《The Lost Art of Healing》ⅢHealing the Patient: Science
11. Digitalis – The Price of Invention
Despite a high dosage of drudgery, experimental word has been a heady adventure. The triumphs of discovery made me feel the way I imagine a mountaineer must feel on reaching the top of a hitherto unscaled peak.
As a young researcher in 1950, I soon realized that even experienced medical practitioners were not too clear about when and how to use this medicine (Digitalis).Erroneous ideas were passed, like religious writ, from generation to generation, from one medical text-book to another.
Mrs. M died
A distressing yet empowering experience relating to the use of digitalis occurred at the beginning of my medical career in 1950.
I was dismayed to hear him prescribe a large dose of digitoxin (one of the family of digitalis drugs) and a mercurial diuretic. Without thinking, I burst out, saying, “This combination will kill her. She will surely die within the day.”
The next morning I raced to see Mrs. M., but her bed was empty. She had died during the night. The resident told me that the diuretic finished her off. As she began to pass large quantities of urine, her situation worsened by the moment. Her heart rate reached 220 beats per minute, she turned blue, gasped, and died. Resuscitation was not attempted, as the technique was not to be discovered until a decade later.
Dr. Levine locked the door, Looking ashen; he startled me with the words “What did I do wrong?” / Levine listened attentively without a single interruption. When I finished, he asked a few questions and then commented, “Bernie, I appreciate your teaching me. I should have been less proud and paid attention to what you said.”
Murdered Ms. W.
Judging her situation critical, I hooked up an electrocardiogram and infected in her one remaining vein a bolus of what I gram and injected in her one remaining vein a bolus of what I thought was a small dose of ouabain, one-fifth the usual dose. Nothing happened for five minutes. Then abruptly Ms. W. began to flail her arms and thrash around like a fish out of water. Her mouth grimaced monstrously, repeatedly opening in a wide yawn as though she was hungering for air. Instead of tuned a ghastly shade of purplish blue. As I looked down on the strips of electrocardiographic paper, the rhythm turned chaotic, proclaiming the death knell pattern of ventricular fibrillation. Small bundles of wasted muscle twitched agonally, grasping for the last molecule of oxygen from the no longer circulating bloodstream. Transfixed into helplessness, I stood quavering as though watching a murder committed on a 3-D movie screen. Ms. W. was dead within eight minutes of receiving the injection.
It was unreal! A summary execution had taken place but no moral tremor was felt. Granted, the action was not premeditated and it arose out of ignorance, but when is ignorance a mitigating justification for such a transgression? These very well-trained doctors, who were good human beings, had commiserated with the physically scratched culprit, apparently indifferent to his dead victim.
Without any fiscal support or technical assistance, I was forced to do all the scut work. The investigation did not free me from the heavy clinical load as resident. But the excitement of the work, the important clinical implications revved up extraordinary energies.
Then came my well-rehearsed punch line, namely, that every good scientist believes that next to the promulgation of truth, the public recantation of error was the greatest virtue.
Shakespeare stated it more poetically. In《Romeo and Juliet, Friar》 Virtue itself turns vice, being misapplied; And vice sometime’s by action dignified.
I remain convinced that good ends rarely justify bad means. The gragedy I inflicted on Ms. W. occurred early in my life and honed my moral sensibilities in confronting the myriad of problems a doctor faces. I became sensitized to the fact that reasonable goals propel evil deeds.
Lying in bed for twenty-four hours, in addition to being uncomfortable and unnatural, sapped physical strength and undermined the psychological resolve to recovery. By the third week in bed, depression was the rule, and many patients lost interest in surviving. By contrast, patients managed in a chair did not consider themselves hopelessly ill. After all, in our culture the act of dying takes place in bed, so there was some sense of safety in being out of it. The progressive increase in time allowed out of bed provided a gauge for judging progress. The patient was made an informed and active participant in the healing process. This empowerment, I came to believe, was the critical factor, far more patent in allaying fear and dissipating anxiety than any reassuring words from the medical staff.
