我们医院没有机器,ECMO机器需要借,全市只有那一台。百多万的机器,是立时三刻就可以拿来的吗?

支援的技术团队需要外请;即使有坚强的后援,ECMO的运行过程需要全部自行管理,直到病情好转。这就象飞机,起飞的时候有人帮助,飞翔和降落需要完全自主进行。这个病情进展的时间跨度几天还是几周,要看天意;我这个没有驾驶过的飞行员能平安着陆吗?

而且我跳槽后新组建的ICU团队,系统训练才一年多。我的“管家婆”护士长刚30岁,很多护士刚工作3年。大部分成员还不具备成熟的专科能力。

对我这样一个跳槽私立医院的医生而言,失败会造成的名誉上的损失。毕竟ECMO是那样引人瞩目的事情。

但是病人已经不具备转院的可能性,转运的呼吸机支持不住那样重的病人,两个小时的转运,他会缺氧死在路上。而且病情还在继续快速发展,用常规机械通气顶过肺水肿高峰的机会非常渺茫。

不能等,也不能转,除了做ECMO外,似乎没有别的选择。

一切,只在于我的决心。下决心只在一瞬间。

放下一切,立刻开始准备。动用所有的能量去筹备这件事:借机器,请支援,临阵磨枪翻资料,联系管路耗材。医院全力支持我,为了赶时间,医务科长和设备科长让医院派车,两个人立刻出发去市一医院借机器。设备,后勤,护理,很多部门快速响应帮我办这桩事,让我可以把精力全部放在治疗上。

待到万事俱备,磕磕绊绊终于上机运行的时候,已经入夜,8个小时过去了。

万幸,ECMO开始正常运行。床边拍片显示:在这8个小时中,病人的肺部状况继续恶化,没有8个小时前下的决心,这个夜晚将以病人的缺氧死亡终结。我的决定正确。

但是还没有完,严重的毒气吸入,肾功能同时出现问题,尿量极少。于是立刻又在ECMO上串联了一个CRRT机。

呼吸机,ECMO,CRRT,B超机。每个来上班的ICU护士妹妹,看着这前所未有的“排场”,都有倒吸一口冷气的表情。



兴奋,焦虑,小心翼翼,充满盼望,是团队每一个人的情绪。第一次,就和奥运金牌零的突破是一样的感觉:象征意义太大,令人倍感压力。如果天天有几台ECMO在持续运转中,不断有人上机下机,熟极而流,习以为常就不会有那样的心理压力。

疾病的胶着阶段会持续多少天,是一个未知数。中间会不会有意外的变故,致死性的并发症,会不会有机器运转上的异常,都不知道。

所有人都紧张地盯着每个细节。每天的查房就像在阅兵。护士长领着当班护士拿着核查表,两眼瞪大了,从头查到脚。从早上交班,查到晚上交班。

病人处于深度镇静状态,天罗地网的管道和机器,让每天探视的家属和单位同事不敢走近。远远看这都是震惊的表情,小心翼翼地问:医生,他能活下来吗?

不,我也不知道,若没有这些天罗地网,他已经死了,现在他还有可救的机会。床边胸片的结果出来:两肺白茫茫的渗出。正在疾病的极期。

记得一年前我曾经在晨会上放浙二医院急诊ICU的照片,病人上着ECMO+CRRT,需要不断用超声评估容量。我问科室的护士们:妞们,敢不敢在这么天罗地网的状态里上一个班。有没有能力保证你这个班没有失误。保持呆萌的大小姑娘们吐吐舌头不说话,干脆戴上口罩,不让我看见表情。

现在,呆萌表情的大小姑娘们很亢奋,不计精力体力地投入,上班时时刻刻瞪着大眼睛忙活,目标是“我就是想他活下来”。下班忙着临阵磨枪。用她们的话来说:做梦都在训练换耦合剂。

很多同事,在早晨路过ICU的时候,站在门口看一下。问一句:怎么样了?

