《The Medical Republic》案例分享
——“斗牛犬”不僅是澳式足球冠軍Dogs Are More Than Just AFL Premiers

Leon Piterman，蔚文禮(譯)，邱珊嬌(譯)，黃文靜(譯)，楊 輝(譯)

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·世界全科醫(yī)學(xué)工作瞭望·

《The Medical Republic》案例分享
——“斗牛犬”不僅是澳式足球冠軍Dogs Are More Than Just AFL Premiers

Leon Piterman1，蔚文禮(譯)2，邱珊嬌(譯)2，黃文靜(譯)2，楊 輝(譯)1

全科醫(yī)生；社會支持；老年人

PITERMAN L.斗牛犬不僅是澳式足球冠軍[J]. 蔚文禮，邱珊嬌，黃文靜，等，譯.中國全科醫(yī)學(xué)，2017，20(22)：2691-2693.[www.chinagp.net]

PITERMAN L.Dogs are more than just AFL premiers[J]. WEI W L,QIU S J,HUANG W J,et al,translators.Chinese General Practice，2017，20(22)：2691-2693.

作為一名被公認和長期備受折磨的澳式足球西部斗牛犬隊的支持者，我仍然為其華麗且當(dāng)之無愧地獲得冠軍而自豪。

這是一個實例，來自球迷大眾的嫉妒不等于是普遍的民眾情緒。澳大利亞人喜歡失敗者和澳式猛將。西部斗牛犬征戰(zhàn)了62年，人們都感覺到我們這些鐵桿球迷理所應(yīng)當(dāng)?shù)爻两诖舜螉Z冠的輝煌成就里。狗狗們不僅僅是俱樂部的吉祥物，我希望下面的案例可以說明這一點。

比亞的故事

當(dāng)我第一次見到阿特里斯時，她剛七十歲出頭，她跟我說：“叫我比亞好了”。比亞是第二次世界大戰(zhàn)的遺孀，靠政府發(fā)放的軍人遺孀撫恤金生活。她轉(zhuǎn)到我的診所來就診，是因為30多年來一直照顧她和家人的全科醫(yī)生退休了。

比亞知道自己有心臟病、支氣管哮喘、高血壓。她給我看了一個裝著藥和霧化吸入器的特百惠箱(塑料貯藏盒)，藥箱里裝著各種藥物，幫助我給她做出診斷。給比亞看病不是一項困難的任務(wù)，但讓我感到驚訝的是，她的常規(guī)處方中有一瓶500 ml的魚肝油。我盡職盡責(zé)地按照常規(guī)處方給她開藥，她的藥費由退伍軍人事務(wù)部(聯(lián)邦政府的一個部門)支付。我覺得可以用更好的現(xiàn)代復(fù)合制劑來為比亞治療便秘，但她堅持要求按照常規(guī)處方開魚肝油。

某個冬季潮濕寒冷的周一上午，比亞非常焦慮地給我打了一個緊急求救電話，說她肚子痛得厲害，已經(jīng)兩天未排便了，這對她來說是不正常的。應(yīng)比亞的電話要求，我去她家出診。我知道，文獻中并未報道過魚肝油的副作用。到比亞家后，我受到一條華麗而溫順的紅色獵犬的歡迎。我給比亞做了檢查，她在發(fā)熱，左髂窩壓痛明顯，非常痛苦。而在我給比亞做檢查的過程中，她的狗看起來很悲傷。我覺得比亞可能有憩室炎，必須住院治療。我建議她帶上常規(guī)服用的藥物，不過可以把魚肝油留在家里。

我在感嘆她有一只多么漂亮的狗，也擔(dān)心如果比亞住院了沒有人來照顧它。比亞突然淚流滿面，跟我說：“我兒子杰克會來照顧勞倫斯(狗的名字)。但這不是我如此悲傷的原因。我不得不告訴你，醫(yī)生，這些年開的魚肝油都不是我吃的，都是給勞倫斯吃的。你注意到了嗎，它的毛發(fā)多漂亮啊，這是魚肝油的作用”。

比亞恢復(fù)得很快，1周后出院，和她心愛的勞倫斯在家團聚了。我對這個病案做了反思，我覺得很有必要繼續(xù)給她開魚肝油。如果從比亞的幸福角度來考慮，迎合和滿足她給狗狗吃魚肝油的做法，無疑是符合成本-效益原則的。

珍妮弗的故事

珍妮弗90歲，長期存在的主動脈狹窄開始成了大問題。她稍微用力就會氣促，半年內(nèi)因為心力衰竭住院3次。另外，珍妮弗還患有慢性阻塞性肺疾病，這段時間處于穩(wěn)定期，還有嚴(yán)重的骨質(zhì)疏松。

