愛善醫院對開斜坡 車禍現場 專線小巴內58Please respect copyright.PENANAGBmTVa4yaW
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"哎...." 漸漸恢復知覺的輝SIR,微微睜開眼,驚見其他座位上盡是重傷昏迷的乘客,回過神來,記得從小巴滾下斜坡時令自己失去知覺,心想若沒扣上安全帶,早已被拋出車外,神志稍定後立即想以左手解開安全帶扣,才驚覺左臂因撞擊導致脫骹,只好轉以右手解開帶扣後,雖發覺雙腿移動時出現劇痛,仍忍痛緩緩地爬出車廂,好讓自己呼吸新鮮空氣之餘,亦靜待救援,深懂拯救之道的輝SIR,評估自己現時情況後,已自知並不符合拯救他人條件,因此縱使面對遍地盡是被小巴拋出傷者,心中感覺如何不忍仍愛莫能助,況且輝SIR漸漸感覺到,意識開始再度陷入模糊,可能全因腦部受劇震所致,正當眼見救援隊伍向自己步近時,身後突然發出隆然巨響,人隨即被氣流震飛,將要著地時剛好被數個救援隊員接著,但已因衝力再度失去知覺...58Please respect copyright.PENANAef7BQBQZHF
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15分鐘後 急症室內58Please respect copyright.PENANAKS1mYw4eJ0
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"DR.張,呢度有個傷者雙耳出血,呼吸脈搏微弱,仲有INTERNAL BLEEDING...."急症室護士正高聲作出呼喚58Please respect copyright.PENANAvB3DAhLcuW
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"係佢!? 瞳孔開始放大,係顱內出血,人來同我搓住上CT,要快!!" DR.張驚覺重傷者竟是輝SIR,即時進行施救,並邊推病床邊下指令" 唔該CALL埋心胸肺DR.楊,骨科DR.劉同神經外科DR.洪去CT室.."58Please respect copyright.PENANAiFEpGoXHVY
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30分鐘後 電腦素描室58Please respect copyright.PENANAj8xv5meAeR
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"診斷結果係SDH,二尖瓣撕裂,肝臟出血,雙腿骨折同左臂脫骹,小巴爆炸後剩低佢仲有得救,而且係我地同事,點都唔可以俾佢死,SDH就由我同DR.洪負責!!" DR.張正與幾位醫生研討如何拯救輝SIR58Please respect copyright.PENANAscSiDIxj8W
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"我都要救番佢,repair of mitral valve就交俾我!!" DR.楊自信地拍了拍胸口58Please respect copyright.PENANAwOSTC383Rv
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"肝臟止血就由我負責,仲會睇埋有冇其他部位出血..." DR.羅看了看CT之後說58Please respect copyright.PENANAI6LkCfHiN5
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"同一時間要開刀,麻醉科醫生仲處理緊手術,咁搵邊個去負責....."DR.洪正在質疑58Please respect copyright.PENANA2q4osyzuik
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"仲有我可以處理.." 自動門打開,一名醫生徐徐步進58Please respect copyright.PENANA7iQKeoAtG4
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"DR.洛,你返左來?" 眾醫生訝異地望向DR.洛58Please respect copyright.PENANAaLu8wKMmVA
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"我啱啱由英國到香港,一落機DR.林就通知我醫院有災難警報,要我即刻返來.."58Please respect copyright.PENANAT0ZaRtA7Eq
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"咁駁骨就由我去做啦,之不過打石膏就....."DR.劉欲言又止58Please respect copyright.PENANAslutumcKlL
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"救左人先,唔好諗咁多!! CALL OT STAND BY!!" DR.洛以代CEO身份下令58Please respect copyright.PENANASOu7IwnqcD
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"咁我地去準備,5分鐘後OT見!!"一眾醫生隨即離開,同一時間,床邊盡是維生儀器,奄奄一息的輝SIR被推進手術室準備接受手術58Please respect copyright.PENANAvRA5z9aobd
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硬腦膜下血腫(Subdural hematoma, SDH)發生於20%~40%的嚴重頭部外傷患者,是最常見的頭部創傷性腫塊。Subdural hemtoma位在硬腦膜和蜘蛛網膜之間,形狀通常呈新月型,挫裂傷是出血的主要來源。又依時程分為acute subdural hematoma(3天內,發生率占70%)、subacute subdural hematoma、chronic subdural hematoma。通常是由於靜脈血管破裂而引起,主要是由於腦組織與顱骨相對磨擦的結果,造成穿越硬腦膜下腔注入硬腦膜竇的大靜脈因牽扯而破裂。根據臨床症狀之出現,可分為急性,次急性及慢性三類,其中急性硬腦膜下腔出血因其表示有嚴重腦損傷,故死亡率高。58Please respect copyright.PENANAHG8WQMJ0LJ