我的原单位,迅速借出ECMO的市一医院,也在关注我的进展。所有的好奇和关切,都汇聚成隐隐的压力。

上机的第三天,那个星期天状况频发。病人的肺水肿进入高峰期,大量的黄色渗液从气管插管中不停外溢。

然后ECMO的引血管道出了点状况,出现异常的抖动。又是拍片,又是B超。刚处理停当。紧接着,下午ECMO机器突然停转,面板死机。一阵兵荒马乱,四脚朝天。

当我赶到床边的时候,机器已经重新启动。用护士小兰的话说:吓得怕都不会了,马上用手动模式转机,现在才知道脚软。

状态频出的星期天,一帮人都焦虑地注视着监护仪,呼吸机,ECMO的种种参数。医生下了班都逗留在病房,不想离去。胶着状态是最难的。抗凝开始出现这样那样的问题;机器故障;每天紧盯着炎症指标。盯着CRRT的脱水,盯着膜肺上的小血栓。盯着越来越大的镇静剂剂量。病情没有半分转机,心理上真是煎熬。

看着蔚为奇观的机械通气状态,气管插管和呼吸机管道里全是肺泡渗出的黄水。我象解数学题一样发一会儿呆,就知道可以怎么做了。一个成熟的ICU医生,对危重病人的病理生理足够熟悉,解题能力足够驾驭它。我调整完参数,嘱咐完晚上需要注意的事项,就回去了。

病人的儿子,在门外的长凳上已经睡了3天。隆冬的夜晚,裹着棉被。他看不见病人的状况,也不敢看。没有什么事情可以做,但是坚决不肯离去。关切因此焦虑。但是,我不能焦虑。

现在的整个ICU团队都是枕戈待旦的战士。于我而言,18年的ICU医生生涯,已经懂得把所有焦虑,急切,担忧等负面情绪变成坚决的表情。三军的军心,此时最需要我来抵抗压力。

谋事在人,成事在天。我要做的,是平静应对所有麻烦,给团队信心。

眼睛干涩中,迎来第四天。病情出现明显好转,病人的肾功能大为改观,尿量增多,顺利地撤掉了肾脏替代的CRRT机。气管插管内发大水一样的冒黄水迅速停止。整个病情象雨后见到彩虹一样的感觉。

第五天,终于可以撤机。没有血管外科的我们,撤机也是磕磕绊绊十分艰难。但是终于平安结束了ECMO。只待肺的进一步好转,最后拔掉气管插管了。

过了麻烦频出的那个星期天,病情一路顺风顺水,顺利得出奇。病人撤除了镇静药物,醒了过来,拔掉了气管插管。拔管的时刻,听到偌大的ICU,护士妹妹的欢呼从各个方向传来。

10天以后,好转离开重症监护室。这个壮汉茫然地看着我们围着他,完全不知道生命在悬崖上走了那么久。

他的床位离开ICU的时刻,重新平静的ECMO机器在病房的角落,等待归还。

用过了它,经历了这一程,我已经彻底明白:机器并非王道,治愈病人最终考验的还是医生,考验重症医学团队同质化的整体质量。ECMO就像一样倚天剑,用得好与不好,在于武士的功力,和人剑合一的相得益彰。面对全新的东西,难的是技术,难的是整合能力,难的是心理的抗压能力,难的是综合分析能力。

经历完这一程,我们的新团队就像大树,过完寒冬,又粗大了一轮。底气强健了不少。

这是本市第一例成功的VV-ECMO。

那天,我的微信被很多同事转发,现在医院的,和原单位的。是,周边的地区都已经成功开展了ECMO,我们的起步已经晚了些许,越是如此,越是渴望。

医生对治愈的渴望是这个职业最原始的驱动力;零的突破那种欢欣和喜悦,是对挑战难度的技术突破,也是对着病人的新生。成功完成了第一例ECMO,就像成功拔掉了我心头的一条刺。从此可以更客观,更稳定,更自信地去评估这项技术,圆转如意地使用倚天剑。

