医学人文翻译：有时候，少就是少…

Sometimes, less is just less…

有时候，少就是少…

July 1, 2020—The first day of my critical care fellowship in the eye of a pandemic and my first day back in American healthcare after practicing for five years in resource-limited hospitals in Kenya. Comparatively speaking, I felt like I was returning to the land of limitless options. Sure,it （感情上）was a little overwhelming（感情上） at first, but having more time before saying,“That is all we can do,” was incredibly encouraging.

2020年7月1日，我踏入了重症医学专科学习的征途，这一天，也是我在美国医疗体系中直面疫情挑战的首日。过去5年，我在肯尼亚行医。当然，对比那边的资源匮乏，美国医疗系统的资源之丰富让我一开始有些不知所措，然而，想到在最后说出“我们已经尽力了”之前，能有更多的时间救治患者，我感到信心满满。

One morning while making endless laps（一段段）in the unit, a resident on the team and I made the decision to transfuse one of our patients. They were positive for coronavirus disease 2019 (COVID-19) and also positive for（表示赞成的，同意的，positive for需要）all of the critical care accoutrements（手段）: mechanically ventilated，proned, vasopressors, and a few nephrons shy of renal replacement therapy. Their hemoglobin had drifted down to 7.2 g/dL and seeing their pressor requirement continue to climb, I gave the go ahead for transfusion. Later during rounds, the resident came to the hematology section of their presentation and proudly announced that we had decided to transfuse. Much to our dismay, our attending was not impressed. Instead, they reminded us of laboratory margin of error, the Villanueva [1] and TRISS trials [2], and how that unit of blood could have gone to someone else before sticking（支持、同意、采用） the landing with“less is more.”

清晨，一如既往的紧张与忙碌，我和一位住院医决定给一名患者输血，他不仅新冠病毒阳性，还处于重症监护的多重治疗之下（机械通气、俯卧位、血管加压药治疗）、以及濒临肾脏替代治疗的边缘。当患者的血红蛋白降至7.2g/dL，且升压药用量持续攀升时，我批准了输血。随后的查房中，住院医生汇报患者情况谈及贫血时，自豪地宣布我们决定输血。令我们沮丧的是，主治医生不以为然，而是提醒我们检验结果是有误差的、并从Villanueva和TRISS研究结论（译者注：Villanueva研究：严格输血策略相比宽松输血策略，能够显著改善上消化道出血的预后。TRISS研究：在感染性休克患者中，“高血红蛋白阈值输血”和“低血红蛋白阈值输血”患者的90天死亡率、缺血事件发生率和生命支持使用率相似，后者输血更少。）、以及其他患者可能更需要输血出发，建议采用“少即是多”的原则。

This had not been the first time I had heard those words. I have undoubtedly said them myself, but it was the first time that they made me cringe like nails on a chalkboard（nails on a chalkboard 是一个固定的说法。原意是指用手指甲或硬东西在黑板上划是发出的那种令人无法忍受的讨厌的声音。可以理解成“如坐针毡”、“受不了”、“抓狂”、“发疯”之类的意思。）. If I am being honest, those words actually made me angry because I felt they suggested that our decision was flippant and without consideration. Rewind five years and you will see why. My family and I left the United States and moved to Kenya where I lived, worked, and taught in two rural, resource constrained hospitals until boarding the plane to begin fellowship.

这并非我第一次耳闻“少即是多”，毫无疑问，我其实也支持这么做，但只有这次让我抓狂。实话实说，我有点生气，因为我觉得主治医师的“提醒”，暗示他觉得我们未经深思熟虑就轻率地决定输血。倒退五年，你就会明白我为何会生气了。5年前，我和家人离开了美国，远赴肯尼亚生活，在我踏上归程，开始我的专科进修之旅前，我一直在当地的两所资源匮乏的乡村医院行医和教学。

During those years, I learned way more than I could have ever taught. I learned that for nearly all hospitals outside of the capital, the closest thing to a blood bank was the antecubital fossa of relatives and individuals like myself willing to donate blood in real time for a loved one or patient. If a patient needed two or three units of blood,then we needed two or three family members to lend their arms (barring they are a match of course).

那5年，我领悟到的远比我教给当地医生的多。我了解到，除了首都，几乎所有医院，最接近“血库”就是人，也就是随时愿意献血去拯救亲人或其他患者的人的臂弯。如果患者需要2到3单位的血液，那么我们需要两三个家庭成员，让他们伸出手臂，准备献血（当然，前提是他们的血型要匹配……）。

I have also learned the hard way what resource allocation really looks like. Our hospital has five of the country’s 256 mechanical ventilators for a population of nearly 54 million [3]. This is a boastful surplus compared to many other countries on the continent. And pandemic or not, there is always an ongoing struggle to use these precious resources well. I, as well as others, have lost countless nights of sleep, wondering if we made the right decision in who should get them.