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一般Subdural hematoma的治療取決於大小與發展速度,一些小型的subdural hematoma可以在監控下由身體自行吸收,或是用暫時性導管穿過顱骨將血腫吸出。較大型或有症狀的subdural hematoma則多以手術打開硬腦膜將血腫取出並止血,然而手術後有併發症如顱內壓上升、腦水腫、出血、感染及癲癇等可能性。58Please respect copyright.PENANA0py4l8L9aL
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repair of mitral valve二尖瓣修補手術,在過去30年已有重大的改良;雖然過去其治療角色一度受到懷疑,然而因為它比二尖瓣置換術更符合生理,並且較能降低人工瓣膜相關的併發症,令其今日成為二尖瓣逆流的主要治療方式之一。長期累積的實證亦使心臟外科醫生採取更積極的態度進行修補手術,藉此改善病人的生活品質。在現今主要的醫學中心裏,二尖瓣修補術已是司空見慣的常規手術。58Please respect copyright.PENANAVYIYBCu4Gr
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5分鐘後 手術室外58Please respect copyright.PENANA98A0j0GPHr
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"ANNIE,係妳? 師傅強呢?" DR.劉望著身穿綠色手術服的ANNIE迎面而來58Please respect copyright.PENANAUSwY3FzrGH
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"強哥有第二個手術要跟,叫我幫你手,不過今次係我第一次單獨做..."58Please respect copyright.PENANA8vMkdjU9Sl
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"師傅強都覺得妳得,就應該俾D信心,一陣我地係最後先開始,所以唔使緊張...之不過..."58Please respect copyright.PENANAeXOKWnLcku
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"不過咩呀DR.劉?" ANNIE見DR.劉欲言又止,配上口罩的她不禁展現疑惑眼神58Please respect copyright.PENANAfaowXgYLcr
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"冇咩....我地入去啦....."DR.劉無奈引領她進內....58Please respect copyright.PENANA7nhZWrSwYf
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當第一重門打開,兩人進入內門前,按下腳踏開門58Please respect copyright.PENANAFaMyQ1LfTi
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當左右門向兩邊徐徐展開,首先映入ANNIE眼簾的,乃一眾準備就緒的醫生及手術室護士,然後再望向躺於手術床上全身插滿喉管的,竟是...58Please respect copyright.PENANAPg7JWHaMQ6
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"輝!!"ANNIE呆立了一秒,對眼前的景象顯得難以接受,眾醫生同時以無奈目光望向她58Please respect copyright.PENANAeIahjtulxj
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"妳如果要出去,呢度冇一個人會怪妳..."DR.劉實在不願ANNIE接受如此殘酷時刻58Please respect copyright.PENANADdOsH3fKRZ
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"DR.劉,各位醫生,我OK!!" ANNIE眼神顯露前所未有的堅定58Please respect copyright.PENANAjHbvYjKIK3
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"ANNIE,我係代CEO DR.洛,妳唔需要勉強自己,如果妳要離開我唔會話妳擅離職守..."DR.洛之前有替至愛開刀相同經歷,從DR.張口中得知情況後實在不願ANNIE步自己後塵58Please respect copyright.PENANAJcf3ozkxAi
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"多謝你DR.洛,我要陪住佢,用精神支持佢!!我控制到自己情緒!!"ANNIE仍舊以堅定目光示人58Please respect copyright.PENANAfWIIgD4jdm
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"OK,咁我地開始..." 眾醫生點頭示意下,護士按動跳字鐘開始計時....58Please respect copyright.PENANA5ah0qE0Si5
