还有他们!美国急诊科医生的「左膀右臂」

2018-04-28 15:07 来源:丁香智汇 作者:
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今天,我们来聊一聊美国急诊科医生是如何与其他专科医生合作的呢?

Dr. 宋:Dr. Hou, our audience in China are keen to know more about How Emergency Physicians collaborate with other specialists. Let’s talk about it today.

侯医生,我们在中国的听众想要了解急诊科医生如何与其他专科的医生合作。今天就让我们来谈谈这个话题吧。

Dr. 侯:Sounds good.

好的。

Dr. 宋:First let’s talk about those collaborations in ED settings. Many patients in ED need consultations from other specialties. Could you tell us more about it?

首先让我们谈谈急诊室里的合作。许多急诊科患者需要其他专科医生的会诊。您能和我们聊聊这方面吗?

Dr. 侯:Yes, I agree.  Many patients do require subspecialty expertise in addition to their emergency care. So as background for our department, we have already set up a sort of individual attending staff physicians have liaison to the individual subspecialties such as somebody will be speaking with the cardiology representative and oncology representative. 

Even among the surgical subspecialties I am currently in charge of liaising the cardiac surgery patients who may come into the ED once in a while. And we want to make sure those processes and communications of care for those patients are transparent to the primary providers.

是的,我同意。除了急诊科的治疗外,许多患者确实需要亚专科的协助治疗。作为背景了解,我们部门已经建立了一种主治医生个人与不同亚专科的联系。例如有人会与心脏科代表和肿瘤科代表交谈。在外科亚专科中,我目前负责联络可能会偶尔进入急诊科的心脏外科手术患者。我们希望确保这些患者的治疗过程和其中的沟通对其家庭医生是透明的。

Dr. 宋:Then, are there any multi-disciplinary care for patients in ED?

那么,急诊科患者是否有多学科治疗呢?

Dr. 侯:Absolutely! I think multi-disciplinary care now is such an important process for care in patients who require time sensitive interventions. For example, we already know that STEMI care, often time we require the communication with our pre-hospital ambulance, paramedic specialists who can do the 12-lead EKG pre-arrival. And if it is a good story of the chest pain and the ST elevation on the cardiogram then we actually have a process to activate the cardiac cath lab. So this is an example of multi-disciplinary care also involving pre-hospital providers. 

当然!我认为多学科治疗对于需要时间敏感干预的患者来说是一个非常重要的过程。例如,我们已经知道 ST 段抬高心肌梗死的治疗,通常我们需要与我们的医院前救护车中可以在抵院前做 12 导联心电图的医疗救护专家沟通。如果其病史是胸痛和心电图 ST 段抬高,那么我们实际上有一个流程来激活心导管实验室。这是涉及医院前治疗者的多学科治疗的一个例子。

Additionally, as we know stroke care with our t-PA process for patient within a time window for our stroke specialist as well as our radiologist need to be closely prepared for this kind of team effort approach to take care of the right patient and the right care at the right time. Same with our trauma care as well, often times we need our trauma colleagues and surgical colleagues of subspecialty surgeons such as orthopedic doctors, neurosurgeon or spine surgeon to be activated so that in the poly-trauma patient that we are ready to take care of the patient from multiple viewpoints in addition to the emergency care that we provide. So these are the classic examples of we do multiple disciplinary care for patients in the ED.

此外,由于我们知道在一定时间窗口内应用 t-PA 的卒中治疗,我们需要卒中专家及放射科医师为这种团队协作方式做好准备,以确保正确的患者在正确的时间得到正确的治疗。我们的创伤治疗也是一样,通常我们需要激活我们的创伤外科同事,以及骨科医生,神经外科医生或脊柱外科医生等外科专家,以便在多创伤患者中使患者在急诊科治疗以外得到多个专科的照顾。这些就是我们为急诊科患者提供多学科治疗的典型例子。

Dr. 宋:I see. How about patient being admitted to the ward? Any communication on this process with other specialists?

我明白了。那么当患者收入病房时呢?此过程中是否与其他专科医生进行沟通呢?

Dr. 侯:Absolutely! We often times admit patient to the ward and usually under the hospitalist service. Or maybe even the oncologist service they have their own service, or cardiologist service. So we will be communicating with cardiologist, oncologist or even other subspecialist such as a patient came in with GI bleed. So we will be communicating, letting the GI specialist know that this patient has been admitted and will require their services sooner or later depending on the clinical condition. 

当然!我们经常将患者收入病房,并且通常由医院医生负责。或者肿瘤科医生或心内科医生有自己的服务。因此,我们将与心内科专家,肿瘤科专家甚至其他亚专科医生进行沟通。如患者出现胃肠道出血,我们将与消化科专家进行沟通,让其知道这名患者已被收住院,并将根据临床情况需要他们的服务。

Other subspecialty services we do get involved is infectious disease. There are a lot of patients who are unfortunately immunocompromised and maybe have chronic infections. Then we will call the specialist to titrate our antibiotic therapy more appropriately. So these are just examples that we have specially that we consult for patient who are stable to be admitted to the ward.

