<<主治醫師的第一周：中耳炎也要花15分鐘…..>>

我的第一份工作是在大醫院裡的urgent care，中文翻成急門診。在美國除非你有公共保險像是medicaid，一般都會避免去急診，於是有了urgent care的制度：專門處理有點急又不太急的病症。營業時間也故意跟一般門診錯開，大部分是傍晚開到晚上（美國晚上很少有門診）。

也因此在urgent care看的病種類很廣（一半的病會在急診看到、一半會在門診看到），對我這個初出茅廬的主治醫師來說，是個很好的開始。學習曲線直線上升✈✈。

我們的urgent care因為在醫院裡，工作時間比一般社區urgent care長：早上11點到晚上11點。地點就在急診隔壁。急診護士triage後常會將病人直接送到這裡（但有時醫師評估之後會再把病人轉回去）。病人常在11點關門前才出現，工作到半夜12點1點是很平常的事。聽護士說冬天常要看到半夜兩三點……抖😟。不過好險我們跟急診一樣是算時薪的，over hour也一樣有錢拿。

因為COVID的關係，現在病人量是平常的2/3。在這個時期開始剛好給我更多時間上手 ❤️

第一個禮拜我一個小時看兩個病人（包括寫病歷）。職前訓練時，medical director說據研究，一般小兒急診合理的病人數是每小時1-2個病人; 我們因為acuity較低，平均下來每個provider每小時是看3個病人。

Urgent care不像一般門診能夠follow up病人，風險較高，因此需要詳細解釋病情、告知注意事項，包括甚麼時候該去看門診、甚麼時候該去急診。任何的主訴就算只是耳朵痛，我也一定會做詳細的身體檢查，很怕漏看。

以兒科常見的中耳炎來說，並不是每個耳朵痛的孩子都是中耳炎。就算是中耳炎也不是每個孩子都需要治療。許多中耳炎都是病毒感染，不需要抗生素。治療方向跟年齡、單邊雙邊以及症狀有關。這些我們都要跟病人討論。不然病人會覺得為什麼上次拿到的是十天的抗生素，這次卻只有五天，或是不開。

在醫院工作最大好處是常見疾病都有evidence based guideline，會隨著研究更新，也有很多online class跟workshop可以參加。

醫師有兩個最重要的武器，一是知識、一是經驗。醫學日新月異，許多過去認為正確的作法會被推翻。即使是基層醫師，也需要大量閱讀文獻跟吸收新的知識。院方的guideline可以幫忙簡化並加速這個過程。

我下個月開始也會在一個大型社區中心（聯合診所，30幾個醫生）看診，在醫院學到的新知剛好可以用到社區裡。對我這個喜歡evident based medicine、看文獻，同時也喜歡在社區工作的菜鳥主治來說，這樣的組合真的是太夢幻了🌈(灑花🌺🌺🌺)。

不過......現在光一個簡單中耳炎我就可以跟病人講個15分鐘 …. 加上covid時期，病人只要有任何screen positive（包括輕微發燒），我們都是全套隔離（N95、護目鏡、隔離衣、手套），進出診間相當麻煩。老實說以這樣的速度，我是有點擔心冬天來了怎麼辦🤣記得以前在教學門診，看到許多有經驗的醫師看病真是又快又詳細。解釋病情時也是一口氣就能揭露所有病人需要知道的資訊，相當厲害！！目前我最需要的是建立一套自己的work flow，將常見系病需要cover的東西系統化，就比較不怕漏看、漏講囉😊

照片一: 診間一隅
照片二: 敝院中耳炎治療方針

醫者有社會責任去保障公眾健康，我們認為梁卓偉教授和陳家亮教授作為香港兩所醫學院院長責無旁貸。因此，我們呼籲所有醫護人員參與連署，懇請兩位院長履行社會使命發表聲明保障社會大眾的健康和人身安全。

連署連結: https://forms.gle/teMGNCiZPMYatVbh8
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《致香港大學李嘉誠醫學院院長、中文大學醫學院院長的公開信》

梁教授、陳教授道鑒：

　　有鑑於在六月十二日、七月二日及二十一日，香港警察濫用武力以控制群眾。如此行徑實對公眾健康遺害無窮，我們一眾醫療人員對此極為關切。作為香港大學李嘉誠醫學院院長、中文大學醫學院院長，吾等懇請兩位院長細察香港警察控制群眾之手段，以保障公眾健康。

　　據多家本地及國際媒體報導，香港警察於六月十二日，發射多輪催淚彈、橡膠子彈及布袋彈，以驅散聚集在金鐘的示威者。報導提及，警方向示威者發射至少一百五十枚催淚彈，二十輪布袋彈以及數枚橡膠子彈，造成至少七十二人受傷。從多家媒體直播可見，橡膠子彈更直射一名教師眼球，創傷嚴重，對其視力之損害非同等閒。另外，警方亦曾以數枚催淚彈包抄示威者，堵塞其退路；而當示威者被逼退守至中信大廈，警方竟朝人群中央投以催淚彈，造成數以百計的市民受傷及呼吸困難，生死攸關，不容小覷。此外，警方向一名手無寸鐵的市民，近距離發射橡膠子彈，以致其下腹嚴重受傷，情況慘不忍睹。

