医学人文翻译：咽气

Breathless

咽气

I never got to hear the sound of his voice. Mr. C. was intubated by the time I assumed his care, less than 24 hours after he was admitted to the ICU with rapidly progressive respiratory failure due to Covid-19. His blood gases confirmed that he had severe acute respiratory distress syndrome (ARDS); his chest x-rays showed fluffy bilateral infiltrates. We paralyzed and proned him, recruiting physical therapists and nursing assistants to help with his twicedaily repositioning. He received remdesivir and dexamethasone.His kidney function declined to the point where he required dialysis. I reviewed the mainstays of ARDS management and scoured the literature to make sure we weren’t missing any options. And yet he did not improve.

在我接手他的治疗，也就是C先生因Covid-19引起的快速进展性呼吸衰竭入住ICU后不到24小时，他已经气管插管了，所以我从未听到过他说话。血气分析证实他患重度急性呼吸窘迫综合征（ARDS），胸部X线示双肺呈毛玻璃样浸润影。我们给他用了肌肉松弛剂并将其俯卧位，请了物理治疗师和护工来帮助他每天两次的翻身。治疗用了瑞德西韦和地塞米松，然而，他的肾功能急剧下降，以至于不得不透析。我并不满足于已知治疗ARDS的主要手段，仔细检索了文献，生怕遗漏了文献报道的任何治疗建议，尽管如此，他依然没有改善。

Each day, I met with Mr. C.’s extended family over Zoom. I dreaded these meetings. It’s hard to feel a connection through an iPad, and the large collection of small faces usually extended onto two screens. We tried to designate a family point person, but they wanted us all to meet. My morning prework runs, normally a time to clear my head, became consumed with planning for these discussions. On any given day, Mr. C.’s imaging or blood work might reveal tiny changes, positive or negative. I reexplained mechanical ventilation and multiorgan failure daily, trying to describe his poor prognosis without destroying all hope.

日复一日，通过Zoom，我与C先生的亲属线上会面，老实说这种会面让我难堪。在iPad的屏幕前，人与人间的联系似乎遥不可及，而那些密密麻麻堆积的小头像，通常需要两块投射屏才能完全容纳。我们试图让他们指定一位亲属作为联系人，但他们希望我们能与所有的亲属在Zoom上见面。工作前晨跑的时间，通常是我用来整理思绪的，现在却不得不用来筹划这些沉重的讨论。C先生的影像或血液学检查，无论是微小的改善还是恶化，每天都在变化。每24小时，我都要向其亲属解释什么是机械通气和多器官衰竭，试图在不破坏所有希望的同时描述他那黯淡的预后。

I had cared for my first patient with Covid back in February. That patient had presented with fever, shortness of breath, and a dry cough. His chest x-ray suggested a viral pneumonia and his workup was otherwise negative, so we sent a sample across the state to the one facility processing Covid tests. Days later, his test came back positive. As I donned my personal protective equipment (PPE) to see him the following morning, I felt unusually fearful. Anxiety and apprehension were not new to me, but running codes, having difficult conversations, and managing diagnostic uncertainty had taught me how to cultivate calm even when I couldn’t control outcomes.Caring for this patient with a disease that we knew so little about, however, struck a new fear into me. What if his condition worsened? I took five slow, deep breaths and entered the room.

二月，我迎来了第一位Covid患者，该患者发热、气促和干咳，胸部X线提示病毒性肺炎，然而他的病毒性肺炎的其他检查为阴性，所以我们把他的样本寄到了州内唯一的进行新冠检测的机构，几天后，检测结果回报为阳性。第二天早晨，当我穿上我的个人防护装备（PPE）去探视时，我感到前所未有的恐惧。对我来说，焦虑和恐惧其实已司空见惯，实施紧急抢救、进行艰难的对话、处理诊断不明的疾病都教会了我如何在无法控制结果而感到恐惧时保持冷静。然而，治疗这个我们知之甚少的疾病，我内心的恐惧被重新点燃，如果他的病情恶化，我们又该如何是好？我深吸了五口气，缓缓走进了他的病房。

As spring unfolded, we cared for a steady stream of patients with Covid. Some are cemented into my memory. A frail but asymptomatic elderly woman who sobbed uncontrollably when I shared her test result — “Is this going to kill me?” A patient whose final words to me, as he tearily clutched my hand after I told him we needed to intubate him, were “Confío en ti” (“I trust you”). He died a week later. A patient who adamantly denied he had Covid, day after day, despite a positive test and history of likely exposure. The last day I took care of him before going off service, he looked me straight in the eye, breathless: “I still think you’re missing the mark, Doc.” He died days later.