最后一次住院時，她看了心臟?？茍F隊。專家們建議她接受經(jīng)導(dǎo)管主動脈瓣膜置換術(shù)，她和她的女兒與專家探討這個手術(shù)的利弊。幸運的是，我對這個手術(shù)也有一些了解。我的家人在與珍妮弗相似的年齡也曾做過這種手術(shù)，而手術(shù)給我的這位家人增加了5年無癥狀生存時間。我最近還參加了一個心臟病學(xué)會議，在會上有好幾篇論文介紹了通過股動脈或肱動脈進入主動脈瓣的新的手術(shù)方式的成功率。所以，我強烈建議珍妮弗接受這個手術(shù)。

珍妮弗的丈夫已經(jīng)去世，但她并不孤獨。她有魯佛斯，一條16歲的拉布拉多犬，魯佛斯是家中不可缺少的成員，在珍妮弗的生命中占據(jù)著重要地位。珍妮弗最關(guān)心的是，在接受手術(shù)的過程中，誰來照顧魯佛斯，魯佛斯的聽力越來越不好了，而且后腿有關(guān)節(jié)炎。珍妮弗曾經(jīng)和朋友們做過短期的跨省旅行，88歲的時候坐過太平洋游輪。外出期間，都是她的女兒凡妮莎照顧魯佛斯，這次她的女兒也同意這樣做，所以珍妮弗同意接受這次手術(shù)。

手術(shù)后5 d， 我收到了醫(yī)院的信息，說手術(shù)順利，珍妮弗恢復(fù)得很好，已經(jīng)準(zhǔn)備出院回家。我打電話給她的女兒，但得到了一個悲傷的消息：魯佛斯已經(jīng)去世了。魯佛斯患上了皮膚感染，導(dǎo)致敗血癥，在24 h內(nèi)死亡。凡妮莎非常傷心，她正準(zhǔn)備去醫(yī)院把這個壞消息告訴她的母親。

珍妮弗出院回到家，知道這個消息后傷心欲絕。凡妮莎陪伴了她幾天。雖然醫(yī)生們向凡妮莎保證她的母親目前狀況良好，但她不能放下母親不管。珍妮弗仍然說自己氣促、乏力，經(jīng)?？奁?，夜間不能入睡，她為魯佛斯的死而自責(zé)。

在接下來的幾周里，珍妮弗明顯情緒低落，沉浸在悲傷中不能自拔。珍妮弗以前一直非常獨立，但最終她同意搬進養(yǎng)老院。心臟手術(shù)在技術(shù)上是成功的，但患者并沒能完全恢復(fù)。

有大量證據(jù)表明，寵物會給主人的生活帶來好處，尤其是年邁的主人，或者獨自生活的主人。孤獨是老年人最大的苦惱之一，在失去配偶的老年人中尤其如此。雖然政府可以為其提供日常生活支持的經(jīng)濟補貼，但無法替代寵物給老年人帶來的生活支持。也許，現(xiàn)在就是糾正的時候了。

志謝：特別感謝原文出版者《The Medical Republic》同意將此文編譯后刊登于《中國全科醫(yī)學(xué)》。

As an avowed and long suffering Western Bulldogs AFL supporter,I am still coming to terms with our magnificent and well-deserved premiership win.

Here was one instance when envy from the wider football public was not a prevailing emotion.Australians love the underdog and the Aussie battler.

After 62 years,it was widely felt that we Bulldogs fans deserved to bask in this glorious achievement.However,dogs are more than merely a club mascot,as I hope the cases below illustrate.

Bea′s story

Beatrice("call me Bea") was in her early 70s when I first met her.She was a World War Ⅱ widow in receipt of a widow′s pension and attended our clinic only because the doctor down the road,who had cared for her and her family for 30 years,had retired.

She knew that she had a heart condition,"bronical asthma" and "blood pressure" and presented me with a Tupperware box of pills and inhalers from which I was meant to derive her various diagnoses.

This was not a difficult task,however,I was rather surprised that among her regular scripts was a 500 ml bottle of cod liver oil,which I dutifully prescribed on a regular basis.The cost of her medications were covered by the Department of Veteran′s Affairs.I felt that we had more modern concoctions for constipation,but Bea insisted on her regular script for cod liver oil.

I did a house call in the knowledge that cod liver oil resistance would not be described in the literature.I was welcomed by a magnificent and rather tame-looking red setter.When I examined Bea,she was febrile,tender in the left iliac fossa and seemed quite distressed with the pain.Her dog looked on rather sorrowfully as I carried out the examination.

I felt that Bea may have diverticulitis and that hospital admission would be essential.I suggested that she take her medications with her but she could leave the cod liver oil at home.

I commented in passing what a beautiful dog she had and wondered who would look after him if she was in hospital.Bea suddenly became tearful as she replied:"Jack,my son,will look after the Lawrence the dog,but that′s not why I am so upset.I have to tell you doctor that the cod liver oil that has been prescribed all of these years was not for me but for Lawrence.You noticed what a fine coat of hair he has.It′s the cod liver oil".

Bea made a rapid recovery and a week later was home reunited with her beloved Lawrence.On reflection,I felt continued prescribing of cod liver oil was warranted.I have no doubt the cost-benefit equation in relation to Bea′s wellbeing was very much in favour of such action.

Jennifer′s story

Jennifer was aged 90 and her long-standing aortic stenosis was beginning to take its toll.