Perhaps the most important lesson I derived from this experience is that many medical practices are not soundly based. They are sustained, as is true of other human pursuits, by an inertia supported by fashion, custom, and the word of authority. The security provided by a long-held belief system, even when poorly founded, is a strong impediment to progress. General acceptance of a practice becomes the proof of its validity, though it lacks all other merit. In the words of the great nineteenth-century French physiologist Claude Bernard, the innovator’s talent is in “seeing what everybody has seen, and thinking what nobody has thought.” Once a new paradigm takes hold, its acceptance is extraordinarily rapid and one finds few who claim to have adhered to a discarded method. This was succinctly captured by Schopenhauer, who maintained that all truth passes through three stages: first, it is ridiculed; second, it is violently opposed; and finally, it is accepted as being self-evident.
However, listening to Mr. C.’s heart with a stethoscope, I heard the happy tidings of a strong, regular lub-dub. These heart sounds gave me a goose-pimply thrill, recalling my first hearing, as a youngster, the opening bars of Beethoven’s Fifth Symphony.
Never having seen an AC defibrillator, I hadn’t the remotest idea how to use one. A host of questions needed prompt answers: was the shock painful? Was anesthesia required? Was there an appropriate voltage setting to reverse ventricular tachycardia? If the first shock failed, how many additional ones could be delivered? Did the electric discharge traumatize the heart or injure the nervous system? Could it burn the skin? Were there any hazards for bystanders? Was it explosive for the patient receiving oxygen? My head was migraines from the avalanche of questions.
Resolution of a problem invariably brings new challenges in its wake.
Since the ignorant are the most certain of what is right, the least experienced called the shots.
The PBBH (Peter Bent Brigham Hospital) unit was revolutionary in several respects. It was built with an eye to diminishing psychological stress factors; the lights, for example, were on a rheostat so patients would not be aroused by a burst of bright lights when staff entered. Quiet was emphasized. Patients who wished to listen to a radio had to use earphones. As surgeons are invariably loud, boisterous and threatening, a sign was posted at the CCU door: SURGEONS, DO NOT ENTER UNLESS CONSULTED. The unit was designed to maximize privacy while permitting direct visual contact with the nursing station, that is, patients could see the nurses, and vice versa. In endless exhortations to staff, I emphasized that a tranquil, low-key environment was essential if they were to sense a patient’s mood and state of anxiety. Only when quiet reigns can one detect a low moan and the submerged turmoil of despair.
Nurses were upgraded form medical underlings, their historical role until then, to the level of fellow professionals. The nurses, like the doctors, carried a stethoscope. They participated in morning rounds and commented about patients, providing invaluable insights on what was troubling them ─ information the house staff rarely picked up themselves. An overburdened intern or medical resident on a fleeting visit to deal with some urgent clinical problem rarely took time to listen to the patient. We had teaching conferences for nurses, and I gave a weekly one-hous session exclusively for them. It was a new type of participatory nursing. Excitement was palpable and morale high.
With a cardiac arrest, nurses were instructed not to wait for doctors but to initiate immediate defibrillation(去顫器). Exquisitely trained in cardiopulmonary resuscitation (CPR), they were more skilled than the medical house staff. While the latter received training in CPR, they had no time to practice. It was and aesthetic experience to watch a specialist nurse respond to a cardiac arrest.
We were on the threshold of a new age in medicine, where the excitement resided in the application of novel technologies more than in caring for individual patients.
Of course, every silver lining has its cloud. Every advance exacts a cost. Medicine grew even more depersonalized. Technology took precedence and patients became secondary. A paradox of my life and its ultimate irony is that my research work facilitated that which I utterly deplore.
15. The Ventricular Extrasystole: Heartthrob or Harbinger
These observations were at odds with my hypothesis, reminding me of a remark by Thomas Henry Huxley: “The tragedy of scientific inquiry is that a beautiful hypothesis may be slain by an ugly fact.” Was my theory relating extrasystoles (心室期外收縮) to sudden death merely an insupportable fancy?
In talking about my half century of research, I want ot make crystal clear my unalterable commitment to and deep roots in the scientific medical community. I am convinced of the indispensability of scientific medicine and advanced technology to effective doctoring. Frrom the vantage point of a clinical researcher, I have come to realize that caring without science is well-intentioned kindness, but no medicine. On the other hand, science without caring empties medicine of healing and negates the great potential of an ancient profession. The two complement and are essential to the art of doctoring.