在完成任务以后,写下本文,写下在一样新技术面前,一个ICU医生的盼望,坚持和领悟。

谨此感谢浙江省人民医院体外生命支持中心的大力协助。

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    2020-01-25 林晓1193

    厉害

    0

  2. 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createdName=1e145228m78(暂无匿称), createdTime=Sat Jun 23 11:47:28 CST 2018, time=2018-06-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=326115, encodeId=bc99326115f6, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Fri Jun 22 14:17:19 CST 2018, time=2018-06-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=297388, encodeId=cd5929e3880a, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Sun Mar 18 11:00:10 CST 2018, time=2018-03-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=293996, encodeId=3ba62939963e, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Thu Mar 08 01:07:50 CST 2018, time=2018-03-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=293266, encodeId=a599293266ee, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Mon Mar 05 16:08:43 CST 2018, time=2018-03-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279949, encodeId=f2ce2e9949cf, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRvvXNvY0kOJqn4liar3Q6V6yPuEIawCVUyP3jVADh5icIz0ibrsxia6fKAqKsDr33jPWrjqM3D7wcRNu/0, createdBy=5a881701729, createdName=小树熊, createdTime=Fri Jan 19 07:21:55 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=128378, encodeId=00b91283e8eb, content=天职啊。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f1271950233, createdName=优质青年, createdTime=Fri Sep 16 07:25:00 CST 2016, time=2016-09-16, status=1, ipAttribution=)]
    2019-11-14 147455d6m36暂无昵称

    开卷有益

    0

  3. 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likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Mon Mar 05 16:08:43 CST 2018, time=2018-03-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279949, encodeId=f2ce2e9949cf, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRvvXNvY0kOJqn4liar3Q6V6yPuEIawCVUyP3jVADh5icIz0ibrsxia6fKAqKsDr33jPWrjqM3D7wcRNu/0, createdBy=5a881701729, createdName=小树熊, createdTime=Fri Jan 19 07:21:55 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=128378, encodeId=00b91283e8eb, content=天职啊。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f1271950233, createdName=优质青年, createdTime=Fri Sep 16 07:25:00 CST 2016, time=2016-09-16, status=1, ipAttribution=)]
    2018-06-26 1e145228m78(暂无匿称)

    学习了.谢谢作者分享!

    0

  4. 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likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Mon Mar 05 16:08:43 CST 2018, time=2018-03-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279949, encodeId=f2ce2e9949cf, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRvvXNvY0kOJqn4liar3Q6V6yPuEIawCVUyP3jVADh5icIz0ibrsxia6fKAqKsDr33jPWrjqM3D7wcRNu/0, createdBy=5a881701729, createdName=小树熊, createdTime=Fri Jan 19 07:21:55 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=128378, encodeId=00b91283e8eb, content=天职啊。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f1271950233, createdName=优质青年, createdTime=Fri Sep 16 07:25:00 CST 2016, time=2016-09-16, status=1, ipAttribution=)]
    2018-06-23 1e145228m78(暂无匿称)

    学习了.谢谢作者分享!