那5年，我也从艰难的经历中学到了资源分配的真正含义。在肯尼亚这个拥有近5400万人口的国家，全国仅有256台机械呼吸机，我所在医院有幸拥有其中的5台。与非洲许多其他国家相比，已经相当优越了。但无论是否有疫情，我们总是在为如何充分利用这些宝贵的资源而苦苦挣扎。和同事们一样，我也经历了无数个不眠夜，心中反复思考：我们是否做出了正确的决定，将这些呼吸机分配给了最需要的患者。

Further，being the attending on service when the average age and average oxygen saturation are both hovering in the upper 70s is not the ideal time for the charge nurse to come to me and say,“daktari, there is no more oxygen in the hospital.”This occurred several years before the pandemic. Deciding who will get our last vials of ceftriaxone before helping family members find a chemist(pharmacy) so they can go buy the remaining doses or choosing which combination or permutation of tests and investigations we can order based upon the amount of money the family has are the least“glamorous” aspects of being a cross-cultural global health worker. None of this was part of a global health curriculum that I was ever exposed to, but they were all lessons, nonetheless.

这还不是最糟的，一天，我作为当班的主治医生，负责的都是平均年龄70多岁、平均氧饱和度也70%多的重症患者，这已经足够艰难，突然，主管护士告诉我：“医生，医院里没氧气了”，这可真是雪上加霜，这一幕还是发生在新冠疫情发生几年前的真实事件。类似的还有：由我们来决定谁使用最后几瓶头孢曲松（译者注：作者的意思是人生来平等，每个患者都有相同的治疗机会，然而由于资源有限，不得不做取舍），然后再想办法帮助其家人找到药剂师或药房以购买剩下的剂量、或者说我们只能根据患者的经济情况选择相应的检查（而不是根据实际病情该做哪些就做哪些检查），这些都是我作为无国界医生工作中最“无奈”的一面。在我的全球健康课程中，从未有人告知我这些的艰难现状与选择，但我在肯尼亚期间不得不去学着接受这一切。这些经历，无疑都很宝贵。

Over time, my decisions on who may benefit from our scarce resources have been as much shaped by the local culture and values as it has been by my clinical training.Many of you reading this may instantly say, this rationale is contributing to poor resource utilization, but I would counter with attempting to understand the culture is as much multidisciplinary care as ventilator -acquired pneumonia bundles and out of bed initiatives. In this context，it is also patient centered.

时光流转，我在决定谁可以从我们稀缺的资源中受益时，除了专业学识，同样深受肯尼亚当地文化和价值观的塑造。读到这里，你们中的许多人很可能不加思索地说，这会导致资源浪费，但我想反驳的是，尝试理解文化，同呼吸机相关性肺炎综合治疗和早期床旁训练一样，也是多学科治疗的一部分。

Circling back, we have seen many clinicians and caregivers early on during the pandemic, in what many would consider the darkest night of our careers, struggling in earnest to do all they can not to have to say,“that is all we can do.” Although,“less is more” is likely applicable in these situations, those words would likely ring hollow, and possibly seem detached.

回到之前话题，疫情初期，我们目睹到的很多医疗工作人员都认为自己经历了职业生涯的至暗时刻，他们倾尽全力，尽其所能，只为不必说“我们已经尽力了”。这种情况下，虽然“少即是多”的决策可能适用，但听上去却像是空洞、甚至冷漠的说教。

After completing my first year of fellowship, I find myself back in Kenya and striving to thoughtfully implement some of what I have learned over the past year（去年）. I often reflect on that morning and know deep down that our attending meant nothing more than the medically cliché platitude in the midst of a chaotic unit. Though their retort centered on the medical decision making，it was probably not the genesis of their disagreement.

一年专科培训后，我仿佛回到了肯尼亚，与当年一样，我努力认真地实践去年一年中所学到的新知识（译者注：作者的意思是指专业知识之外的可能影响治疗的文化等东西）。我经常回想起那个早晨，深知主治医生无非是在繁忙的病房中重复着医学上的陈词滥调。尽管他主要在反驳医疗决策，但这可能并非分歧的根源。

If I am truly being honest and introspective，I can relate and likely recall a time, or possibly several, when being confronted with stressful circumstances I have resorted to feverish attempts to control what I think are under my control. I believe the learning objective for me moving forward has absolutely nothing to do with transfusion thresholds and everything to do with remembering that our medical community is a growing and beautifully diversifying community that invariably includes individuals who have trained，worked, and struggled to care for their patients in far greater ways than you or I may ever know. When you have more, less becomes a choice. So, if we find ourselves thinking that less is more, I would challenge us to remember that more is a luxury of excess.And when less fails, more still remains an option. In that moment, I beseech you and me to be grateful for the alternative of more before the words“less is more”lands in the middle of our unit or ward. Because for many of our colleagues across the globe, sometimes, less is just less.

在这里，我坦诚且自省地说，当前的工作，让我想起了一些时刻，也许是一个或几个，想起我顶着巨大的压力、竭力控制那些我认为己掌控之物的时刻。当前，作为一个不断成长的医生，我的学习目标并不是任何输血相关知识，而是告诉自己医疗界是一个不断发展、出色多元化的团体，有很多受训的、勤恳工作的、并以远比你我所知的更努力的方式照顾患者的医务人员。当你拥有“多（资源多、治疗方法多）时，“少（少用资源、少用治疗方法）”一些就成了一种选择。因此，如果我们思考“少即是多”时，我会呼吁，“多”其实是一种使你愉悦的过度，因为当“少”不奏效时，我们依然可以选择“多（多用资源、多用各种治疗方法）”。此时此刻，我请求你和我一起，感恩能选择“多”，因为在我们医院或病房里，‘少即是多’的策略，有时可能并不是最好的选择。因为对于全球的许多同事来说，有时候，少（资源少、治疗方法少）真的就意味着少（康复机会少、生存机会少）。