本文為emDocs近期文章EM MINDSET – JOE LEX – THINKING LIKE AN EMERGENCY PHYSICIAN中英對照版本，已取得轉載同意。
JOE LEX的簡介，僅節錄其中一句：參與急診醫學超過49年，曾為越戰軍醫, 急救技術員,急診護理師, 然後是急診醫師.
EM MINDSET – JOE LEX – THINKING LIKE AN EMERGENCY PHYSICIAN
“Emergency Medicine is the most interesting 15 minutes of every other specialty.”
– Dan Sandberg, BEEM Conference, 2014
Why are we different? How do we differentiate ourselves from other specialties of medicine? We work in a different environment in different hours and with different patients more than any other specialty. Our motto is “Anyone, anything, anytime.”
While other doctors dwell on the question, “What does this patient have? (i.e., “What’s the diagnosis?”), emergency physicians are constantly thinking “What does this patient need?Now? In 5 minutes? In two hours?” Does this involve a different way of thinking?
The concept of seeing undifferentiated patients with symptoms, not diagnoses, is alien to many of our medical colleagues. Yes, we do it on a daily basis, many times during a shift. Every time I introduce myself to a patient, I never know which direction things are going to head. But I feel like I should give the following disclaimer.
Hello stranger, I am Doctor Joe Lex. I will spend as much time as it takes to determine whether you are trying to die on me and whether I should admit you to the hospital so you can try to die on one of my colleagues. You and I have never met before today. You must trust me with your life and secrets, and I must trust that the answers you give me are honest. After today, we will probably never see one another again. This may turn out to be one of the worst days of your life;for me it is another workday. I may forget you minutes after you leave the department, but you will probably remember me for many months or years, possibly even for the rest of your life.
I will ask you many, many questions. I will do the best I can to ask the right questions in the right order so that I come to a correct decision. I want you to tell me the story, and for me to understand that story I may have to interrupt you to clarify your answers.
Each question I ask you is a conscious decision on my part, but in an average 8 hour shift I will make somewhere near 10,000 conscious and subconscious decisions – who to see next, what question to ask next, how much physical examination should I perform, is that really a murmur that I am hearing, what lab study should I order, what imaging study should I look at now, which consultant will give me the least pushback about caring for you, is your nurse one to whom I can trust the mission of getting your pain under control, and will I remember to give you that work note when it is time for you to go home? So even if I screw up just 0.1% of these decisions, I will make about 10 mistakes today.
I hope for both of our sakes you have a plain, obvious emergency with a high signal-to-noise ratio: gonorrhea, a dislocated kneecap, chest pain with an obvious STEMI pattern on EKG. I can recognize and treat those things without even thinking. If, on the other hand, your problem has a lot of background noise, I am more likely to be led down the wrong path and come to the wrong conclusion.
你好 陌生人, 我是Joe Lex醫師。 我將花些時間決定你是否有機會在我的手上死亡，或者我應該讓你住院，所以你有機會死於我同事手上。今日之前，我不曾見過你，但你必須以生命和秘密為所本相信我，而我必需相信你的答案是信實的。今日之後, 我們可能也不會再相見。今天可能是你生命中最糟糕的日子之一，但對我而言，這只是另一個工作天。在你離開急診後幾分鐘，我也許已忘了你，但你可能將記得我幾個月，幾年，甚至你的餘生。
I am glad to report that the human body is very resilient. We as humans have evolved over millennia to survive, so even if I screw up the odds are very, very good that you will be fine. Voltaire told us back in the 18th century that “The art of medicine consists of amusing the patient while nature cures the disease.” For the most part this has not changed. In addition, Lewis Thomas wrote: “The great secret of doctors, learned by internists and learned early in marriage by internists’ wives, but still hidden from the public, is that most things get better by themselves. Most things, in fact, are better by morning.” Remember, you don’t come to me with a diagnosis; you come to me with symptoms.
You may have any one of more than 10,000 diseases or conditions, and – truth be told – the odds of me getting the absolute correct diagnosis are not good. You may have an uncommon presentation of a common disease, or a common presentation of an uncommon problem. If you are early in your disease process, I may miss such life-threatening conditions as heart attack or sepsis. If you neglect to truthfully tell me your sexual history or use of drugs and alcohol, I may not follow through with appropriate questions and come to a totally incorrect conclusion about what you need or what you have.
The path to dying, on the other hand, is rather direct – failure of respirations, failure of the heart, failure of the brain, or failure of metabolism.
You may be disappointed that you are not being seen by a “specialist.” Many people feel that when they have their heart attack, they should be cared for by a cardiologist. So they think that the symptom of “chest pain” is their ticket to the heart specialist. But what if their heart attack is not chest pain, but nausea and breathlessness; and what if their chest pain is aortic dissection? So you are being treated by a specialist – one who can discern the life-threatening from the banal, and the cardiac from the surgical. We are the specialty trained to think like this.
If you insist asking “What do I have, Doctor Lex?” you may be disappointed when I tell you “I don’t know, but it’s safe for you to go home” without giving you a diagnosis – or without doing a single test. I do know that if I give you a made-up diagnosis like “gastritis” or “walking pneumonia,” you will think the problem is solved and other doctors will anchor on that diagnosis and you may never get the right answers.
Here’s some good news: we are probably both thinking of the worst-case scenario. You get a headache and wonder “Do I have a brain tumor?” You get some stomach pain and worry “Is this cancer?” The good news is that I am thinking exactly the same thing. And if you do not hear me say the word “stroke” or “cancer,” then you will think I am an idiot for not reading your mind to determine that is what you are worried about. I understand that, no matter how trivial your complaint, you have a fear that something bad is happening.
