26岁医学生反复腹泻,所有肠道严重水肿,入院2天肾功能衰竭……

2019-01-14 殳儆 王筝扬 医学界

持续高热,反复腹泻,荷兰医生看不好的病我们看好了。

我是一个ICU医生。
 
春意深浓的午后,从医院下夜班出来,一时兴致在花店的门口停留了片刻。在炫目的颜色和馥郁的甜香里徘徊驻足,淡粉色的樱花花瓣随风从树上飘落。迎面而来的关于季节和时间流转的旖旎气息让我一时不愿意迈开步子离去。
 
夜班之后心情复杂、情绪交错、身心疲劳,最适合在春日的艳阳里,慢慢平复。
 
莉莉用转运救护车花了5个多小时转运到我们医院,刚在ICU住院下来,当地医院吴医生的电话就“追”来了。

“郭,这个女病人很奇怪,诊断有困难,这个趋势会死的。如果你这里能搞定,一定要告诉我结果。”吴医生是我的朋友,普外科医生,对肠外科颇有造诣。他们医院是当地最大的市级三甲医院。

“好的,你告诉我腹腔镜下的状态”。我一边翻看当地医院带来的化验资料,一边在电话里问吴医生。病房里传来粪便的臭味。——这是我们外科监护室最熟悉的气味,粪便、脓液、呕吐物。衣着光鲜漂亮的偶像剧里不会有这些,但在真实世界中却是常态。
 
“没有肠壁穿孔,没有肿瘤,所有肠道都严重水肿。腹腔里有一些积液。总体来说,看不到什么特征性的病变。”吴医生把手机里腹腔镜下的肠道照片一张一张发过来给我看。
 
搁下电话,我去看莉莉的情况。

40℃的高热下,这个才26岁的女学生完全“蔫”了。才刚刚更换完的床单上,满是水样的大便,气味熏人。

“今年已经是第三次,这次最厉害。”莉莉的中文很生涩,常年住在荷兰,中文说得如同外语一样磕磕巴巴。

“前两次的样子,你仔细说一下。”我一边体检,一边问。莉莉的腹胀很严重,水样便不停地流出来,但她虚脱到已经无力羞涩了。

“最近2-3年有经常腹泻、近2个月特别严重的发作有3次”。莉莉的中文生涩,但身为一个医科大学生,病情描述得非常清楚。“先呕吐再严重腹泻,在我们学校附属医院检查过肠镜,治疗一下就会好转,好转了就不影响上学”。她的腹泻已经在荷兰多次就诊,并没有一个明确的结果。
 
护士要为她处理排泄物,见她非常虚弱疲惫的样子,我停止继续询问,去找莉莉的父母。

“她在荷兰读医学院,过年回国来,参加表姐的婚礼,本以为是回国来饮食不一样是吃坏了”。莉莉的父母和姑姑在她生病的10天里,已经折腾得十分憔悴... ...

“本以为读的医学院,自己会照顾自己的身体... ...”方寸大乱的父母除了翘首盯着监护室的大门外已经无法可想。
 
再三问完病史,看完厚厚一叠CT和化验单。我决定尽快邀请请全院多科联合讨论。身为一个常年处理外科危重症的ICU医生,在这么多的信息下,我并没有诊断出莉莉究竟是什么病。吴医生的判断非常正确,病情不会给我们多少时间去诊断,严重的全身炎症反应,严重的肠道失水,如果仍然在原因上不能清晰诊断的话,莉莉会死的。
 
况且,她已经在荷兰做过肠镜,在当地医院用腹腔镜探查过,都没有清晰的结果。能够诊断疾病的手段,已经用到接近极致。

莉莉病情象一列停不下来的高速火车一样,正在向无底深渊冲过去。很快不能再交流了,每时每刻都在腹泻,快速进展:入院才48小时,气管插管,呼吸机支持,肾功能衰竭,需要CRRT机维持。

“她怎么了?她到底是中了什么毒了?”“莉莉啊... ...”