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"首先做Craniotomy同佢減腦壓,再放EVD,DR.洪,妳幫我HOLD 住..."DR.張邊在輝SIR頭蓋開孔邊吩咐DR.洪在旁準備58Please respect copyright.PENANAg6YlGMe0aY
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"DR.洛,出血量.."DR.楊已作好準備58Please respect copyright.PENANA85lQBEiJSb
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"UNDER CONTROL,DR.楊你可以開始.."DR.洛望了望身旁血量計後示意DR.楊可以準備開胸58Please respect copyright.PENANAW8VrTem0mO
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"OK...手術刀.....RETRACTOR...Mitral Valve exposure..."DR.楊以最少出血量熟練地完成開胸58Please respect copyright.PENANAmsjHPfo1By
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"人工心肺機已經STAND BY..."DR.洛作出指示58Please respect copyright.PENANAqD9j9EoHSI
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"OK,喉管接駁好,可以START.." DR.楊同樣以最快速度完成接駁58Please respect copyright.PENANAhJY1Es034v
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"人工心肺機START!!倒數計時30分鐘!!"DR.洛示意操作員開動按鈕58Please respect copyright.PENANAbttDbEZoSq
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"而家開始REPAIR OF MITRAL VALUE....Malleable spatula.....你同我撐開同HOLD住...Cardiac stabilizer.."DR.楊示意助手協助擴闊空間以進行二尖瓣修補...58Please respect copyright.PENANAM6IHUzsvf1
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"唔該CROSS MATCH 4包血...DR.羅可以開始..." DR.洛檢視出血量後作出準備輸血指示,以防DR.羅閞始剖腹時因出血量大增導至輝SIR出現失血過多風險...58Please respect copyright.PENANAWavRBjXIKC
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"OK...手術刀.....Self-Retaining RETRACTOR,紗布止血,太多血睇唔清楚出血位, Suction,見到出血位....Hemostatic Forceps.....已經夾住血管止血,Vein Retractor,幫我拉開....暫時未有其他出血位...Needle Holder 4號線.....開始縫合肝臟....."DR.羅同時以快速手法進行止血並縫合以盡快減低出血量58Please respect copyright.PENANAY3xaPJkudG
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"頭蓋骨開左...走燈,MIRCOSCROPE....DR.洪準備EVD....POINT MATCH....HOLD....."58Please respect copyright.PENANAUnUoIrliHB
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"DR.張,腦壓比之前回落10% BP110/80 SPO2 90....DR.楊,仲有15分鐘..." DR.洛不時發布儀器顥示維生指數及剩餘時間58Please respect copyright.PENANARYbC0rC4Gf
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"OK....仲差少少....輝SIR,撐住呀...."DR.楊正埋首與時間競賽,務求盡快完成...58Please respect copyright.PENANAarzlK1Cpc3
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同樣地,表面強作鎮定的ANNIE此刻只好默默在精神上作出支持...58Please respect copyright.PENANAewnGAGq0K9
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"已經搵到血塊,左手SUCTION....右手BIPOLAR........開始止血....止血完成,麻煩DR.洪同PATIENT做瞳孔檢定..."58Please respect copyright.PENANA2xnnRJHmYw
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"PATIENT左右瞳孔已收細..."DR.洪作出回報58Please respect copyright.PENANApXgAJAb6Xo
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"GOOD,暫時放置引流管,腦腫脹開始消退,可放回頭蓋骨縫合,兼且沖洗積血..."DR.張在DR.洪協助下開始進行最後步驟並縫合58Please respect copyright.PENANAcuVSImOA8E