随着春天绽放，我们迎来了一波又一波的的Covid患者，有些我至今难以忘怀。一位体弱多病的但无症状的老年女性，在我告知她的检测结果时，她不由自主地抽泣起来——“这会要了我的命吗？”。一位患者，在我告诉他需要给他气管插管后，他泪眼婆娑地紧握着我的手，对我说的最后一句话是“Confío en ti”（“我信任你”），一周后，他不幸离世。一位患者尽管检测结果为阳性，并可能有接触史，但仍日复一日地坚决否认其患有Covid。在我下班前给他做最后治疗那天，他直视着我的眼睛，上气不接下气地对着我说：“医生，我依然认为你误诊了”，几天后，他也不幸去世了。

Over the weeks and months, my fear waned. Covid’s presence began feeling routine. I settled into new habits that helped mitigate my anxiety: white coat gone, scrubs immediately into the washer at home, run to the shower before touching anything. I discovered new gratitude for my teachers who showed me how to critically appraise medical literature, as I read through piles of journal articles. My work life quietly shifted, as Covid became enmeshed in my practice

随着时光流逝，数周乃至数月，我的恐惧逐渐消退，Covid的发病成为常态。我养成了一些有助于缓解焦虑的新习惯：一到家便脱下白大褂、立即将洗手衣扔进洗衣机、未触及家中任何物品前先奔向淋浴（译者注：在美国医院除了医生的白大褂和护士穿的护士服外，其它时候医生和护士还有其它工作人员贴身穿的都可以叫洗手衣，医务人员上下班都可以穿着洗手衣，洗手衣和白大褂也是可以穿回家的，在医院周围餐厅吃饭时都可以不脱，这和国内情况不一样）。当我阅读成堆的期刊论文时，我对老师们心怀感激，因为他们教会了我如何批判性地阅读医学文献。随着Covid融入我的职业生涯，我的工作悄无声息地变化着。

Yet Mr. C. was one of those patients I thought about day in and day out — his recent cancer diagnosis, his chronic medical problems, the uphill battle for patients from marginalized populations to access high-quality n engl j med 384;10 nejm.org March 11, 2021 care, his extended Native American family who attended our daily calls. I desperately wanted him to get better, and I could sense that other staff members did, too, as they spoke to him quietly after repositionings, smoothed his hair gently, called him by his nickname, squeezed his hand before leaving the room. But it became increasingly clear to me, with his pulmonary function showing no improvement and other organ systems declining, that Mr. C. was unlikely to have a meaningful survival.

然而，C先生是我日夜牵挂的患者之一——他最近的癌症诊断、他长期的疾病困扰、他为弱势群体的患者获得高质量医疗服务而进行的艰苦斗争、还有他那个参加我们的日常电话沟通的美国本地大家庭都是让我挂念的原因。我拼命地想让他好起来，我能感觉到其他工作人员也是这样，因为他们在俯卧位通气后与他轻声交谈、轻柔地梳理他的头发、亲昵地呼唤他的昵称、在离开房间前握住他的手。但我越来越清楚，他的肺功能未见起色，而其他器官系统功能也在衰退，C先生康复希望渺茫。

Had I given this family an inaccurate understanding of Mr. C.’s clinical course? Or was theirs a natural reaction to impending, incomprehensible loss?

我是否让这个家庭误解了C先生的病情？还是说，他们所表现出的，是对即将到来、难以理解的失去亲人的自然反应？

Late one day, I called his wife to discuss that prognosis. She seemed shocked: “I thought he was getting better.” It dawned on me that Mr. C.’s family had been fiercely clinging to any mention of improvement, however small, despite the overarching message that he might die from complications of Covid. We again talked through his whole hospital course.I answered old and new questions.Intensely uncomfortable, I forced myself to slow down. Had I given this family an inaccurate understanding of Mr. C.’s clinical course? Or was theirs a natural reaction to impending, incomprehensible loss? His wife said she needed to talk with the family, and we agreed to meet at our usual time the following day. I hung up in a swirl of emotions.I worried about Mr. C.’s family thinking that we were premature ly giving up. But I did not think he could survive.

一天深夜，我拨通他妻子的电话，讨论他的预后。她似乎很震惊：“我以为他越来越好了。”我突然意识到：他的家人一直以来强烈地提及任何一个好转，无论这种好转是如何的微不足道，而忽视了他很可能死于Covind并发症的重大信息。我们又聊了一遍他住院的整个过程，我不仅回答了新问题又给她解释了老问题。我感到非常郁闷，强迫自己放慢语速。我是不是让这家人对C先生的临床过程有了误解？还是说，这是他们面对即将到来、难以理解的失去亲人的自然反应？他的妻子说她需要和家人商量，我们商定次日约定时间再联系。我思绪万千地挂断了电话。我担心C先生的家人认为我们过早放弃了，但内心深处，我认为他生还希望渺茫。

As I lay awake that night, I realized that my anxiety centered on an uncomfortable vulnerability. I did all I could to try to save Mr. C.’s life. I set aside time each day to update his family. I fulfilled my doctorly responsibilities for him. And I also felt a strong desire for him to live. Though we want the best for all our patients, some stand out in our hearts and minds. Mr. C. was one of those patients for me, for reasons I can’t fully explain, given that he had been sedated on a ventilator for the entire time our lives overlapped. Despite my earlier struggles with other Covid-related losses, this one hurt in a new way.

