一開始看小產的手術治療程序（Dilatation & Curettage） 時總會覺得很傷感。

看著被用吸管吸出來和Curette刮出來的死胎組織，我在想對我們來說這只是Product of Conception，但對媽媽們來就這是他們的親生骨肉。

到早上第5個D&C時，已慢慢習慣不再傷感，但對那位媽媽來說，大概是永遠不會忘記的回憶吧。

目前法例20周前的小產死胎會被視作「醫療廢物」，實在蠻令人無奈的，但當中涉及的法律和倫理原則倒不無道理。

颱風來襲，高雄夜空，陰霾已兵臨城下，
風雨前的寧靜，總暗藏危機。

夜診後，內科打電話來，有緊急照會。

「蔡醫師，病患尿液滯留，困難插管，好像尿道有狹窄...」

「今天，沒吃鳳梨酥，應該99%是小Case吧～」心想。

到了病房，看到一位榮民伯伯，
很躁動，雙手被保護性約束著。

「伯伯，放輕鬆，我幫您潤滑麻醉啊，不會痛的啦...」

安撫了病人與看護，伯伯很配合，就不亂動了，
感恩辛苦的內科護理師，動作很快，備物也很快。

關關難過，關關要過！

跟OR, 急診，都調了器械。

可是，
換了幾條尿管，
什麼法寶都上了...

Xylocaine jelly injection
Bougie dilatation
Stylet-assistance...

不斷彎腰，伸腰，
可是，尿道，還是狹窄崎嶇，又怕弄出血...

But，
還是要鎮定，深吸一口氣，
看了看伯伯，
頓時發現，
這尿道崎嶇的手感，
這碩大的陰莖睪丸，
好像，
哪裡看過？
有似曾相識的熟悉感....

閉上眼，
深呼吸，默念阿彌陀佛，
再順著手感...

「哇，進去了，成功了，也沒出血耶...」

留下滿目瘡痍的器械戰場，
等著跟健保申請微薄的幾百點技術費。

（通尿管，比不上通水管！）

感恩護理師看護幫忙，感恩病人很配合，
免除了颱風天還要進一步的膀胱造廔或內視鏡手術，
也免除了內科醫護這颱風天要處理更多狀況的困擾，

再看看伯伯的臉龐，

他睡著了！

怎麼覺得，好面熟啊…

回到護理站，
寫病歷，也翻翻舊病歷。

「哇，原來，是我8年前的老病人啊…
原來，是P伯伯....」

當年，
外院開攝護腺，後來，血尿，來我們急診。

超音波，幫他發現膀胱癌，做了刮除手術乾淨，
也發現，一大段尿道狹窄，好崎嶇，
還好，
當時都平安，處理完，

門診追蹤一陣子，
每次他來，都很客氣，爽朗的笑容，
有時，還會跟我行舉手禮：

「醫官好！」

後來，
伯伯就沒固定回來追蹤了。

看看舊病歷，
才知道，後來他跌倒，顱內出血手術，神智已不復當年。

過了多年，
終於，又再見到他，
在這颱風夜，
爽朗的笑容，已不復見...

只留下熟悉的...
碩大陰莖睪丸與尿道手感...

感恩護理師們，
12:00下班，小心颱風啊！
感恩病人配合，
感恩醫病善緣，
讓閱鳥無數的我們，可以逢凶化吉，關關難過關關過！

ARDS 的血行動力學

Experts’ opinion on management of hemodynamics in ARDS patients: focus on the effects of mechanical ventilation

Acute respiratory distress syndrome (ARDS) is frequently associated with hemodynamic instability which appears as the main factor associated with mortality. Shock is driven by pulmonary hypertension, deleterious effects of mechanical ventilation (MV) on right ventricular (RV) function, and associated-sepsis. Hemodynamic effects of ventilation are due to changes in pleural pressure (Ppl) and changes in transpulmonary pressure (TP). TP affects RV afterload, whereas changes in Ppl affect venous return. Tidal forces and positive end-expiratory pressure (PEEP) increase pulmonary vascular resistance (PVR) in direct proportion to their effects on mean airway pressure (mPaw). The acutely injured lung has a reduced capacity to accommodate flowing blood and increases of blood flow accentuate fluid filtration. The dynamics of vascular pressure may contribute to ventilator-induced injury (VILI). In order to optimize perfusion, improve gas exchange, and minimize VILI risk, monitoring hemodynamics is important.
During passive ventilation pulse pressure variations are a predictor of fluid responsiveness when conditions to ensure its validity are observed, but may also reflect afterload effects of MV. Central venous pressure can be helpful to monitor the response of RV function to treatment. Echocardiography is suitable to visualize the RV and to detect acute cor pulmonale (ACP), which occurs in 20–25 % of cases. Inserting a pulmonary artery catheter may be useful to measure/calculate pulmonary artery pressure, pulmonary and systemic vascular resistance, and cardiac output. These last two indexes may be misleading, however, in cases of West zones 2 or 1 and tricuspid regurgitation associated with RV dilatation. Transpulmonary thermodilution may be useful to evaluate extravascular lung water and the pulmonary vascular permeability index. To ensure adequate intravascular volume is the first goal of hemodynamic support in patients with shock. The benefit and risk balance of fluid expansion has to be carefully evaluated since it may improve systemic perfusion but also may decrease ventilator-free days, increase pulmonary edema, and promote RV failure. ACP can be prevented or treated by applying RV protective MV (low driving pressure, limited hypercapnia, PEEP adapted to lung recruitability) and by prone positioning. In cases of shock that do not respond to intravascular fluid administration, norepinephrine infusion and vasodilators inhalation may improve RV function. Extracorporeal membrane oxygenation (ECMO) has the potential to be the cause of, as well as a remedy for, hemodynamic problems. Continuous thermodilution-based and pulse contour analysis-based cardiac output monitoring are not recommended in patients treated with ECMO, since the results are frequently inaccurate. Extracorporeal CO2 removal, which could have the capability to reduce hypercapnia/acidosis-induced ACP, cannot currently be recommended because of the lack of sufficient data.
http://bit.ly/1Xdb1Kv