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"我呢便都完成...可以準備DISCONNECT人工心肺..."一番努力,DR.楊亦完成二尖瓣修補..58Please respect copyright.PENANALLRmOCInM5
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"OK...人工心肺STOP..."再次確認後,DR.洛指示操作員關閉人工心肺運作..58Please respect copyright.PENANAlZAQUHThcX
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眾人屏息以待,手術床上的輝SIR心臟再次跳動....58Please respect copyright.PENANAKx8ilHA0O3
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然而經過1秒.........58Please respect copyright.PENANAJODAgn3ftX
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2秒.............58Please respect copyright.PENANAPGLOB83HNN
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3秒...............58Please respect copyright.PENANAIZTXPCVn7x
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4秒................58Please respect copyright.PENANAOxAmgmQbi4
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5秒.....................58Please respect copyright.PENANAflFqnDLXpp
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輝SIR心臟仍舊處於靜止狀態.................58Please respect copyright.PENANALjujfcXI5w
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朦朧中,輝SIR感覺自己置身一片草原上,望到遠處一個熟悉身影,意念一動,已站於身影之前58Please respect copyright.PENANA8dhQcHmzrg
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"CONNIE,原來真係妳..." 輝SIR頓時喜出望外58Please respect copyright.PENANAd591x25BD9
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"輝,點解你咁快會黎到呢度㗎?" CONNIE訝異地望向輝SIR "你唔應該黎,快D返去....."58Please respect copyright.PENANAemZj5bzstp
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"妳要趕我走?而家可以同妳一齊唔係好好咩?點解要咁對我?"58Please respect copyright.PENANAmCQtdbwUrc
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"輝....."CONNIE顯得無奈 "總之呢度唔係你應該黎,快D返去,返去佢身邊..."58Please respect copyright.PENANAfl7UbwJEEJ
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"我冇面目再見佢,我想一直陪住妳,唔想返去喇....."輝SIR苦苦哀求CONNIE讓他留下58Please respect copyright.PENANAkJvxAkDRb3
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"輝,唔好再逃避,返去啦,呢度唔屬於你...."58Please respect copyright.PENANA9IGpRBamng
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"我唔返,點都唔返....." 輝SIR將CONNIE擁入懷內.."我唔會再離開妳㗎喇...."58Please respect copyright.PENANAe916zlhBcq
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"輝....." CONNIE無言以對,雙手緩緩環抱輝SIR.....58Please respect copyright.PENANA9Y7kXWwFJz
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手術室內 58Please respect copyright.PENANAWao6Tx2DNv
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輝SIR心臟靜止後10秒.......58Please respect copyright.PENANAgShzvapMCM
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"唔可以再等....心臟按摩!!" DR.楊邊以右手握著輝SIR心臟邊向助手下指示 "ADRENALINE0.5mg,用10ml生理鹽水稀釋之後直接注入左心尖.."58Please respect copyright.PENANAvxcSFvRz6E
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ANNIE此時緩媛步向手術床,望著正被搶救,臉孔蒼白的輝SIR,不發一言58Please respect copyright.PENANA3bSNJhqqyP
