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.

整篇文章有趣又睿智，所以我盡力的完成了翻譯。

 

EM MINDSET – JOE LEX – THINKING LIKE AN EMERGENCY PHYSICIAN
急診之心-JOE LEX-像急診醫師一樣的思考

“Emergency Medicine is the most interesting 15 minutes of every other specialty.”
"急診醫學是所有專科最精采15分鐘的集合"

– 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.

我們有何不同？我們如何將自己和其它專科區辨？和其它專科相比，我們更常在異常的時間，異樣的環境，面對不平常的病患。我們的格言是「任何人 ，任何事，任何時間。」

當其它醫師環繞著「這個病人有什麼問題？診斷是什麼？」打轉；急診醫師持續想著「這個病人需要什麼？現在？五分鐘後？兩個小時內？」這是否牽涉到思考方式的不同？

診視僅帶著症狀，未具診斷，尚未明確呈現分化的病人，對許多醫療同業像是外星人般陌生。是的，這就是我們每天執行的工作任務。每一次，我向病人介紹我自己，我從來不知道，之後的事態會如何發展。但我覺得我應該作如下的免責聲明：

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。

我將問你許多問題.  我將盡我所能以正確的順序，問正確的問題，使我能作正確的決定。我期望你告訴我「故事」。為了能更了解你的「故事」，我會為了澄清你的答案而打斷你。

我問你的問題是一個有意識的決定，但在一個平均八小時的班中，我將作約一萬個有意或無意的決定–下一個要看誰，下一個問題該問什麼，我應執行哪些項目的理學檢查，我聽到的真的是心雜音嘛，我應該開立什麼檢驗，我現在應該看哪種影像，幫你會診哪一個醫師不會被打槍，我是否能信任照顧你的護理人員能達成我所指派的任務，當你將返家時，我是否會記得將回家注意事項交給你？所以即使我只搞砸了0.1%的決定，我今天將犯下十個錯誤。

為了你我雙方共同的利益，我期待你有直白的急症–即高訊噪比：淋病，髕骨脫位，心電圖具典型ST段上升的胸痛。我想都不用想就可以辨認並治療這些疾病。相對的，若你的疾病呈現含有大量的背景噪訊，我有較高的可能走向錯誤的路徑，並得出錯誤的結論。

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.

很高興可以向各位報告，人體非常強韌。我們(人類)經過數千年的演進生存，因此即使我搞砸的機會很…，有很高的機會，你仍將過得好好的。早在18世紀，伏爾泰即告訴我們“醫學的藝術在於–當大自然治癒疾病時，娛樂病人“，這並未有太大的改變。此外路易斯·湯瑪斯醫師寫過：「醫生的小秘密–由內科醫師發現，婚後很快也被他的太太學到，但仍未向大眾開誠布公–許多疾病自行改善，實際上，很多事早晨就會好了。」記得，你不是帶著診斷來找我，你是帶著症狀來找我。

你可能正處在超過一萬個可能疾況之一，而老實說，我達到絕對正確診斷的勝算不高。你可能僅有常見疾病的少見表現，或有著罕見疾病的常見表徵。若你正在病程發展的早期，我可能錯失些致命的狀況–如心臟病發或敗血症。若你忽視如實告知性接觸，藥物及酒精濫用史的重要性，我可能無法接續正確的問題，而得到完全不正確的結論–你的醫療需求或者你的診斷。

往死亡的路，相對的簡單直接–呼吸衰竭，心臟衰竭，腦功能衰竭，或代謝功能衰竭。

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.

你可能因你不是被專家診視而感到失望。許多人期待當他們心臟病發時，他們應受到心臟科醫師的照顧。所以他們認為胸痛的症狀是召喚心臟科醫師的魔咒。但，若他們心臟病發不表現為胸痛，而是噁心嘔吐、呼吸困難；或是他們的胸痛是主動脈剝離引起？所以，你其實是被分辨致命疾病及平凡無奇不適的專家診治，專於分辨僅需內科處理或需外科介入。我們是被訓練如是思考的專家。

「Lex醫師，我今天到底是什麼問題呢？」若您堅持得到答案，在未給予你一個診斷，未執行一項檢查時，當我告訴你：「我不知道，但你現在回家是安全的。」，您可能感到失望。我確切的知道若我給你一個捏造的診斷，像是「胃炎」或「支氣管肺炎」，你會以為問題已經解決了，而其它的醫生將徘徊在那捏造的診斷旁，使你永遠無法得到真正的答案。

這兒有個好消息：我們也許正同時考慮著最壞的情況。您因感到頭痛而懷疑「是否有腦瘤？」；有點胃痛，而煩腦「是癌症嘛？」。好消息是我正在考慮完全相同的問題。若您沒聽到我說“癌症“或是“中風“，可能覺得我是個笨蛋，無法抓住您心中的苦腦。我了解，不論您的主訴是何等的細瑣，您都恐懼惡運將降臨了。當我們正在對談，我都會被打斷個幾次。看吧!每個小時我將被打斷許多次–回覆會診醫師的電話，回應到院前救護人員，向護理人員澄清有疑義的醫囑，或者我將被喚去治療遠比您更嚴重的病患。我盡力不使這些干擾影響到您的最佳治療處置。

我將依我的知識及經驗為您提供正確的決定。但我會受到偏誤的影響，而對偏誤的知識不足以改變我的偏誤。舉例來說，我詳盡知道肺栓塞的生理及病理，但文獻顯示，我仍可能至少在半數病患錯過這個診斷。

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.

診視你之後，我將坐在電腦前，花費和診視你一樣多的時間製造病歷。必須如此，醫院和我才能拿到給付。我越詳細的記錄你說了什麼和我做了什麼, 我就可以從你的保險公司收到更多的錢。病歷對醫療團隊了解今天的病況進展沒有助益，除非–我能放下滑鼠鍵盤，並真正的寫下我們聊了些什麼，解釋我的診斷思考過程。在我今日八小時的工作中，我將進行約4000次的點擊。 

什麼？你沒有保險？好！那也可以。美國政府規定，我必須為你看診，而不需問你將如何付錢。不！他們沒有向我保證這樣做，我可以得到任何金錢。事實上，如果我不這麼做，將被罰一大筆錢。一篇2003年的文章，估計因此條法律提供的免費照護，我每年損失13.8萬元。

但你來對地方了，若你需要救命的處置像是氣管插管或是針刺開胸減壓，我會。若你需要緊急分娩或止血，我也會。我可以抽脊髓液，縫合傷口。我可以將脫臼的肩關節歸位，放尿管。我可以飄放暫時性心臟節律器，也可以將那討厭的異物移出你的體外，不論它在你的眼裡，耳裡，或肛門裡。我可以停止你的抽筋，也帶你走過恐怖幻覺。

急診醫學科真的惹毛了許多其它的專科。我們每週七天，每天二十四小時守在這裡。而我們真的希望當我們需要時，會診醫師就在那等著。是的！若你真的需要，我們已經全力準備好，打擾會診醫師的安眠。

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。

好了，你今天為什麼來急診, 希望我怎麼幫助你？