父母的哭声在监护室门外隐隐约约传来。

我心里很明白,重症监护室里,常规生命支持的手段虽然强大,但是找不到病因,所有的支持,都只能拖住一段时间,不能从根本上解决问题。高速列车一样的病情,最后会坠入深渊。
 
几个医生同时在电脑信息系统上,翻看所有能够查到线索的化验和影像资料,光是熟悉病情,就让参加多学科讨论的高年资医生们花了不少时间。
 
危重病人大多就是这样,信息太繁杂,有太多的混淆因素,治疗的干扰、应激状态的干扰、生命支持治疗的干扰、无数个线头和箭头,象一个迷魂阵,需要仔细找线索。

肠瘘、肠梗阻、内疝、伤寒、肠炎、肠功能失调、肠结核、肿瘤 任何一个疾病到出现“爆发”状态的时候,都有点相似。困扰每一个医生的难题。需要用各种不同的专业眼光来审视。
 
“郭,红斑狼疮危相,是可以出现这样严重的消化道症状的。”消化科医生在看片灯上仔细看莉莉的腹部CT:全肠道扩张积气、肠壁肿胀,大量腹水。
 


“她的干燥综合症的指标SSA、SSB都阳性,她的姑姑有干燥综合症,说明免疫系统疾病对她来说,可能只是不典型,没有诊断明确。红斑狼疮、干燥综合症理论上都是全身累及的疾病,虽然我也没有看见过这么严重的肠道表现。”风湿科医生的建议更加清晰。
 
“肠系膜血管的问题基本可以不考虑。也不很符合感染性休克的表现,当然这个你是专家。”外科医生看完CT很坚决地否定另外一个诊断的考虑。
 
MDT(多学科联合讨论)给出了一个我不太熟悉的结果:红斑狼疮危相、累及肠道,建议大剂量皮质激素冲击。
 
我对这个结果,不是不踌躇的。皮质激素对危重病人来说,一向来是双刃剑。如果诊断正确,它是灵丹妙药。如果判断失误,或者出现消化道大量出血的副作用,它可能是致命一击。
 
病情却没有给我多少犹豫的机会,莉莉的休克和呼吸衰竭很快进展到了需要纯氧维持,需要极大剂量升压药物维持的最后阶段。CRRT机,呼吸机,天罗地网的管道重重地护卫着她即将坠落的生命。
 
最好的抗菌药物,昂贵的免疫球蛋白。甲强龙80mg q8h 没有阻挡住病情恶化的脚步。
 
“郭,昨晚查了不少文献,对照起来看,我还是考虑红斑狼疮危相,你用1000mg甲强龙冲击一下”。风湿科医生这几天,每天都到ICU来看莉莉的情况,一个危重的疑难疾病,是医生内心关注的重点。
 
“OK”虽然同意,我的内心还是犹豫了一下,莉莉没有多少机会了!
 
1000mg甲强龙推注下去,我看着监护仪想,病情有太多的不确定性。尽管这暴风骤雨一样的疾病,出乎所有人的预料,但如果最后治疗导致的并发症成了病人的直接死因的话,我的心还是会受伤。
 
激素产生的作用,不会马上显现,但是午夜时候打到ICU询问夜班护士的电话,却有了意外的转折:“主任,12点了你还不睡觉啊!莉莉前半夜没有再腹泻过,升压药剂量也减下去一点了,看上去还算稳定。”
 
“我觉得昨天的激素是有效的。”风湿科医生早晨一大早又在ICU病房了,来得比我还早。
 
“我觉得是激素的效果。”又是一个24小时,又是一大早,他的话里已经有点欢呼的味道了。莉莉的腹泻奇迹般地停止了,生命体征象是海啸过后的波涛,还在动荡中,但是一波比一波平静。
 
我握住他的肩膀晃一晃,长久一起合作的伙伴无需多言,他的判断帮助我们在关键点上,扳回了这一局。

瞪着监护仪,做各种努力的人是我们ICU医生,但他的判断真正挽回了这一局。
 
“哇!真的押对了啊!这个肠道反应真的是暴发型的。”消化科医生,这几天也常常在莉莉的床边逛一下,看看病情的进展如何。此刻的欢欣鼓舞不亚于我们。
 
年轻病人的恢复能力,好得出奇,三天大剂量甲强龙冲击,再两天,呼吸功能好转,顺利拔除了气管插管。病情像海啸过后,休克纠正、呼吸功能恢复、肠功能恢复、肾功能恢复... ...
 