One anecdote remains to be told. Life’s paradoxical unpredictabilities worked themselves out far differently than I had imagined. The Soviet connection, rather than galvanizing interest in sudden death in the United States, resulted in my lasting friendship with Dr. Evgeni Chazov. This in turn led to our cooperation in organizing the International Physicians for the Prevention of Nuclear War. In 1985, Chazov and I were honored to be the recipients of the Nobel Peace Prize on behalf of the organization we had founded to mobilize world opinion against the nuclear threat.
DR. BERNARD LOWN is a cardiologist of world renown. He is professor emeritus of cardiology at the Harvard School of Public Health and senior physician at Brigham and Women’s Hospital in Boston; he is in active cardiology practice at the Lown Cardiovascular Center in Brookline, Massachusetts.
A pioneer in research on sudden cardiac death, Dr. Lown invented the defribillator and the cardiovertor and introduced the drug lidocaine, used worldwide to control disturbances of the heartbeat. His current research focuses on the impact of adverse psychological stresses on cardiac performance.
Dr. Lown has been instrumental in involving physicians globally in raising public awareness of the catastrophic consequences of nuclear war and the urgency of the abolition of these weapons of genocide. He is cofounder and co-president emeritus of International Physicians for the Prevention of Nuclear War (IPPNW), which has seen its membership grow to more than 200,000 physicians in 80 nations since its establishment in 1980. In 1985 Dr. Lown accepted the Nobel Peace Prize on behalf of the organization.
Currently Dr. Lown is chairman of the AD Hoc Committee to Defend Health Care, a group of doctors who are campaigning against market managed health care and for-profit medicine.
Dr. Lown is the author or coauthor of four books and over four hundred articles that have been published in leading medical journals worldwide. He graduated from University of Maine and received his M.D. from Johns Hopkins University School of Medicine.
6 則留言:
將觸角從「台灣心跳聲」延伸，閱讀羅恩醫師搶救心跳之思與行的智慧。
《The Lost Art of Healing》ⅢHealing the Patient: Science
11. Digitalis – The Price of Invention
Despite a high dosage of drudgery, experimental word has been a heady adventure. The triumphs of discovery made me feel the way I imagine a mountaineer must feel on reaching the top of a hitherto unscaled peak.
As a young researcher in 1950, I soon realized that even experienced medical practitioners were not too clear about when and how to use this medicine (Digitalis).Erroneous ideas were passed, like religious writ, from generation to generation, from one medical text-book to another.
Mrs. M died
A distressing yet empowering experience relating to the use of digitalis occurred at the beginning of my medical career in 1950.
I was dismayed to hear him prescribe a large dose of digitoxin (one of the family of digitalis drugs) and a mercurial diuretic. Without thinking, I burst out, saying, “This combination will kill her. She will surely die within the day.”
The next morning I raced to see Mrs. M., but her bed was empty. She had died during the night. The resident told me that the diuretic finished her off. As she began to pass large quantities of urine, her situation worsened by the moment. Her heart rate reached 220 beats per minute, she turned blue, gasped, and died. Resuscitation was not attempted, as the technique was not to be discovered until a decade later.
Dr. Levine locked the door, Looking ashen; he startled me with the words “What did I do wrong?” / Levine listened attentively without a single interruption. When I finished, he asked a few questions and then commented, “Bernie, I appreciate your teaching me. I should have been less proud and paid attention to what you said.”
Murdered Ms. W.
Judging her situation critical, I hooked up an electrocardiogram and infected in her one remaining vein a bolus of what I gram and injected in her one remaining vein a bolus of what I thought was a small dose of ouabain, one-fifth the usual dose. Nothing happened for five minutes. Then abruptly Ms. W. began to flail her arms and thrash around like a fish out of water. Her mouth grimaced monstrously, repeatedly opening in a wide yawn as though she was hungering for air. Instead of tuned a ghastly shade of purplish blue. As I looked down on the strips of electrocardiographic paper, the rhythm turned chaotic, proclaiming the death knell pattern of ventricular fibrillation. Small bundles of wasted muscle twitched agonally, grasping for the last molecule of oxygen from the no longer circulating bloodstream. Transfixed into helplessness, I stood quavering as though watching a murder committed on a 3-D movie screen. Ms. W. was dead within eight minutes of receiving the injection.
It was unreal! A summary execution had taken place but no moral tremor was felt. Granted, the action was not premeditated and it arose out of ignorance, but when is ignorance a mitigating justification for such a transgression? These very well-trained doctors, who were good human beings, had commiserated with the physically scratched culprit, apparently indifferent to his dead victim.