其他我们涉及的亚专科服务是传染病科。有很多患者不幸免疫功能低下,可能会有慢性感染,我们会给传染科专家打电话从而更恰当地调整抗生素治疗。这些就是我们为那些病情稳定的收住病房患者进行会诊的例子。

Dr. 宋:How about for patients being admitted to the ICU?

那么对于收住 ICU 的患者是怎样的呢?

Dr. 侯:Likewise, we speak to our intensivist colleagues closely. We have many ICUs here quite specialized to medical, coronary and other different surgical intensive care units. And respectively depending on what the patient’s condition is that require the ICU care, we will communicate to that specialty and ICU service taking care of that patient.

同样的,我们也和我们的重症监护科同事密切交流。我们有很多重症监护病房专门用于医疗,冠状动脉和其他不同的外科重症监护病房。根据患者的病情需要什么样的 ICU 护理,我们将与负责治疗患者的该专科和 ICU 服务团队沟通。

Dr. 宋:Ok, I see. Then what is the communication between emergency physician and the primary care providers?

好的,我明白了。那么急诊科医生和初级保健提供者(家庭医生)之间的沟通是什么样的呢?

Dr. 侯:Yes.  This is of utmost importance for most patients who come to the ED. For example, in our ED, we admit about 30% of patients, so 70% will be discharged to go back home or go to outside of the hospital setting, and then we of course will try to understand how is their relationship with their primary care physician. And if possible if they are within our hospital network, we will communicate with them by email or even call them during business hours to close the loop with the primary care physician especially many time the primary care physician will refer their patients to the ED for acute workups, and hence our close communication is most important.

是的。这对大多数来急诊室的病人来说是最重要的。例如,在我们的急诊科,我们收住院 30% 的患者,所以 70% 的患者将会出院回家或去医院外,然后我们当然会试着了解他们与他们的家庭医生的关系。如果他们在我们的医院网络内,我们将通过电子邮件与他们沟通,甚至在工作时间打电话给他们,以便与初级保健医师的沟通形成闭环,特别是在初级保健医生很多时候将他们的患者转诊给急诊室做急性检查时,(医生间的)密切沟通是最重要的。

As an example, we also have a primary care physician group in the hospital here at Brigham, they are called the Brigham’s circle group and they are one of the more traditional primary care group onsite where in the past our PCP would take care of their patients even when they are admitted to the hospital. And this group will attend on their own patients and they have a service in our hospital taking care of them. I still remember when I started back in the mid to late 2000, the PCPs would like to be called 24 hours a day anytime a day. And often time when they call they will response in a timely manner. And in acute emergency, a lot of these PCPs within the group would physically come to see their patient in the ED and contribute to the workup because they know these patients so well over time for decades. 

举一个例子,我们在布列根和妇女医院也有一个初级保健医生组,他们被称为布列根圈子组,他们是当今较传统的初级保健组之一,过去如果他们的病人被收住院,这个小组的医生将去照看他们自己的病人,并且在我们的医院为患者提供服务。我仍然记得,当我从 2000 年中后期开始时来布列根医院工作时,家庭医生每天 24 小时的任何时候都能被叫到。而且往往他们接到电话时会及时回应。在紧急情况下,该组中的许多家庭医生将亲自到急诊科看望他们的患者,并开具检查,因为他们已了解这些患者多年。

And for example, memorably an example I have was Dr. Marshall Wolf, a Professor in Medicine at Harvard Medical School. At 2 o』clock in the morning, I had one of his patients coming in looked like ST elevation but patient was also in heart failure. So, it was kind of mimic of acute decompensate heart failure causing a STEMI, and he came in and felt that it was not a true acute coronary event, and we treated the heart failure. So that was a memorable experience for me as an attending to know these back then and still now their PCPs care for their patients this way.

举个例子,我记得哈佛医学院医学教授马歇尔沃尔夫医生在凌晨 2 点出现在医院,我的一位病人就诊时看起来像 ST 段抬高性心肌梗死,但患者也出现了心力衰竭。所以,这有点像急性失代偿性心脏衰竭引起的 ST 段抬高性心肌梗死,他来医院后觉得这不是一个真正的急性冠脉事件,于是我们治疗了心力衰竭。这对当主治医师的我来说是一段难忘的经历,我知道过去和现在这些家庭医生仍然是以这种方式照顾他们的病人。

Dr. 宋:Thank you so much for your sharing. Let’s call it a day for today’s program.

非常感谢您的分享。今天的节目就到这里啦。

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中美医生介绍

美国医生:侯全益医生,哈佛医学院急诊科讲师, 布列根和妇女医院急诊科医生,外科 ICU 重症监护专家。

U.S. doctor: Dr. Peter Hou is an Instructor in Emergency Medicine at Harvard Medical School, an Emergency Physician at Brigham and Women’s Hospital, and a critical care specialist in the Surgical ICU.

中国医生:宋瑞医生,曾在中国和新加坡担任内科住院医师,现为自由作家,同时在波士顿进行自闭症相关临床研究。
Chinese doctor: Dr. Rui Song, former resident physician of internal medicine in China and Singapore,  freelancer  and she is doing clinical research on Autism in Boston.

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