　　據多份醫學期刊綜述──如《刺針》（Lancet）[1] 及英國醫學期刊（BMJ (Open)）[2]，橡膠子彈乃可致命武器。同時，橡膠子彈不易操控，準確性低，有引致重傷，乃至死亡之風險。多份期刊不約而同指出，橡膠子彈不適宜用於密集人群之管制。

　　然而，香港警察漠視上述已知風險，仍於七月二日及七月二十一日繼續使用此類武器。在七月二十一日，警察更於鄰近民居之地，向群眾發射多輪催淚彈及橡膠子彈，當中更殃及記者。此等武器之禍害影響深重，不單有損呼吸系統，更會導致燒傷、嚴重鈍物創傷及爆炸性創傷。據媒體報導，武器造成至少十四人受傷；更有市民懼於警方之搜捕行動，而未敢求醫，致使受傷數字難以估算。

　　人權醫療組織（Physicians for Human Rights）醫生哈爾（Dr Rohini Haar）在接受紐約時報訪問時指出，警方對市民使用不成比例的武力，實有濫用武力之嫌。早在二零一四年，潘冬平教授[3]亦對香港警察使用催淚氣體情況深表關注，擔心催淚氣體損害市民呼吸系統。可見，催淚彈、橡膠子彈及豆袋彈等武器危害不輕，對香港市民公眾健康的損害不容置疑。

　　兩大醫學學院一直致力培育杏林菁英，不遺餘力。一眾醫療人員亦謹承《希波克拉底誓詞》之教誨，不論病患身份職要，一直為全人類之福祉著想，嚴守不懈。學院循循善誘，吾等縷心刻骨。誓詞薪火相傳，代代不息；缺少對生命健康之尊重，醫療人員何以自立？故此，我們一眾醫療人員懇請院長，發表聲明，呼籲香港警察：

一、避免濫用催淚彈及任何類型子彈，以免導致人命傷亡及其他不可見之損傷。
二、在使用武力時，必須顧及市民安全，並保持專業克制。

　　醫療人員一直存仁心，行仁術；保護市民之健康，乃至生命，吾等責無旁貸。院長為學為醫，高風峻節，茍以吾等同心同德，捍衛市民之生命健康，必見杏林春暖。

　　謹祝
道安

一眾醫療人員謹上
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Dear Professor Leung and Professor Chan,

We are a group of healthcare professionals, some of us being also graduates from the Faculty of Medicine of the University of Hong Kong and the Chinese University of Hong Kong. We are writing to express our gravest concerns over the persistent and serious threats to the health of members of the public posed by weapons deployed in crowd control by the Hong Kong Police Force (HKPF) on 12 June, 2 July and 21 July. We hereby urge the Deans of the sole Faculties of Medicine in Hong Kong to take actions in censuring the HKPF and the Hong Kong Government against the serious health risks in their crowd-control tactics.

On 12 June, as reported by multiple local and international news agencies, the HKPF fired multiple rounds of tear gas, rubber bullets and bean-bag rounds to disperse protesters in Admiralty. Over 150 canisters of tear gas, 20 bean-bag rounds and several rubber bullets have admittedly been directed at protestors which resulted in at least 72 injuries. As evident in the live reports from various media sources, a teacher suffered traumatic ocular injury causing significant vision loss when his eye was hit by a rubber bullet; hundreds of citizens suffered various degrees of injuries and respiratory distress consequential upon the numerous tear gas canisters shot at Citic Tower in Admiralty where protesters were trapped in a life-threatening space filled with tear gas; an unarmed man sustained injury in his lower abdomen when a rubber bullet was directed at him in a short distance.

According to multiple studies and reviews from high impact factor medical journals, in particular the Lancet[1] and BMJ (Open)[2], rubber bullets can be lethal. Their notorious inaccuracy and risk of severe injury and death render them inappropriate and unsafe means of force in crowd control.

However, despite the known risks of these weapons, the HKPF tenaciously deployed them on citizens on 2 July and 21 July. On 21 July, 55 canisters of tear gas, 5 rubber bullet rounds and 24 sponge bullets were admittedly shot, some without immediate warning, at protestors and even at journalists notwithstanding the numerous residential buildings and citizens in the vicinity. The use of these weapons has left members of the public with at the very least, various types of injuries and further, burns, blunt force trauma and explosive injuries. 14 injuries have by far been reported where others did not present themselves to the hospital in fear of the risk of prosecution.

Dr Rohini Haar of Physicians for Human Rights had in a recent interview told the New York Times that the force used by the HKPF was disproportionate and excessive. In Hong Kong, Professor Ronnie Poon had as early as in 2014 expressed openly his earnest concern over both the short term and long term health risks in the use of tear gas in particular to one’s respiratory system when the HKPF first fired tear gas at Hong Kong citizens [3]. It is indisputable that these named weapons put the health of Hong Kong citizens at serious risks.

