双语·当呼吸化为空气 我做了住院总医生

我做了住院总医生，几乎所有的责任都落在肩上，成功的机会比过去更多，失败的可能也大得空前。失败的痛苦让我明白，专业技术上的出类拔萃，其实是道德要求。光有一颗善心是不够的，关键还是要靠技术。有时候一两毫米的差距，可能就是悲剧与胜利的分水岭。
As a chief resident, nearly all responsibility fell on my shoulders, and the opportunities to succeed—or fail— were greater than ever. The pain of failure had led me to understand that technical excellence was a moral requirement. Good intentions were not enough, not when so much depended on my skills, when the difference between tragedy and triumph was defined by one or two millimeters.

有一天，马修再次入院了。这个得了脑瘤的小男孩，几年前住院的时候真是人见人爱。当时，他的下丘脑在肿瘤切割手术的过程中受到了微微的损伤。当时那个俏皮可爱的八岁男孩，现在变成了一个十二岁的怪兽。他一刻不停地暴饮暴食，常常充满暴力地拳打脚踢。他母亲的手臂上全是青紫的抓痕。最后马修被送进了专门的机构，就因为那一毫米的损伤，他变成了一个魔鬼。每次手术都是家人和医生共同做的决定，认为利大于弊，才会进行。但这样的事情仍然令人心碎。没人愿意去想，当马修二十岁的时候，体重高达三百磅，会是什么样子。
One day, Matthew, the little boy with the brain tumor who had charmed the ward a few years back, was re-admitted. His hypothalamus had, in fact, been slightly damaged during the operation to remove his tumor; the adorable eight-year-old was now a twelve-year-old monster. He never stopped eating; he threw violent fits. His mother’s arms were scarred with purple scratches. Eventually Matthew was institutionalized: he had become a demon, summoned by one millimeter of damage. For every surgery, a family and a surgeon decide together that the benefits outweigh the risks, but this was still heart-breaking. No one wanted to think about what Matthew would be like as a three-hundred-pound twenty-year-old.

有一天，我把一条九厘米长的电极放进病人脑中，治疗帕金森综合征引起的震颤。目标是丘脑底核，躺在脑中的一个杏仁形状的小东西，不同的部分支持着不同的功能：动作、认知和情感。手术室里，我们打开电流对震颤进行评估。我们全都盯着病人的左手，一致认为震颤的情况要好一些了。
Another day, I placed an electrode nine centimeters deep in a patient’s brain to treat Parkinson’s tremor. The target was the subthalamic nucleus, a tiny almond-shaped structure deep in the brain. Different parts of it subserve different functions: movement, cognition, emotion. In the operating room, we turned on the current to assess the tremor. With all our eyes on the patient’s left hand, we agreed the tremor looked better.

接着，病人困惑地开了口，盖过我们纷纷表示肯定的低语：“我感觉……特别悲伤。”
Then the patient’s voice, confused, rose above our affirmative murmurs: “I feel. . . overwhelmingly sad.”

“关电流！”我说。
“Current off !” I said.

“哦，现在没感觉了。”病人说。
“Oh, now the feeling is going away,” the patient said.

“那我们再试一下电流和阻抗，好吗？好，打开电流……”
“Let’s recheck the current and impedance, okay? Okay. Current on. . .”

“不，一切都……就是觉得……好悲伤，又黑暗，又……悲伤。”
“No, everything. . . it just feels. . . so sad. Just dark and, and. . . sad.”

“把电极拿出来！”
“Electrode out!”

我们抽出电极，重新插进去，这次往右边移动了两毫米。震颤消失了。谢天谢地，病人感觉也不错。
We pulled the electrode out and reinserted it, this time two millimeters to the right. The tremor went away. The patient felt, thankfully, fine.

一天深夜，我和神经外科一个主治医生一起动手术，纠正脑干畸形的枕骨下颅骨切除术。这是最要求优雅精确的手术，这个部位大概是全身最难动手术的部位。要到达那里就很需要技巧了，不管你经验多么丰富。但那天晚上，我觉得无比流畅，那些器械就像我手指的延伸：皮肤、肌肉和骨头似乎都是自己打开的，然后眼前就出现了那黄黄的、闪着亮光的、凸起的小东西，藏在脑干深处的包块。
Once, I was doing a late-night case with one of the neurosurgery attendings, a suboccipital craniectomy for a brain-stem malformation. It’s one of the most elegant surgeries, in perhaps the most difficult part of the body— just getting there is tricky, no matter how experienced you are. But that night, I felt fluid: the instruments were like extensions of my fingers; the skin, muscle, and bone seemed to unzip themselves; and there I was, staring at a yellow, glistening bulge, a mass deep in the brain stem. Suddenly, the attending stopped me.

突然，主治医生叫我停下。
“Paul, what happens if you cut two millimeters deeper right here?”

“保罗，要是你再往深处多切两毫米，会有什么后果？”他指了指相应的部位。
He pointed.

我脑中掠过一幅幅神经解剖学的幻灯片。
Neuroanatomy slides whirred through my head.

“复视？”
“Double vision?”

“不是，”他说，“闭锁综合征。”如果我多切了这两毫米，病人就会全身瘫痪，只剩下眼睛可以眨一眨。主治医生的眼睛没离开显微镜。“我之所以知道，是因为我第三次做这个手术的时候，就发生了这个情况。”
“No,” he said. “Locked-in syndrome.” Another two millimeters, and the patient would be completely paralyzed, save for the ability to blink. He didn’t look up from the microscope. “And I know this because the third time I did this operation, that’s exactly what happened.”