She was becoming short of breath with very little exertion and had three hospital admissions over a six-month period for heart failure.She also suffered from COPD,which appeared stable over this period of time,and generalised osteoporosis.

Following her last hospital admission,she met the cardiology team who advised her to have a transcatheter aortic valve replacement.She came with her daughters to discuss the pros and cons of this procedure.

Fortunately I knew a little about it.A family member had undergone this procedure at a similar age and it had added five symptom-free years to her life.

I had also recently attended a cardiology conference where papers were presented on the success rate of inserting a new aortic valve through a femoral or brachial artery approach.I strongly encouraged Jennifer to have the procedure.

Jennifer was a widow but did not live on her own.She had Rufus,her 16-year-old labrador who had been an integral part of the family and a vital part of Jennifer′s life.Her main concern was who would look after Rufus.He was losing his hearing and had arthritis in his hind legs.

Jennifer had gone on short interstate trips with her friends,and at the age of 88 went on a Pacific cruise.Her daughter Vanessa had looked after Rufus during these times and was prepared to do so again.So Jennifer agreed to have the procedure.

Five days after the procedure I had a message from the hospital that the procedure had gone well,Jennifer had made a wonderful recovery and was ready to be discharged home.I phoned the daughter and was met with the tragic news that Rufus had died.He had developed a skin infection,which resulted in septicaemia,and within 24 hours he was gone.Vanessa was devastated and was preparing to go to the hospital to break the news to her mother.

Jennifer came home,but was inconsolable.Vanessa stayed with her for several days and although the doctors reassured her that her mother was now fine,this was not the way she appeared.Jennifer still complained of shortness of breath,had no energy,was tearful and could not sleep at night.She blamed herself for Rufus′ death.

It became clear in the coming weeks that Jennifer was depressed,was having a grief reaction,and was struggling to cope on her own.Previously fiercely independent,she ultimately agreed to go into a residential aged-care facility.The cardiac procedure was a technical success,but the patient did not recover.

There is plenty of evidence to support the benefit of pets to the lives of their owners,particularly when those owners are elderly and live on their own.

Loneliness is one of the greatest afflictions of the elderly,especially widows or widowers.While all sorts of aids to daily living are subsidised,there is no subsidy to support the presence of a pet in the life of an elderly person.Perhaps it is time to rectify this.

(本文編輯：王鳳微)

General practitioners;Social support;Aged

wintery Monday morning I

an urgent call from a very distressed Bea.She was suffering severe abdominal pain and had not opened her bowels for two days,which was most unusual for her.

R 197

A

10.3969/j.issn.1007-9572.2017.22.002

2017-06-17)

【編者按】 澳大利亞的全科醫(yī)生具有行業(yè)自律性，體現(xiàn)在其自行制定行業(yè)標(biāo)準(zhǔn)、自主進行資質(zhì)考核及自主執(zhí)業(yè)等方面，也體現(xiàn)在《The Medical Republic》這一共享平臺上。Leon Piterman是醫(yī)學(xué)學(xué)士，醫(yī)學(xué)博士，教育學(xué)碩士，英國醫(yī)生學(xué)會會員，澳大利亞全科醫(yī)生學(xué)會會員，Monash University副校長、全科醫(yī)學(xué)教授，從事全科醫(yī)學(xué)臨床服務(wù)近40年；研究興趣為慢性病管理、心理健康、醫(yī)學(xué)教育；曾獲澳大利亞勛章，醫(yī)學(xué)部醫(yī)學(xué)教育獎，澳大利亞全科醫(yī)生學(xué)會研究獎，香港全科醫(yī)生學(xué)會研究獎等；獲多項澳大利亞衛(wèi)生和醫(yī)學(xué)研究理事會等大型研究項目，發(fā)表科學(xué)文章和著作章節(jié)120余篇，是《全科醫(yī)學(xué)中的精神病學(xué)》合作著者。Leon Piterman教授建議我國的全科醫(yī)生應(yīng)培養(yǎng)“共和”思想，以為全科醫(yī)學(xué)領(lǐng)域提供更多的平等交流機會。目前Piterman教授定期為《The Medical Republic》撰寫文章，本刊深受“醫(yī)學(xué)共和”思想的啟發(fā)，特邀本刊編委Monash University楊輝教授對Piterman教授的文章進行編譯，并進行連載刊登！本期Leon Piterman教授為我們講述了兩例老年患者與寵物的故事，指出孤獨是老年人最大的苦惱之一，經(jīng)濟支持和單純的診療不足以給老年人以慰藉，寵物的陪伴或許為老年人提供了無可替代的生活支持。因此，Leon Piterman教授建議全科醫(yī)生，在為該類老年人提供診療服務(wù)的同時，也要關(guān)注其情緒和心理健康，敬請關(guān)注！

1.3168 Monash University,Melbourne,Australia

2.518003 廣東省深圳市，羅湖醫(yī)院集團黃貝嶺社區(qū)健康服務(wù)中心

注：本文首次刊登于《The Medical Republic》