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10月4日， 《Intensive Care Medicine》在线发表了一篇有趣的短文：Intensive care medicine in 2050: the future of ICU treatments（2050年的重症医学：未来的ICU治疗），作者是Jean-Louis Vincent与Arthur S. Slutsky及Luciano Gattinoni 三位最大牌的老教授。 在这篇只有10个自然段的文章中，开篇是这么说的：It’s unlikely that any of the three of us will still be around, but we can imagine how our children would describe their experience if they were admitted to the ICU in 2050. Here is what they might say: 2050年的时候我们老哥仨已不可能在了，不过我们倒是能够想象那个时候我们的孩子将如何描述他们入住ICU的体验，他们可能会这样说：... 第二自然段：“The hospital is definitely smaller than in the past with lots of ICU beds, but very few other beds. And, it looks more like a five-star hotel than a hospital, with nice shops and restaurants in the lobby—it makes you forget you’re in hospital. My ICU room is fantastic! Really spacious, with a comfortable sofa for my family who can visit anytime.... 说的是ICU的环境如同五星酒店般宽松，室内有巨大的电子屏，可以显示包含生命体征、检验、影像等一切的信息，包括将患者与世界各地同样病况的患者进行联结，当然还有醒目的红键， 能够及时联系护士。 第三自然段：In the past, I remember the phlebotomist used to visit regularly to take blood for various tests, but now I’ve got a percutaneous sensor that measures almost every lab test. Everything seems to be non-invasive. I remember all the tubes and lines that patients used to have to monitor their heart rate and function—... 无创检验以及大量对呼吸、循环、微循环、代谢的传感器监测以及基于闭环监测的持续液体反应的监测系统以便于缩血管与正性肌力药物的持续滴定治疗。 第四自然段I remember lots of my dad’s patients used to have tubes in their trachea to help them breath, but they hardly use those anymore! I need help breathing, but just have a special helmet, which is very comfortable. In really severe, acute cases, there’s an intubating robot that can insert an endotracheal tube already connected to the respirator, which sits out of the way in the closet! I’m also receiving extracorporeal lung/renal/metabolic support—this is an impressive system that, by passing my blood through an external system, oxygenates it and cleans it of CO2, urea, potassium, inflammatory mediators, and other products that my failing kidneys can no longer eliminate, and replaces them with a caloric mixture including specialized nutrients, all in one smooth passage. 气管插管已经很少应用，取而代之的是特殊的头罩式（Helmet）吸氧装置，只有极少的重型病人可经机器人进行插管，插管本身已经与呼吸器连接。当然还有各种体外肺、肾、代谢支持装置... 第五、六自然段：A weird-looking machine just scanned my chest for about a minute and then showed these amazing pictures and videos of my lungs on that huge screen. ... They do quite a lot of surgical procedures here, but there are hardly any surgeons: all surgery is done remotely with surgeons only present in case of exceptional technical breakdown. ...There are also fewer nurses than in the past, but they are very well trained; they follow protocols and regularly practice and rehearse on simulators. 能够替代过去笨重的CT、MRI的新型3D的肺部床旁扫描...关于外科治疗，几乎均由远程手术取代，气管镜以及血管内操作也是由机器人完成。感染科医生将监测治疗规程，计算机负责抗菌药物及其剂量的选择，如愿的第一步治疗常常是针对耐药病原的疫苗接种。貌似医生和护士大量减少，不过这些家伙都是受过极佳训练的家伙——他们能依从规程、规矩行医并且常先模拟排练...(危通注：我有点搞不清楚，这种情况是否真的代表受过良好训练——ICU有排演的机会吗？) 第七自然段：You might think this all sounds a bit inhuman, but it’s not at all. Although there are fewer doctors doing procedures and interventions, the ones that are present are much more available to talk to you, to explain, answer questions, and reassure me and my family. After all, they tell us that the word “doctor” comes from the Latin word docere that means “to teach” and that is now their primary role. In fact, one of the doctors explained to me how my treatment was specifically tailored precisely for me. Somehow they match the therapies I