莉莉在惊涛骇浪的病情过后3个星期出院。
 
“郭医生,太感谢你们了,我们差点失去莉莉。”

正是郁金香盛开的季节,痊愈的病人和欢欣的父母,捧来大蓬金红色的郁金香,在医生办公室里点缀出绚丽的颜色。莉莉用生涩的汉语和我们告别。
 
这个26岁的女生,会继续回荷兰修完医科大学的学业,成为一个医生。
 
今天最开心的是看见她出院。
 
但是6床挣扎了2个多月的小林昨晚去了,他的重症胰腺炎没有挨过感染性休克和腹腔大出血的双重打击。他年轻的面容,会留在我的记忆中很久,我和小林仿佛是一同奋战了很久的战友。
 
老张的家属,刚签署了自动出院的意愿,把他带回家去了,经济条件决定了那种无可奈何的命运... ...
 
我是一个ICU医生。用血肉之躯承受着压力,承受着失望和希望。看见美好也看见无奈。
很少有人能真的理解一个ICU医生的执念、焦灼和骄傲。
 
(感谢浙江大学附属邵逸夫医院外科监护室郭丰主任提供病例)
  
作者的话: 
 
临床医生每天都可能遇到病因难以确定的疑难病例。

当诊断决策的信息不够时,医生倾向于使用更多逻辑推理分析可能的诊断。早期的研究曾试图借助通用的诊断思维策略解决临床问题,但结果却表明专业能力只能限于特定的专业领域。

例如呼吸科医生虽然可以熟练的处理呼吸系统疾病,但是在处理其他专科的问题上,与一个低年资的住院医师可能没有差别。

┃要解决这种困局有两个方法:
 
1.长远来说就是对住院医师注重进行内科全专业的培训,至少在常见疾病的诊断思维与治疗决策方面要做到熟悉,在此基础上再按兴趣进行亚专科的方向培训;
 
2.另一个实效的方法就是组织多科协作的方式,由多名专科医师通力合作来照护病人的病情。毕竟患者得病的过程是无法由人为割裂成只与某个专科相关,与其他人无关。
 
这种调动应用协作的能力,在医生综合培训的核心能力也确有要求:关于“患者照护能力”中提到了“能领导和参与多学科合作”的要求;
 
在“人际交流能力”又提到了“能有效的领导或参与医疗专业团队工作”的要求;
 
最后在“基于体系的行医能力”中也提到了“调动各级医疗资源,与相关医疗机构合作诊治患者,提高医疗质量”。所以,如同现代社会组织形式,现代医学也需要分工与协作;
 
与此同时,每个医生也要具备整合、利用与参与这种协作的素质,才能为患者造福。

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    2019-09-25 yese
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    2019-01-16 小华子
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  4. [GetPortalCommentsPageByObjectIdResponse(id=1850702, encodeId=52451850e024a, content=<a href='/topic/show?id=46c682469e4' target=_blank style='color:#2F92EE;'>#肾功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82469, encryptionId=46c682469e4, topicName=肾功能)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=28d456, createdName=yese, createdTime=Wed Sep 25 00:07:00 CST 2019, time=2019-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1333426, encodeId=841a13334264f, content=<a href='/topic/show?id=4ce26423802' target=_blank style='color:#2F92EE;'>#水肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=64238, encryptionId=4ce26423802, topicName=水肿)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKCRibWHQArPHdSkqP90U1HwwqlGeU7BUgzY240D3v2ibBDJ09ybkGkwOjxz7qRmngZaGlK1taX6hfA/132, createdBy=2e772500094, createdName=小华子, createdTime=Wed Jan 16 11:07:00 CST 2019, time=2019-01-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1503363, encodeId=fd3715033630d, content=<a href='/topic/show?id=2e8582490f1' target=_blank style='color:#2F92EE;'>#肾功能衰竭#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82490, encryptionId=2e8582490f1, topicName=肾功能衰竭)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=277b9614951, createdName=naiwu80, createdTime=Wed Jan 16 11:07:00 CST 2019, time=2019-01-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358219, encodeId=f467358219b9, content=谢谢分享,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Tue Jan 15 15:04:43 CST 2019, time=2019-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358150, encodeId=5461358150af, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a09e2282255, createdName=121ca4e0m95暂无昵称, createdTime=Mon Jan 14 22:23:23 CST 2019, time=2019-01-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358147, encodeId=580c35814ed8, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Mon Jan 14 21:17:43 CST 2019, time=2019-01-14, status=1, ipAttribution=)]
    2019-01-15 明月清辉