    0

  5. 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GetPortalCommentsPageByObjectIdResponse(id=327201, encodeId=d07b32e2019b, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Tue Jun 26 17:29:40 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=326336, encodeId=7b0a3263366b, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Sat Jun 23 11:47:28 CST 2018, time=2018-06-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=326115, encodeId=bc99326115f6, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Fri Jun 22 14:17:19 CST 2018, time=2018-06-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=297388, encodeId=cd5929e3880a, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Sun Mar 18 11:00:10 CST 2018, time=2018-03-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=293996, encodeId=3ba62939963e, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Thu Mar 08 01:07:50 CST 2018, time=2018-03-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=293266, encodeId=a599293266ee, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Mon Mar 05 16:08:43 CST 2018, time=2018-03-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279949, encodeId=f2ce2e9949cf, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRvvXNvY0kOJqn4liar3Q6V6yPuEIawCVUyP3jVADh5icIz0ibrsxia6fKAqKsDr33jPWrjqM3D7wcRNu/0, createdBy=5a881701729, createdName=小树熊, createdTime=Fri Jan 19 07:21:55 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=128378, encodeId=00b91283e8eb, content=天职啊。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f1271950233, createdName=优质青年, createdTime=Fri Sep 16 07:25:00 CST 2016, time=2016-09-16, status=1, ipAttribution=)]
    2018-06-22 1e145228m78(暂无匿称)

    学习了.谢谢作者分享!

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=378507, encodeId=b2fa3e850760, content=厉害, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/q5LBt6emqCZazBsHSP9GtE4W6icZa5us7UywLic1AtZuRdY8g5A2q0fV28WictLxn9lfOp3TbgeLkGibadnHicUEibZA/132, createdBy=9f365263540, createdName=林晓1193, createdTime=Sat Jan 25 22:55:22 CST 2020, time=2020-01-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=375165, encodeId=ceba3e51651f, content=开卷有益, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a32b5203853, createdName=147455d6m36暂无昵称, createdTime=Thu Nov 14 18:55:34 CST 2019, time=2019-11-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=327201, encodeId=d07b32e2019b, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Tue Jun 26 17:29:40 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=326336, encodeId=7b0a3263366b, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Sat Jun 23 11:47:28 CST 2018, time=2018-06-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=326115, encodeId=bc99326115f6, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Fri Jun 22 14:17:19 CST 2018, time=2018-06-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=297388, encodeId=cd5929e3880a, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Sun Mar 18 11:00:10 CST 2018, time=2018-03-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=293996, encodeId=3ba62939963e, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Thu Mar 08 01:07:50 CST 2018, time=2018-03-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=293266, encodeId=a599293266ee, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Mon Mar 05 16:08:43 CST 2018, time=2018-03-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279949, encodeId=f2ce2e9949cf, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRvvXNvY0kOJqn4liar3Q6V6yPuEIawCVUyP3jVADh5icIz0ibrsxia6fKAqKsDr33jPWrjqM3D7wcRNu/0, createdBy=5a881701729, createdName=小树熊, createdTime=Fri Jan 19 07:21:55 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=128378, encodeId=00b91283e8eb, content=天职啊。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f1271950233, createdName=优质青年, createdTime=Fri Sep 16 07:25:00 CST 2016, time=2016-09-16, status=1, ipAttribution=)]
    2018-03-18 1e145228m78(暂无匿称)

    学习了.谢谢作者分享!

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=378507, encodeId=b2fa3e850760, content=厉害, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/q5LBt6emqCZazBsHSP9GtE4W6icZa5us7UywLic1AtZuRdY8g5A2q0fV28WictLxn9lfOp3TbgeLkGibadnHicUEibZA/132, createdBy=9f365263540, createdName=林晓1193, createdTime=Sat Jan 25 22:55:22 CST 2020, time=2020-01-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=375165, encodeId=ceba3e51651f, content=开卷有益, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a32b5203853, createdName=147455d6m36暂无昵称, createdTime=Thu Nov 14 18:55:34 CST 2019, time=2019-11-14, status=1, ipAttribution=), 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createdName=1e145228m78(暂无匿称), createdTime=Sat Jun 23 11:47:28 CST 2018, time=2018-06-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=326115, encodeId=bc99326115f6, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Fri Jun 22 14:17:19 CST 2018, time=2018-06-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=297388, encodeId=cd5929e3880a, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Sun Mar 18 11:00:10 CST 2018, time=2018-03-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=293996, encodeId=3ba62939963e, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=29, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Thu Mar 08 01:07:50 CST 2018, time=2018-03-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=293266, encodeId=a599293266ee, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Mon Mar 05 16:08:43 CST 2018, time=2018-03-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279949, encodeId=f2ce2e9949cf, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRvvXNvY0kOJqn4liar3Q6V6yPuEIawCVUyP3jVADh5icIz0ibrsxia6fKAqKsDr33jPWrjqM3D7wcRNu/0, createdBy=5a881701729, createdName=小树熊, createdTime=Fri Jan 19 07:21:55 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=128378, encodeId=00b91283e8eb, content=天职啊。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f1271950233, createdName=优质青年, createdTime=Fri Sep 16 07:25:00 CST 2016, time=2016-09-16, status=1, ipAttribution=)]
    2018-03-08 1e145228m78(暂无匿称)

