By Dr. Florence On, Pediatrician
　文／小兒科醫師　安芳蓮
　中文翻譯／和信醫院臨床藥師　方麗華
   發表時間：2004年5月1日台東基督教醫院四十週年

幫新生兒輸完血後，安芳蓮醫師正在寫病歷，攝於1983年。照片提供／德師母

Many people think medical records and medical record keeping are boring, a tedious chore, but I have never thought so. Therefore a few years ago when the TaitungChristianHospital needed to cull the patient charts to make space, I volunteered to help. The Government has rules about how long medical records must be kept before disposal. But a hospital may want to save some charts, for teaching or research purposes, even when the statute of limitations has passed. I was to decide on the fate of the charts for disposal or retaining.

許多人認為病歷與保存病歷是件單調瑣碎之事，但我從不認為如此。幾年前台東基督教醫院想縮減病歷量以便有更大的利用空間，我自願幫忙這件病歷篩選工作。政府有規定病歷丟棄之前需有相當年限的保留，但醫院為研究或教學的目的，即使已超過年限，也會保留一些珍貴的病歷。我自告奮勇來決定這些病歷的去留。

When I started to go through the charts, I became more and more involved. There were so many interesting and complicated cases, patients, whom other hospitals rejected as being hopeless, but who were saved due to innovative procedures, exceptional dedication, care and prayer, by our physicians and nurses. There were the notes of beloved old staff, of Dr. Dennis, Dr. Stafford, Dr. Bob Long, Dr. Titus Loong, Dr. Tucker, Dr. Kyle, Dr. Alice Chen, of Carol on the pre-op and anesthetic records, of the nurses who carefully followed and recorded the patients’ changing condition signing off as: Helen, Naomi, Brenda, Misako, Nellie etc. Reading these charts made me alternately sad and happy.It was like a reunion with old friends, some still alive and some in heaven.

當我開始閱讀這些病歷時，情感卻深陷無法自拔。病歷中有太多有趣或複雜的個案、或別家醫院認為無望而拒收的病人，卻因新的科技再加上醫護人員的奉獻、照顧、禱告而得以痊癒。這些病歷有我們喜愛的老員工譚維義院長、蘇輔道醫師、美國龍樂德醫師、中國龍醫師、德法全醫師、凱醫師、陳愛莉思醫師的字跡紀錄，或耿喜音手術前與手術中的麻醉紀錄。Helen、Naomi、Brenda、Misako、Nellie 這些護士小心依照醫囑記錄病情的變化。閱讀這些病歷令我悲喜交加，如同與這些朋友再度敘舊，雖然有些依然健在，而有些已在天堂。

A Doctor’s record keeping is as important as his healing skill, intuition, and medical knowledge. This conviction had been drummed into us in MedicalSchool, Internship, Residency. “ Sloppy and incomplete patient chart notes are indicative of a sloppy mind”, to quote a professor. The content of patient charts assist the primary care Doctor’s memory, the thinking process of diagnosis, treatment plan, and in following the patient’s condition. The records are needed for other Doctors involved in the patient’s management, for the nurses, so that continuity of care is provided. Many a medical lawsuit has been decided on the content, or lack of it, on the patient’s chart.

一位醫師的病歷書寫與他的醫治能力、直覺、醫學知識是同等重要。這樣的信念充斥在醫學院、實習醫師、住院醫師的學習過程中。引用某教授所言「邋遢與不完整的病歷紀錄意味書寫人的腦筋也是草率而漫不經心的」。病歷的內容可幫助第一線照顧醫師對病人的記憶、診斷的思考程序、治療計畫、追蹤病情。其他醫師的會診照顧需病歷紀錄，護士也需要病歷才可提供持續的照護。許多醫療訴訟都取決於病歷的內容或完整與否。

It was only because the charting by the writers was done with such care, despite their other time constraints, that I could get a deep impression of the patient, of the Doctor’s hopes, discouragements, perplexities and successes. There were severe snake bite patients cured with Dr. Dennis’s snake gun in the ER, rheumatoid arthritis patients treated with his bee sting therapy, new treatments initiated with apprehension. The severe mauling of a patient by a wild boar, infected monkey bites, and the desperate attempts to save attempted suicide victims from insecticide poisoning, all recorded for posterity.

儘管他們的時間不夠，因為病歷的作者還是詳細記錄他們做了那些治療，讓我對病人、還有醫師的希望、灰心、困惑與成功的病人照顧過程有更深的印像。譚醫師在急診用蛇槍治癒嚴重毒蛇咬傷的病人、用蜜蜂叮咬治療風濕性關節炎，當然開始新的治療總是戰戰兢兢、戒慎恐懼。病人被野山豬嚴重擊傷、猴子咬傷的感染、對喝殺蟲劑自殺病人竭盡所能的搶救。這些所有的紀錄都值得流傳後世。

I was very touched by reading about the tender loving care of countless senior citizens over age 80 with fracture of hips or very complicated medical problems that other hospitals refused to treat and had been sent home to suffer or die, who under our doctors’and nurses’ compassionate, expert care, survived to walk home, sometimes with a walker or cane from the hospital 1 or 2 months later. The daily Progress notes that doctors and nurses are required to write were a story in themselves. Some described the love or neglect by family members. Some represented the dedicated care of our nurses who recorded on the chart every 2 hours that the position of a patient with incipient bedsores was changed.