    谢谢分享,学习了

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1850702, encodeId=52451850e024a, content=<a href='/topic/show?id=46c682469e4' target=_blank style='color:#2F92EE;'>#肾功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82469, encryptionId=46c682469e4, topicName=肾功能)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=28d456, createdName=yese, createdTime=Wed Sep 25 00:07:00 CST 2019, time=2019-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1333426, encodeId=841a13334264f, content=<a href='/topic/show?id=4ce26423802' target=_blank style='color:#2F92EE;'>#水肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=64238, encryptionId=4ce26423802, topicName=水肿)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKCRibWHQArPHdSkqP90U1HwwqlGeU7BUgzY240D3v2ibBDJ09ybkGkwOjxz7qRmngZaGlK1taX6hfA/132, createdBy=2e772500094, createdName=小华子, createdTime=Wed Jan 16 11:07:00 CST 2019, time=2019-01-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1503363, encodeId=fd3715033630d, content=<a href='/topic/show?id=2e8582490f1' target=_blank style='color:#2F92EE;'>#肾功能衰竭#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82490, encryptionId=2e8582490f1, topicName=肾功能衰竭)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=277b9614951, createdName=naiwu80, createdTime=Wed Jan 16 11:07:00 CST 2019, time=2019-01-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358219, encodeId=f467358219b9, content=谢谢分享,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Tue Jan 15 15:04:43 CST 2019, time=2019-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358150, encodeId=5461358150af, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a09e2282255, createdName=121ca4e0m95暂无昵称, createdTime=Mon Jan 14 22:23:23 CST 2019, time=2019-01-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358147, encodeId=580c35814ed8, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Mon Jan 14 21:17:43 CST 2019, time=2019-01-14, status=1, ipAttribution=)]
    2019-01-14 121ca4e0m95暂无昵称

    学习了

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1850702, encodeId=52451850e024a, content=<a href='/topic/show?id=46c682469e4' target=_blank style='color:#2F92EE;'>#肾功能#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=20, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82469, encryptionId=46c682469e4, topicName=肾功能)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=28d456, createdName=yese, createdTime=Wed Sep 25 00:07:00 CST 2019, time=2019-09-25, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1333426, encodeId=841a13334264f, content=<a href='/topic/show?id=4ce26423802' target=_blank style='color:#2F92EE;'>#水肿#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=21, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=64238, encryptionId=4ce26423802, topicName=水肿)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKCRibWHQArPHdSkqP90U1HwwqlGeU7BUgzY240D3v2ibBDJ09ybkGkwOjxz7qRmngZaGlK1taX6hfA/132, createdBy=2e772500094, createdName=小华子, createdTime=Wed Jan 16 11:07:00 CST 2019, time=2019-01-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1503363, encodeId=fd3715033630d, content=<a href='/topic/show?id=2e8582490f1' target=_blank style='color:#2F92EE;'>#肾功能衰竭#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=27, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82490, encryptionId=2e8582490f1, topicName=肾功能衰竭)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=277b9614951, createdName=naiwu80, createdTime=Wed Jan 16 11:07:00 CST 2019, time=2019-01-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358219, encodeId=f467358219b9, content=谢谢分享,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=53, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6Nx0VGA4QMDzOP8oAgnV4h51EjSfehJ9QxyiaSmw8PB56BhY8KXFSxHCibXrzcy4abrzSibXQPxJ9kzrLcJyhhB8a/0, createdBy=1d3b1672603, createdName=明月清辉, createdTime=Tue Jan 15 15:04:43 CST 2019, time=2019-01-15, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358150, encodeId=5461358150af, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=56, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a09e2282255, createdName=121ca4e0m95暂无昵称, createdTime=Mon Jan 14 22:23:23 CST 2019, time=2019-01-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=358147, encodeId=580c35814ed8, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=59, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=82311653708, createdName=医者仁心5538, createdTime=Mon Jan 14 21:17:43 CST 2019, time=2019-01-14, status=1, ipAttribution=)]
    2019-01-14 医者仁心5538

    学习了

    0