While we are talking, I may be interrupted once or twice. See, I get interrupted several times every hour – answering calls from consultants, responding to the prehospital personnel, trying to clarify an obscure order for a nurse, or I may get called away to care for someone far sicker than you. I will try very hard to not let these interruptions derail me from doing what is best for you today.
I will use my knowledge and experience to come to the right decisions for you. But I am biased, and knowledge of bias is not enough to change my bias. For instance, I know the pathophysiology of pulmonary embolism in excruciating detail, but the literature suggests I may still miss this diagnosis at least half the time it occurs.
And here’s the interesting thing: I will probably make these errors whether I just quickly determine what I think you have by recognition or use analytical reason. Emergency physicians are notorious for thinking quickly and making early decisions based on minimal information (Type 1 thinking). Cognitive psychologists tell us that we can cut down on errors by using analytical reasoning (Type 2 thinking). It turns out that both produce about the same amount of error, and the key is probably to learn both types of reasoning simultaneously.
有趣的是：不論我僅憑快速的印象決定或以細密的分析決定，我都會犯下這些錯誤。急診醫師以快速思考及依少量訊息作出早期決斷惡名在外 (Type 1 Thinking)。認知心理學家告訴我們，我們可以通過分析推理（Type 2 thinking）減少這些錯誤。事實證明，兩種類型的推理都產生相當量的錯誤，減少錯誤的關鍵可能是同時學習這兩種類型的推理。
After I see you, I will go to a computer and probably spend as much time generating your chart as I did while seeing you. This is essential for me to do so the hospital and I can get paid. The more carefully I document what you say and what I did, then the more money I can collect from your insurance carrier. The final chart may be useless in helping other health care providers understand what happened today unless I deviate from the clicks and actually write what we talked about and explained my thought process. In my eight-hour shift today I will click about 4000 times.
What’s that? You say you don’t have insurance? Well that’s okay too. The US government has mandated that I have to see you anyway without asking you how you will pay. No, they haven’t guaranteed me any money for doing this – in fact I can be fined a hefty amount if I don’t. And a 2003 article estimated I give away more than $138,000 per year worth of free care related to this law.
But you have come to the right place. If you need a life-saving procedure such as endotracheal intubation or decompression needle thoracostomy, I’ll do it. If you need emergency delivery of your baby or rapid control of your hemorrhage, I can do that too. I can do your spinal tap, I can sew your laceration, I can reduce your shoulder dislocation, and I can insert your Foley catheter. I can float your temporary pacemaker, I can get that pesky foreign body out of your eye or ear or rectum, I can stop your seizure, and I can talk you through your bad trip.
Emergency medicine really annoys a lot of the other specialists. We are there 24 hours a day, 7 days a week. And we really expect our consultants to be there when we need them. Yes, we are fully prepared to annoy a consultant if that is what you need.
Yes, I have seen thousands of patients, each unique, in my near-50 years of experience. But every time I think about writing a book telling of my wondrous career, I quickly stop short and tell myself “You will just be adding more blather to what is already out there – what you have learned cannot easily be taught and will not be easily learned by others. What you construe as wisdom, others will see as platitudes.” As author Norman Douglas once wrote: “What is all wisdom save a collection of platitudes. Take fifty of our current proverbial sayings – they are so trite, so threadbare. Nonetheless, they embody the concentrated experience of the race, and the man who orders his life according to their teachings cannot be far wrong. Has any man ever attained to inner harmony by pondering the experience of others? Not since the world began! He must pass through fire.” Have you ever heard of John Coltrane? He was an astonishing musician who became one of the premier creators of the 20thcentury. He started as an imitator of older musicians, but quickly changed into his own man. He listened to and borrowed from Miles Davis and Thelonious Monk, African music and Indian music, Christianity and Hinduism and Buddhism. And from these disparate parts he created something unique, unlike anything ever heard before. Coltrane not only changed music, but he altered people’s expectations of what music could be. In the same way, emergency medicine has taken from surgery and pediatrics, critical care and obstetrics, endocrinology and psychiatry, and we have created something unique. And in doing so, we altered the world’s expectations of what medicine should be.
Now, how can I help you today?
是！在我50年的經驗裡，我看過上萬病人，每個都是獨特的。但每一次，當我想寫一本書，闡述我驚奇美妙的一生,我很快的打斷自己，並自問自答道：「你將會在已經存在的廢話上，增加更多存量–你所學會的事無法簡單授予，亦不會簡單的被他人學會。你詮釋為智慧的，其他人只認為是老生常談。」 作家Norman Douglas曾寫過：「智慧是存放了老生常談的典藏櫃。選出五十條俗諺，看看它們是這麼的陳舊而平凡。儘管如此，它們體現了族群的集體經驗，依據它的指導生活，離道不遠矣。是否有人經由默想它人的經驗，達到內心的和諧？自天地之初未有！他必先穿越烈火。」
你聽過John Coltrane嘛？他是一個驚人的音樂家，20世紀最偉大的先驅開創者之一。 開始時，他也是舊時音樂的模仿者，但很快擁有自己的風格。他從Miles Davis and Thelonious Monk，非洲音樂和印度音樂，基督教、印度教和佛教音樂借來元素。從這些不同的部分，他創造了一種獨特的，不同於以往時代的聽覺體驗。Coltrane不僅改變了音樂，他改變了人們對於音樂的想像。以同樣的方式，急診醫學取經自外科，小兒科，重症加護，產科，內分泌學和精神病學。我們創造了些獨特的東西。這樣做，我們改變了人們對「醫療是什麼？」的期望。