Without any fiscal support or technical assistance, I was forced to do all the scut work. The investigation did not free me from the heavy clinical load as resident. But the excitement of the work, the important clinical implications revved up extraordinary energies.
Then came my well-rehearsed punch line, namely, that every good scientist believes that next to the promulgation of truth, the public recantation of error was the greatest virtue.
Shakespeare stated it more poetically. In《Romeo and Juliet, Friar》
Virtue itself turns vice, being misapplied;
And vice sometime’s by action dignified.
I remain convinced that good ends rarely justify bad means. The gragedy I inflicted on Ms. W. occurred early in my life and honed my moral sensibilities in confronting the myriad of problems a doctor faces. I became sensitized to the fact that reasonable goals propel evil deeds.
12. A New Medical Tradition
Lying in bed for twenty-four hours, in addition to being uncomfortable and unnatural, sapped physical strength and undermined the psychological resolve to recovery. By the third week in bed, depression was the rule, and many patients lost interest in surviving. By contrast, patients managed in a chair did not consider themselves hopelessly ill. After all, in our culture the act of dying takes place in bed, so there was some sense of safety in being out of it. The progressive increase in time allowed out of bed provided a gauge for judging progress. The patient was made an informed and active participant in the healing process. This empowerment, I came to believe, was the critical factor, far more patent in allaying fear and dissipating anxiety than any reassuring words from the medical staff.
Perhaps the most important lesson I derived from this experience is that many medical practices are not soundly based. They are sustained, as is true of other human pursuits, by an inertia supported by fashion, custom, and the word of authority. The security provided by a long-held belief system, even when poorly founded, is a strong impediment to progress. General acceptance of a practice becomes the proof of its validity, though it lacks all other merit. In the words of the great nineteenth-century French physiologist Claude Bernard, the innovator’s talent is in “seeing what everybody has seen, and thinking what nobody has thought.” Once a new paradigm takes hold, its acceptance is extraordinarily rapid and one finds few who claim to have adhered to a discarded method. This was succinctly captured by Schopenhauer, who maintained that all truth passes through three stages: first, it is ridiculed; second, it is violently opposed; and finally, it is accepted as being self-evident.
13. The Shock that Cures: DC and Cardioversion
However, listening to Mr. C.’s heart with a stethoscope, I heard the happy tidings of a strong, regular lub-dub. These heart sounds gave me a goose-pimply thrill, recalling my first hearing, as a youngster, the opening bars of Beethoven’s Fifth Symphony.
Never having seen an AC defibrillator, I hadn’t the remotest idea how to use one. A host of questions needed prompt answers: was the shock painful? Was anesthesia required? Was there an appropriate voltage setting to reverse ventricular tachycardia? If the first shock failed, how many additional ones could be delivered? Did the electric discharge traumatize the heart or injure the nervous system? Could it burn the skin? Were there any hazards for bystanders? Was it explosive for the patient receiving oxygen? My head was migraines from the avalanche of questions.
Resolution of a problem invariably brings new challenges in its wake.
14. The Coronary Care Unit
Since the ignorant are the most certain of what is right, the least experienced called the shots.
The PBBH (Peter Bent Brigham Hospital) unit was revolutionary in several respects. It was built with an eye to diminishing psychological stress factors; the lights, for example, were on a rheostat so patients would not be aroused by a burst of bright lights when staff entered. Quiet was emphasized. Patients who wished to listen to a radio had to use earphones. As surgeons are invariably loud, boisterous and threatening, a sign was posted at the CCU door: SURGEONS, DO NOT ENTER UNLESS CONSULTED. The unit was designed to maximize privacy while permitting direct visual contact with the nursing station, that is, patients could see the nurses, and vice versa. In endless exhortations to staff, I emphasized that a tranquil, low-key environment was essential if they were to sense a patient’s mood and state of anxiety. Only when quiet reigns can one detect a low moan and the submerged turmoil of despair.
Nurses were upgraded form medical underlings, their historical role until then, to the level of fellow professionals. The nurses, like the doctors, carried a stethoscope. They participated in morning rounds and commented about patients, providing invaluable insights on what was troubling them ─ information the house staff rarely picked up themselves. An overburdened intern or medical resident on a fleeting visit to deal with some urgent clinical problem rarely took time to listen to the patient. We had teaching conferences for nurses, and I gave a weekly one-hous session exclusively for them. It was a new type of participatory nursing. Excitement was palpable and morale high.