receive to my genetic code so that I get the optimal therapy with the minimal side effects. And apparently, they have this huge database of all the patients’ results and outcomes for the past 25 years, so that they can see if anyone else had the weird syndrome I had, and then figure out the best way to treat it. I was also happy to sign a form that all patients sign, agreeing that virtually any treatment I get will be part of a clinical trial, and that all major hospitals are linked as part of a clinical trials network. Apparently, this approach has really advanced medical care. Clinical trials that used to take years are now done in the matter of a few weeks, and the results can be better individualized. They call this large network-based medicine and it replaced the old evidence-based medicine. 这段很有意思,说的是尽管执行操作的医生护士极大地减少了，但总有一位总是陪着患者聊天、解释回答并安定家属——这是因为拉丁语中的“doctor”就是“to teach”的意思——这也正是这些doctors正在依从的。此外，基因编码、精准医学以及大数据已经呢够味患者选择负作用最小的理想化的个体治疗并预测预后，或者发现患者是否存在特殊肚饿综合征。而患者将非常乐意签署一切知情同意书或者表单（危通注：真的吗？），这是因为多数医院都是临床试验研究网络的成员，相关的研究结果也不会像过去耗时几年，而是数周即可完成，而结果将更为个体化——这种基于大型网络的医学模式取代了老式的循证医学。 第八、九、十自然段：Of course, there are still some disciplines where human contact is very important, like obstetrics and pediatrics… and intensive care. But it’s certainly well organized—I’ve been really impressed—physician assistants are available to complement the other staff… and there are even robots that can tell stories or otherwise distract and encourage the patients! 对于老年及儿科患者以及ICU，人们之间的接触非常重要，而这些也都被良好地组织起来，包括护士助手以及会讲故事的机器人统统都有... The older doctors and nurses tell us that in the past ICU patients were often sedated, and some even paralyzed. That’s really difficult to believe. Today, only alcoholic patients may need sedatives (unless they give them some alcohol, as they say it makes more sense). And bed rest is no longer considered a benefit—patients are only allowed to stay in bed at night, unless you’re in shock or in coma. As soon as my shock was resolved, a physiotherapist introduced me to Jim (or is it Gym?), my personalized robot, and explained how “he” would help me exercise and walk with me—we even get out into the landscaped garden surrounding the ICU when the weather is good! 镇静和肌松治疗的湮灭，床边主动以及基于机器人的被动活动的增加.... Anyway, I’ve got to go—they’re calling me for my lung transplant, using a lung made from my own stem cells! Speak later.” 打断一下，我马上要做肝移植——新肝脏当然是来自我本人的干细胞，等会聊... 这篇类似科幻小品的文章点明了未来ICU治疗几种可能或者说发展趋势： 其一：必然是智能化，将导致医疗机器人的广泛应用，而人力成本的大幅减少，人工主要集中于某些特殊行业——此店是否适用中国值得怀疑 其二：诊疗的Protocol化， 一切按照程序与规程进行，但这是否有好处也值得怀疑—— 未来医学的最主要的挑战就在于如果传统的医生对患者的训练模式如果真的变成医生对仿真人的训练的话，经过这样全程训练的医生是否能够真的应付实际有千变万化的病人，这个问题实际的本质就是在追问——对于任何一种疾病（或者说对患有同一疾病的不同患者），究竟是否存在针对其的普适而又深刻的protocol？如果没有，那么protocol化就是在害病人，在简单化，幼稚化问题；如果有，那么人工智能或者编程化要进化到什么程度才能出现合理的规程？ 其三：基于基因和大数据分析的新的医疗模式的产生，包括干细胞、精准医疗、网络医学模式以及大数据预后因素分析等......尽管精准治疗的目标是个体化，但是否能实现真正的个体化以及个体化治疗是否真的能带来收益最大化都是值得考验的——尤其是个体化治疗与上述protocol化出现矛盾的时候怎么办？ 实在说，现代医学的未来发展中重要的矛盾之一很可能就是 个体化与程式化的矛盾！ 其四：无创化，毋庸置疑肯定会是大趋势 其五：人文化、轻松化 其六：参与及互动度的大幅增加 ...... 当然，写了上面这么多，其实都真的不是我想说的！ 不知道你在通读原文的时候，或者在看到我简单翻译的那些你能认识的中文文字的时候，有没有发觉——在上面的科幻的图景中，重症医学与其他专科的区别——无论是专业操作还是就医环境，学科之间的差异好像都在消弭！ 是的，现代医学的发展好像真的是要碾压一切的现有模式！对于重症医学而言，未来很可能发现不了重症医学专业医生与其他专业医生的区别，包括就医的环境。又或者是另外一种场景—— 未来若是单系统功能障碍或衰竭，很可能就由各专科以无创、人性及protocol化的方式自行解决，只有发展为最严重的多脏器衰竭的阶段才可能进入ICU——可是这个时候，还能无创化吗、还能人性化吗、还能protocol化吗，深表怀疑？ 我不知道最终的答案，因为我经历西方重症医学训练已经是快8、9年前了，至于现在它在西方发达国家发展为什么样子我不知道，那些经常出国的可能比我知道的还少，所以我觉得不如在这里写下来我的感觉—— 上面几位我深深尊重与服膺的统领本专业近半个世纪的世界级的老汉怎么现在突然一起变得这么“迷蒙”和“理想化”了呢? 点击左下角的“原文链接”可以通读英文全文。 |
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