Doctors have striven to stand by the Hippocratic oath that they remain members of society, the identity of which comes before their profession, with special obligations to all fellow human beings. The two medical schools in Hong Kong have been established accordingly for the nurture of healthcare professionals to serve the public with benevolent hearts and minds. This is the time to honour our oath that human life should deserve the utmost respect and to maintain by all means such noble traditions of the medical profession.

We, as healthcare professionals, therefore implore the Deans of the only Faculties of Medicine in Hong Kong, in the service of humanity with conscience and dignity, to take the lead in safeguarding the public’s health and to issue a statement to urge the Hong Kong Police Force to:

(1) refrain from using tear gas and bullets in any form on protestors to prevent further bloodshed and severe non-reversible injuries; and

(2) exercise due restraint over the use of force when handling protests and at all times, put the safety of Hong Kong citizens at the highest priority.

Regards,
A group of healthcare professionals
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Healthcare professionals have a social responsibility to safeguard the health of members of the public. We believe that, as Deans of the faculties of medicine in Hong Kong, Professor Leung and Professor Chan bear a paramount obligation in this regard. We appeal to all healthcare professionals to join us in this petition to urge the deans to issue a statement to honour their obligation to defend the public from health risks.
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Petition Link: https://forms.gle/teMGNCiZPMYatVbh8
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參考資料/References
[1] Mahajna, A., Aboud, N., Harbaji, I., Agbaria, A., Lankovsky, Z., Michaelson, M., . . . Krausz, M. M. (2002). Blunt and penetrating injuries caused by rubber bullets during the Israeli-Arab conflict in October, 2000: A retrospective study. The Lancet, 359(9320), 1795-1800. doi:10.1016/s0140-6736(02)08708-1

[2] Haar, R. J., Iacopino, V., Ranadive, N., Dandu, M., & Weiser, S. D. (2017, December 01). Death, injury and disability from kinetic impact projectiles in crowd-control settings: A systematic review

[3] Professor Ronnie Poon Facebook: https://www.facebook.com/138599119760/posts/10152753050039761?s=1014598371&sfns=mo

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Taipei Times Joe's investment
#中國 #美國 #臺灣 #國際關係

Joe：「如果美國國會2019年真的要推這個外交法案，我看中國和美國的外交關係就是空前的惡化了，近期華為高層被捕，加拿大前外交官Michael Kovrig被中國當局拘留，2019年應該很難有風平浪靜的國際局勢了」

美國眾議會外交委員會亞太事務組主席Ted Yoho：是承認台灣為國家的時候了
Recognize Taiwan as the country it truly is

Yoho writes: “The US Congress will stand firm with Taiwan. We will honor our defensive military supply commitment and will work toward achieving full diplomatic relations with Taiwan.”
約霍寫著：「美國國會將與台灣站在一起。我們將會持續表彰對台灣軍售的承諾，並努力朝向和台灣建立完整外交關係。」

“Taiwan exists today as a sovereign state, a status it has earned through the mandate of its people, its democratic institutions and its stewardship of personal freedoms and human rights.”
台灣今天以一個主權獨立國家形式存在。這個現狀是因人民賦權、民主制度、個人自由、以及人權所獲得的。

“The facts are self-evident: China’s authoritarian government, dominated by the CCP, has never ruled Taiwan.”
有些不需要證明的事實是：中共掌握的中國極權政府，從來沒有統治台灣。

“Today, Taiwan is a flourishing democracy with its own economy, education system, military, sovereign borders, political parties, national anthem and flag.”
如今，台灣是一個蓬勃發展的民主國家，擁有自己的經濟、教育系統、軍隊、主權疆域、政黨、國歌、以及國旗。

“China has bullied the world into believing that Taiwan is not a country but some other undefined thing.”
中國持續霸凌世界，迫使全球相信台灣並非一個國家，而是某些不確定的東西

“However, the truth is right in front of our eyes and it is time the world began treating Taiwan as it deserves.”
然而，事實就在我們眼前，而全世界應開始讓台灣擁有應得的待遇。

“I view Taiwan as an independent country and believe that most US citizens and members of our government feel the same way.”
我認為台灣是一個獨立國家，並相信多數美國公民以及政府官員都如此認為。

“Taiwan is a nation, and it is time to embrace and recognize this fact.”
台灣是一個國家，目前是擁抱且承認這個事實的時候了。

另外附上
《美國國會「美中經濟與安全審查委員會」2018年度報告》第三章第三節的內容
https://hackmd.io/s/S1NThQnT7?fbclid=IwAR2INOUurECE52KHMKFMSA7RjgkB3t2A6Nit7NXUyc5bAYkWsIBOah8LSOg
裡面有中文翻譯，其實美國國會對台灣內部和國際上的觀察是非常透徹的，這樣的報告出爐後，加上目前美國兩黨的互動關係，我估計台灣2019年應該會面臨很劇烈的外交局勢驟變

http://www.taipeitimes.com/News/editorials/archives/2018/12/11/2003705885
https://www.ptt.cc/bbs/Gossiping/M.1544547364.A.99D.html