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"輝SIR,快D返來啦..."DR.楊正以一分鐘80次向輝SIR心臟施以擠壓,弄得滿頭大汗58Please respect copyright.PENANAFx4zTZPUJb
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DR.洛面對儀器顯示因心臟擠壓而構成的數據變化正在沉思58Please respect copyright.PENANABbA8cxsQQP
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其他醫生亦唯有站於原位上等待奇蹟出現58Please respect copyright.PENANAHqAP2CyuYt
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可惜,過了30分鐘,輝SIR心臟仍只是由DR.楊右手去"構成"跳動....58Please respect copyright.PENANAbq2YGIRu3H
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"輝SIR,我就來支持唔住喇,唔好玩啦..." DR.楊已漸感不支58Please respect copyright.PENANAj940zbUtxP
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"輝...."一直沉默的ANNIE終於開口 "你係咪唔想再返來?如果係,我唔會勉強你,但我會覺得你係一個....懦夫!!"58Please respect copyright.PENANAjk5n4dMSnS
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草原上58Please respect copyright.PENANAzSbodA2JnZ
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"噢!!.."正擁抱著CONNIE的輝SIR,忽然自內心產生一下刺痛58Please respect copyright.PENANA712iIl0Qt3
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"輝,佢等緊你,你走啦!!"CONNIE即時推開輝SIR58Please respect copyright.PENANAFgzUZpcoLF
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"CONNIE..."58Please respect copyright.PENANAr9Zhr0kD5A
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"唔好再掛住我,你仲有好長嘅路要行...."CONNIE伸手指向輝SIR58Please respect copyright.PENANATCIFqWrc59
58Please respect copyright.PENANAGdmYJALS0l
"噗通" 輝SIR再次感覺自己心跳時,忽然被強大引力扯上了半空58Please respect copyright.PENANANQEB0tORlo
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"哇~~" 隨即再度失去意識58Please respect copyright.PENANArHYN3ip5MQ
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同一時間 手術室內58Please respect copyright.PENANAd82txD8dSO
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"DR.楊,唔好再勉強自己同輝SIR,好多謝咁多位醫生,你地已經盡哂力..."ANNIE低頭示意DR.楊停止58Please respect copyright.PENANALfDKgz7tWY
58Please respect copyright.PENANAuC3fkPdN8w
DR.楊望向DR.洛與DR.張,只見他們同時點頭,於是緩緩鬆開已極度痠痛右手,脈搏儀隨即顯示一條直線58Please respect copyright.PENANAXf9pXrC8hD
58Please respect copyright.PENANA4lmAwnuh7N
面對數天前還生龍活虎,一起奮戰的同事,此刻變成一具屍體,靜靜的躺在手術床上,雖說在醫院已是司空見慣,然而對在場的眾位醫生來說,仍是一個殘酷的事實,只有ANNIE,此刻拿起輝SIR的左臂,熟練的轉動,再施力一推 "卡嘞"一聲,將左臂托回原位58Please respect copyright.PENANAUKOB8vXyAl
58Please respect copyright.PENANATKj1twg6V3
"DR.劉,可唔可以幫我,輝SIR生前咁落力救人,唔好要佢殘廢咁走..."58Please respect copyright.PENANA6LG2ZlIB17
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"好..."58Please respect copyright.PENANAkTVHG5fkkZ
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DR.劉與ANNIE正步向手術床下方時58Please respect copyright.PENANAKM159lwG5U
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58Please respect copyright.PENANAWh6AhK2Erg