    学习了.谢谢作者分享!

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=378507, encodeId=b2fa3e850760, content=厉害, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/q5LBt6emqCZazBsHSP9GtE4W6icZa5us7UywLic1AtZuRdY8g5A2q0fV28WictLxn9lfOp3TbgeLkGibadnHicUEibZA/132, createdBy=9f365263540, createdName=林晓1193, createdTime=Sat Jan 25 22:55:22 CST 2020, time=2020-01-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=375165, encodeId=ceba3e51651f, content=开卷有益, beContent=null, objectType=article, channel=null, level=null, likeNumber=62, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a32b5203853, createdName=147455d6m36暂无昵称, createdTime=Thu Nov 14 18:55:34 CST 2019, time=2019-11-14, status=1, ipAttribution=), 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createdName=1e145228m78(暂无匿称), createdTime=Sat Jun 23 11:47:28 CST 2018, time=2018-06-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=326115, encodeId=bc99326115f6, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=58, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Fri Jun 22 14:17:19 CST 2018, time=2018-06-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=297388, encodeId=cd5929e3880a, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=23, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, 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encodeId=00b91283e8eb, content=天职啊。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f1271950233, createdName=优质青年, createdTime=Fri Sep 16 07:25:00 CST 2016, time=2016-09-16, status=1, ipAttribution=)]
    2018-03-05 1e145228m78(暂无匿称)

    学习了.谢谢作者分享!

    0

  9. 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GetPortalCommentsPageByObjectIdResponse(id=327201, encodeId=d07b32e2019b, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Tue Jun 26 17:29:40 CST 2018, time=2018-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=326336, encodeId=7b0a3263366b, content=学习了.谢谢作者分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, 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encodeId=00b91283e8eb, content=天职啊。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f1271950233, createdName=优质青年, createdTime=Fri Sep 16 07:25:00 CST 2016, time=2016-09-16, status=1, ipAttribution=)]
    2018-01-19 小树熊

    学习了.谢谢

    0

  10. 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likeNumber=19, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mONcle9pic3xJXLtMtt5B40XXuPjn9xn1rBhrM6fHLkX1hI86ZoWoPJkgDkZuJNKkBfBHOcRd1fAdezg7JlHNOokohdAp3WkI/0, createdBy=32c81964262, createdName=1e145228m78(暂无匿称), createdTime=Mon Mar 05 16:08:43 CST 2018, time=2018-03-05, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=279949, encodeId=f2ce2e9949cf, content=学习了.谢谢, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfNLvzZhgPxRvvXNvY0kOJqn4liar3Q6V6yPuEIawCVUyP3jVADh5icIz0ibrsxia6fKAqKsDr33jPWrjqM3D7wcRNu/0, createdBy=5a881701729, createdName=小树熊, createdTime=Fri Jan 19 07:21:55 CST 2018, time=2018-01-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=128378, encodeId=00b91283e8eb, content=天职啊。。, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=f1271950233, createdName=优质青年, createdTime=Fri Sep 16 07:25:00 CST 2016, time=2016-09-16, status=1, ipAttribution=)]
    2016-09-16 优质青年

    天职啊。。

    0

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