那夜，我在床上辗转难眠，我意识到我的焦虑主要来自令人不安的脆弱感。我尽我所能去挽救C先生的生命。每天，我都抽出时间，给他的家人更新他的情况。作为他的医生，我尽到了我的职责。同时，我也强烈地希望他能够活下来。所有患者，无论老幼，虽然我们希望一视同仁，让他们都能得到最好治疗和关怀，但在我们心中，总有些患者印象深刻，对我而言C先生就是其中之一，由于C先生在我对他的治疗过程中始终处于维持机械通气所需的镇静状态，故个中原因我也无法完全解释。我也曾经因其他Covid患者的离去而难过，但这次的痛楚不同以往。

I didn’t know what to expect the next day, but I braced myself for a barrage of questions. I felt that familiar dread as we opened Zoom. I said hello to Mr. C.’s family and asked how their discussion went. Her voice trembling, his wife said, “We want to help him have a good death. We agree that it is time.”

我无从预知次日会发生什么，但我已经准备好回答即将到来的一连串问题。当Zoom的窗口打开，那股熟悉的忧虑感再次涌上心头。我向C先生的家人致以问候，询问他们的商讨结果。他的妻子声音微颤，说道“我们想帮他走得体面些，我们一致认为，现在是时候了。”

I was shocked. I had anticipated resistance, but the family was in full agreement, heads nodding. I assured them that we would work together to ensure a peaceful death. Then one of the elder family members said, “But first, we want to thank you. For everything you have done.” Before I could respond, each relative, old to young, thanked me one by one. Inside, part of me was screaming, wanting them to stop — I did not save Mr. C., after all — but I listened, squeezing my hands together as I accepted this beautiful and unexpected gift.After ensuring that all the necessary details were in place to transition him to comfort care, I hurried off to see other patients.

我很震惊，我曾预料会遭到反对，但他们都点头表示赞同。我向他们保证：我们将共同努力，确保他安详离世。接着，一位年长的家庭成员说“但首先，我们要感谢你，感谢你所做的一切。”我还没来得及回应，每个亲戚，无论老幼，都一一向我表示感谢。面对屏幕那端的家属，"我倾听着，紧握双手".我的内心深感不安，我想大声对他们说“不要再说了”，毕竟我没有救活C先生，但我还是静静地聆听着，我的双手紧紧地攒在一起以接受这份美丽而出乎意料的礼物。在确保他转入舒适照护的所有必要细节都到位后，我赶紧去照看其他患者。

Mr. C. died moments after extubation, his family present with him over Zoom, chanting and singing to support his spirit through this transition. They provided supplies for cleansing and dressing his body. When I passed his room later in the day and saw him disconnected from tubing and machines, wearing vivid colors and with a feather in his hand, it took my breath away.

拔管后不久，C先生便去世了，通过Zoom，他的家人陪伴着他，吟唱圣歌，以最后送他一程。他们提供了清洁用品和寿衣，当天晚些时候，我走过他的房间，看到他解除了插管和仪器，穿着鲜艳颜色的衣服，手中握着一根羽毛，这突如其来的美丽和宁静让我震惊。

Something shifted for me in this experience. The preceding months had forced me to steel myself — when too many patients died despite our best efforts, when others ignored the grim truths of this pandemic, when we faced PPE shortages, when I had to tell my aging parents and disabled brother I wasn’t sure when I could safely see them again. The emotional walls I hastily erected were not solid, and I realized as I left the hospital that night with a lump in my throat that they were starting to crumble.

经历了这次Covid的大流行，我内心发生了一些变化。过去数月，当我们虽竭尽全力，但仍有太多的患者仍不幸离世时、当面对他人漠视这一流行病严酷的真相时、当我们面临个人防护用品短缺时、以及我不得不告诉我年迈的父母和残疾的兄弟，我不确定何时能够安全地再次看到他们时，我不得不克制自己。当晚我哽咽着离开医院，意识到我匆匆筑起的情感壁垒并非坚不可摧，它们正开始轰然倒塌。

I still think about Mr. C. and his family, months later. Thanks to them, I allow myself moments to soften, even when I feel a pull to armor up. I have had to accept an uncomfortable state of not knowing in the landscape of this new disease. I am reminded that vulnerability and authenticity are inexorably linked. If we want authentic relationships with patients and families in a time of tremenHad I given this family an inaccurate understanding of Mr. C.’s clinical course? Or was theirs a natural reaction to impending, incomprehensible loss? dous suffering, we must embrace a degree of vulnerability ourselves.That is the only silver lining I have found in this tragedy, the hundreds of thousands of lives lost — a reminder that the heart of medicine is connection, and that honoring these stories provides a way to heal from this extended season of loss.

数月之后，C先生和他的家人仍萦绕在我的心头。多亏了他们，让我知道即使我披上了盔甲变得坚强，我也会有片刻的温情。面对这种新疾病，我不得不处于一种令人不知所措的尴尬状态，使我无情地认识到脆弱性和真实性其实密不可分。如果我们想和遭受巨大痛苦的患者和家属建立真挚的联系，一定程度上，我们必须承认自己是脆弱的。这是我在这场以数十万人为代价的悲剧中发现的唯一希望，这提醒人们：医学的核心是彼此相联，而铭记这些生离死别的故事，有助于我们在这个漫长的生命陨落之季中得到治愈。