医学生日记2016年5月31日 --- 责任
阿山 （庞静译）
第二个星期我转回妇产科的白班了。第一个星期我有幸协助了三次自然生产，三次都是我取出了胎盘，还有一次半夜剖腹产。和其他妇科见习的同学比起来，有几个同学第一个星期根本没见过一例自然生产或剖腹产。到此为止，没人比我见的多。一方面这是运气，我们这个大学城人口不多，孕妇相对也少。但是，另一方面是我自己学习的积极态度。对我们学生的要求是每班跟一两个病患，而我却想见尽可能多的病患。结果，我更容易适应见习的安排，也更有自信。这随之演变成病患在他们生命的关键时刻愿意我在旁边。而且，住院医也信任我，让我在旁边多帮忙。到此，我学到了受教育的一个关键的基本信条：你必须负责任地为自己创造机会。
今天我第四次参加自然生产。生产过程不太顺。又让我取出胎盘。其实已经有信号了，当时连着胎盘的脐带突然松了，一股血流浅到我的胳膊肘上（穿着大袍子呢）。我们清理干净之后就离开了，让妈妈和她的新生婴儿，还有其他家庭成员在一起，照了很多照片。
大约一小时之后，病房呼叫我们回去。母亲阴道出了很多血。我们进去时都可以听到，就像汨汨流着的泉水。我们看到暗红色的血从她的阴道滚淌而出。住院医压住了她的肚脐，由此向子宫施加压力，血止住了。我们把她清干净，正准备离开，出血又开始了。住院医检查了她的阴道和子宫。大块的黑色血块流出来了。母亲开始感觉头晕，把她怀抱的婴儿递给了祖母。我们搬来了超声波仪器。整个过程，我都在试着用西班牙语解释，因为母亲不会讲英文，我告诉她正在发生什么，我们要怎么处理。
又一大股血流喷出来了。我不停地换着母亲身下的大毛巾，我可以感到那些被血漫透的大毛巾有多重。因为母亲失血太多，一个护士加上了第二袋IV。住院医在做超声波时宣布可能有一部分胎盘还留在子宫内，因此引起出血。住院医说我们可能得去急诊中心手术室止血。
这时我的肚子直往下沉。至此，我们做的每一件事都是严格按照要求做的，做为医学生，我们的训练不允许我们随意做任何事，因为那样就可能造成病患的极大的不幸。但现在，这位新母亲正在迅速失血，面临着死亡。这很可能是我取胎盘时出了什么差错引起的。这个念头在我脑子里飞转。当我取出胎盘时我们检查过，它是完整的。我真的很想去翻专用垃圾筒，找到包着那个胎盘的袋子。我很害怕，但也很有意识地不让这种情绪出现在脸上。我很努力地用西班牙语让病人和家属明白怎么回事。这其实是很难的平衡，既要照顾到病人，还要藏住我自己内心的失望和痛苦。
主治医生来到病房，马上开了一堆药。这些药用上十分钟之后血就止住了。她向我们解释，高龄产妇，以前有过数次怀孕经历，就像我们的病人，生产之后，她的子宫收缩比较慢。这就造成了出血。她开的药就是帮助子宫收缩，增加肌肉能力，最终控制住血管。
出血过程中没有胎盘残片随着流出。再一次超声波检查也看不到胎盘痕迹。我终于松了口气，并不是我造成了产妇的生命危险。但是这件事却使我明白了，以后也会终生受用。病人如此地信任我，把他们的健康交给我，我在治疗他们时会更在意我做什么，怎么做，稍有不慎都会对他们造成巨大的伤害。
这就是真正的责任。
原文
Tuesday, May 31, 2016 – Responsibility
I am back onto the day shift for my second week of Labor & Delivery. In my first week, I had the opportunity to assist in 3 vaginal deliveries, personally delivering 3 of the placentas, and one middle-of-the night C-section. When comparing numbers to the other students on the rotation, there were several that had gone the entire first week without seeing a single vaginal delivery or C-section. No student so far had gotten to see more than me. Part of this is luck, our college town does not have the biggest population, and a population of childbearing women was proportionately smaller. However, I believe part of it is my own aggressive pursuit and control of my education. Medical students on the service are expected to only follow one or two patients per shift, but I come in wanting to see as many patients as I can. Consequently, I feel more comfortable and confident in the setting. That translates into the patients feeling more comfortable with having me in this important moment of their lives. That also translates into the residents trusting me enough to let me stick around and do more. This, I’m learning, is an important basic tenet of education: you must take responsibility for creating your own opportunities.
Today, I was participating in vaginal delivery number 4. The proceedings were quite uneventful. I was allowed to deliver the placenta again. There were the good signs, the cord suddenly losing a bit of tension and a small gush of blood squirting up to my gowned elbow. We cleaned up and left mom to bond with her new baby and the rest of the family to adore and take many pictures.
About an hour later, we get called back to the room. There is a lot of blood coming from mom’s vagina. As we walk in, we can hear it, almost like a gurgling spring, and we can see it, the dark red blood gushing in spurts out of her vagina. The resident presses on the mom’s belly a bit to apply pressure to her uterus, and the bleeding stops. We clean her up and as we’re turning to go, the gushing starts again. The resident manually examine her vagina and uterus. Big dark clots come tumbling out in a sludge of thick dark blood. Mom is becoming light-headed at the moment and has passed her baby off to grandma. We grab the ultrasound machine. All while this is happening, I’m trying to roughly explain in Spanish, because mom did not speak English, what is happening and what we’re trying to do.
Another big gush of blood spurts out. I’m constantly replacing the towels under mom and I can feel how heavy they have become with soaked blood. A nurse is starting a second IV to pump fluid because mom is losing a lot of blood. The resident is doing the ultrasound and announces that there might still be placenta remaining in the uterus that is causing the bleeding and we might need to go emergently to the operating room to stop the bleeding.
My stomach drops at this moment. All throughout our training so far, every thing we did was well supervised and controlled, there was little that we as medical students were allowed to do that could cause serious harm to patients. But here, this new mom was in danger of bleeding to death very rapidly, and it may have been because I improperly delivered the placenta. The thoughts were racing through my head. We had examined the placenta when I delivered it and it was intact. I almost considered digging through the red bio-waste garbage bin to look for the plastic carton that contained the placenta. I was very scared, but also conscious enough to try not to let it show on my face. I was also trying my hardest to give the patient and her family a rough Spanish understanding. It was a weird balance of trying to balance the patient care and my own internal desperation and panic.
The attending physician came to the room and immediately ordered a slew of drugs. As soon as all of them were administered, the bleeding stopped within 10 minutes. She explained to all of us in the room, with women that are slightly older and have had multiple pregnancies, like our patient, sometimes their uterus was slower to firm up after delivery. This allows the blood vessels to continue to leak and bleed. All the drugs she administered were to help the uterus firm up and gain muscle tone and essentially allow it clamp off its bleeding vessels.
During this process, there were no placental fragments that came out with the bleeding. Repeated examinations and ultrasound showed no evidence of retained placenta. I was able to breathe a sigh of relief, it was not my action that had endangered this woman’s life. But it also has me thinking and realizing, for the rest of my life, I will be thinking about how my actions, in their intention to care, can cause serious harm to patients who have entrusted me with their health.
That, is truly responsibility.