"噗通"....輝SIR的心臟微弱的跳了一下,脈搏儀顯示波紋,亦同時重燃了各人希望58Please respect copyright.PENANA5dBuzPbaUD
58Please respect copyright.PENANAIKl94HQNoM
" IV DOPAMINE 3ug,繼續心臟按摩..輝SIR,你唔放棄自己,我地都唔會放棄你!!" DR楊忘了痠痛,再次以右手擠壓輝SIR心臟,務求將輝SIR由鬼門關拉回來58Please respect copyright.PENANAS73dqKIlDD
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"通知NeuroICU準備好CRITICOOL,然後送入來.." DR.洛評估情況後作出以上指示58Please respect copyright.PENANA53HjOM1jNL
58Please respect copyright.PENANAmjeybHd293
腎上腺素(ADRENALINE)舊稱「副腎上腺素」,一般作用是使心臟收縮力上升;心臟、肝、和筋骨的血管擴張和皮膚、粘膜的血管縮小。在藥物上,腎上腺素在心臟停止時用來刺激心臟,或是哮喘時擴張氣管。58Please respect copyright.PENANAIrce2xfY6Z
58Please respect copyright.PENANAz4q2BsVBFl
腎上腺素能使心肌收縮力加強、興奮性增高,傳導加速,心輸出量增多。對全身各部分血管的作用,不僅有作為強弱的不同,而且還有收縮或舒張的不同。對皮膚、粘膜和內臟(如腎臟)的血管呈現收縮作用;對冠狀動脈和骨骼肌血管呈現擴張作用等。由於它能直接運用於冠狀血管引起血管擴張,改善心臟供血,因此是一種效用快而強的強心藥。腎上腺素還可鬆弛支氣管平滑肌及解除支氣管平滑肌痙攣。利用其興奮心臟收縮血管及鬆弛支氣管平滑肌等作用,可以緩解心跳微弱、血壓下降、呼吸困難等症状。58Please respect copyright.PENANAFnChV1Ff00
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多巴胺(Dopamine)為體內合成去甲腎上腺素的前體,具有β受體激動作用,也有一定的受體激動作用。能增強心肌收縮力,增加排血量,加快心率作用較輕微(不如異丙腎上腺素明顯);對周圍血管有輕度收縮作用,升高動脈壓,對內臟血管(腎、腸系膜、冠狀動脈)則使之擴張,增加血流量;使腎血流量及腎小球濾過率均增加,從而促使尿量及鈉排泄量增多。用於各種類型休克,包括中毒性休克1JLl源性休克、出血性休克、中樞性休克、特別對伴有腎功能不全、心排出量降低、周圍血管阻力增高而已補足血容量的病人更有意義。DARPP-32基因有三種變體:TT TC CC ,這些變體決定大腦中多巴胺的水平。 58Please respect copyright.PENANAq3DCdGVl21
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自1960年Kouwenhoven等報告胸外心臟擠壓有效以來,已很少再用開胸擠壓心臟,開胸擠壓心臟需經訓練和有開胸經驗者行之。目前主張僅由外科醫生在手術室內應用。胸腔打開后呼吸支持是很重要的。58Please respect copyright.PENANAlfNA7ar5sK
一經發現心音、脈搏、血壓消失或呼吸停止后,應立即進行心臟按摩,不應反復尋找原因或注射藥物以免延誤時間。在消毒操作及胸部切口的同時,應準備好氣管內插管以進行控制呼吸。開胸心臟按壓術(open cardiac massage),可更直接有效地按壓心臟,同時在直視下行心腔內注射藥物,其療效確切可靠,尤其在外傷等情況下。58Please respect copyright.PENANABrFQUanUY7
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注意事項58Please respect copyright.PENANAiI12nyZ7X6
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1.心臟按摩的成敗關鍵在于按摩是否及時、有效,心搏驟停的原因能否及時消除,故決定手術及剖胸要快,按摩方法要正確。58Please respect copyright.PENANAGmJXnnsZ3p
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2.有病變的心臟按摩更要小心,不要用手指尖與手掌相擠壓,以免擠破心臟。58Please respect copyright.PENANAr7tziDXAXN
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3.按摩時,應力求不過分牽動心臟,以免心臟移位過大,影響腔靜脈回流。58Please respect copyright.PENANAlVIZWwxdBO
58Please respect copyright.PENANACGvb8GoWea
4.開胸心臟擠壓需要特殊器械,併發症包括:感染、心肺外傷。由受過訓練的人員可立即進行有效的胸外擠壓,故開胸心臟擠壓的實用價值有限。58Please respect copyright.PENANAN9UcD9CkJe
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5.多數情況下,如在適當藥物治療和人工呼吸的輔助下,有效地施行胸外心臟擠壓仍無效,再開胸心臟擠壓亦不會成功。因此胸外心臟擠壓失敗不應認為是開胸擠壓的適應證。在任何情況下胸外心臟擠壓總是首選并應立即施行。58Please respect copyright.PENANAnWWDILknvR
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拯救生命時,可否同時拯救愛情?
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拯救生命時,可否同時拯救愛情?
Author:
Haro葉郎
ISSUE #14
CASE 14
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