With a cardiac arrest, nurses were instructed not to wait for doctors but to initiate immediate defibrillation(去顫器). Exquisitely trained in cardiopulmonary resuscitation (CPR), they were more skilled than the medical house staff. While the latter received training in CPR, they had no time to practice. It was and aesthetic experience to watch a specialist nurse respond to a cardiac arrest.
We were on the threshold of a new age in medicine, where the excitement resided in the application of novel technologies more than in caring for individual patients.
Of course, every silver lining has its cloud. Every advance exacts a cost. Medicine grew even more depersonalized. Technology took precedence and patients became secondary. A paradox of my life and its ultimate irony is that my research work facilitated that which I utterly deplore.
15. The Ventricular Extrasystole: Heartthrob or Harbinger
These observations were at odds with my hypothesis, reminding me of a remark by Thomas Henry Huxley: “The tragedy of scientific inquiry is that a beautiful hypothesis may be slain by an ugly fact.” Was my theory relating extrasystoles (心室期外收縮) to sudden death merely an insupportable fancy?
In talking about my half century of research, I want ot make crystal clear my unalterable commitment to and deep roots in the scientific medical community. I am convinced of the indispensability of scientific medicine and advanced technology to effective doctoring. Frrom the vantage point of a clinical researcher, I have come to realize that caring without science is well-intentioned kindness, but no medicine. On the other hand, science without caring empties medicine of healing and negates the great potential of an ancient profession. The two complement and are essential to the art of doctoring.
One anecdote remains to be told. Life’s paradoxical unpredictabilities worked themselves out far differently than I had imagined. The Soviet connection, rather than galvanizing interest in sudden death in the United States, resulted in my lasting friendship with Dr. Evgeni Chazov. This in turn led to our cooperation in organizing the International Physicians for the Prevention of Nuclear War. In 1985, Chazov and I were honored to be the recipients of the Nobel Peace Prize on behalf of the organization we had founded to mobilize world opinion against the nuclear threat.
英文平庸的我，仍在研讀許多片段，在無人可以請教之下，不懂的部分，只能無奈面對無法讀懂的事實。透過打字，將第3單元一字字保存閱讀筆記，除了藉以幫助自己復習之外，同時將這本好書作分享。同一本書，帶給每一位讀者的啟發或有不同，這些筆記如不符您的期待或需求，請多多包涵。無論如何，但願羅恩醫師所思所行，能帶給您我不同角度的感動、啟發與學習。
令我印象深刻的羅恩醫師 (Bernard Lown, M.D.)
- 敏銳與不斷地自我反思
- 可貴崇高的醫德與慈悲
- 勇於承認犯錯，進而以積極、深度思考與明智，讓遺憾不再發生。
- 腹有詩書氣自華。單就這單元引用了：莎士比亞、叔本華名言以及貝多芬作品等等…
以上淺見提供大家參考。
─ About the Author
DR. BERNARD LOWN is a cardiologist of world renown. He is professor emeritus of cardiology at the Harvard School of Public Health and senior physician at Brigham and Women’s Hospital in Boston; he is in active cardiology practice at the Lown Cardiovascular Center in Brookline, Massachusetts.
A pioneer in research on sudden cardiac death, Dr. Lown invented the defribillator and the cardiovertor and introduced the drug lidocaine, used worldwide to control disturbances of the heartbeat. His current research focuses on the impact of adverse psychological stresses on cardiac performance.
Dr. Lown has been instrumental in involving physicians globally in raising public awareness of the catastrophic consequences of nuclear war and the urgency of the abolition of these weapons of genocide. He is cofounder and co-president emeritus of International Physicians for the Prevention of Nuclear War (IPPNW), which has seen its membership grow to more than 200,000 physicians in 80 nations since its establishment in 1980. In 1985 Dr. Lown accepted the Nobel Peace Prize on behalf of the organization.
Currently Dr. Lown is chairman of the AD Hoc Committee to Defend Health Care, a group of doctors who are campaigning against market managed health care and for-profit medicine.
Dr. Lown is the author or coauthor of four books and over four hundred articles that have been published in leading medical journals worldwide. He graduated from University of Maine and received his M.D. from Johns Hopkins University School of Medicine.
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