當讀到無數超過八十歲的老年市民，因為髖部骨折或其他複雜內科疾病，被其他醫院所拒絕或送回家受苦等死，在我們醫師與護士的愛心與專業照顧下活下來能夠走路，有時藉用行走輔助器或柺杖一至兩個月後，可走路回家的故事，令我感動。醫師與護士每天的疾病進展記載也相等於病人他們自己的故事，記錄著有些病人被家人所關愛、有些被家人忽視、醫院護士每兩小時記錄著對初期的褥瘡病人的更換姿勢的悉心照顧。

It was a special joy to see the chart notes by our 3 chaplains. They would visit each and every hospitalized patient at least twice, once on admission, once on discharge and more often if needed. These visits were recorded on the charts. After discharge, home visits would be arranged as well, if requested. Their chart notes revealed the patients’ spiritual needs, whether the patient was a seeker or indifferent, a discouraged Christian, whether he/she found God in his/her troubles, believed in Jesus Christ with great joy just before death, or a libertine who survived miraculously to live a changed life after discharge.

當閱讀三位院牧的病歷紀錄，我會有特別的喜樂，他們對住院病人至少有兩次的訪視，第一次在住院時，另一次在出院時，需要時會有更多次的訪視，這些訪視都會記載在病歷上。當病人出院後，如有需要，會安排家庭訪視。他們記錄著病人的心靈需要，不管病人是宗教的追尋者、或漠不關心者、灰心的基督教徒。是否在困難中發現上帝、直到死前因相信耶穌而得到心靈喜悅、或浪蕩者在奇蹟式的活下來後，出院後，痛改前非。

Tears flowed, as prompted by their medical charts, I remembered patients that died. Sick babies that were taken home by relatives who believed the babies were too sick to continue living, especially female newborns, or because there was no money to pay for continuing hospitalization, though our social service office advised them the hospital could help financially. A child with meningitis whose grandmother came down from the mountains on a motorcycle after midnight and took the child, who was on i.v. antibiotics, home, even though the nurses, (who had called me in), and I pleaded with her to let the child continue treatment. There were the severely jaundiced newborns who needed exchange transfusion, but the relatives refused, although Dr. Long entreated them; later some of those infants would see Dr. Long in OPD hopelessly mentally and physically handicapped with Kernicterus, the result of untreated Hyperbilirubinemia. Dr. Long’s notes were graphic. And there were even still attached to some charts the tiny metal balls and yellow pieces of paper that had been taped to the jaundiced babies’ bodies by the temple monks to “cure” them. (I had saved these relics to remind me of their folly).

當我一見到一些死亡病歷時，眼淚不禁奪眶而出，因為我記得這些病人。生病的嬰兒，家屬認為病太重，難以養活，就強行帶回，特別是女生的新生兒。或因為家裡付不出住院醫療費用，即使醫院的社工部可以在經濟上給予資助。一位腦膜炎的小孩在祖母半夜騎摩托車從山上下來，要求帶走小孩。當時小孩身上還在打抗生素，即使護士、我懇求她讓小孩繼續治療。一些有嚴重黃疸的新生兒需要換血，但家屬反對，雖然龍樂德醫師一再要求他們讓小孩換血。事後其中一些嬰兒回來龍醫師的門診時，已是嚴重的核黃疸導致腦部與身體的重殘。龍醫師的病歷紀錄是圖列式的。許多病歷還貼有小小的金屬球或去廟裡道士求來的符咒，貼在黃疸小孩的身上，宣稱可治癒其疾病。（我留下這些東西用來提醒我關於他們的愚昧）

Viewing the charts called to mind the frantic search for blood for transfusions or exchange transfusions. Sometimes family members refused to donate, despite being of a matching blood type. Our own Doctors and Staff donated blood instead. Sometimes young local soldiers would come to donate; the nurses and lab techs would be particularly friendly, joke and flirt with them a little. Fresh warm blood would flow into the needy.

閱讀病歷也讓我想起為輸血或換血時，瘋狂的尋求血源。即使家族的血型是同型的，有些家族成員也會拒絕捐血，常變成是醫師或員工起而代之捐血。有時當地的軍人會來捐血，這時護士與檢驗師也會對他們特別友善、開開玩笑或小小調戲他們，這時新鮮溫暖的血則源源而至。

Some chart notes recorded how occasionally thesuperstitious relatives of expiring patients not desiring them to die in hospital, fearing their souls might have to wander forever, took them home to die. The patients, often intubated would be placed in a taxi or car, using a borrowed hospital Ambu bag to keep the patient breathing. Then, dressed in the proper burial clothes at home, the endotube was removed and Ambu bag discontinued.

一些病歷也記錄了有時迷信的家屬不要病人死於醫院，害怕他們的靈魂成為孤魂野鬼，要帶病人回家往生。病人常插上氣管內管被放置在計程車或車子內，使用醫院借來的呼吸輔助袋使病人繼續呼吸。回到家後，穿上壽衣後，拔掉氣管，停止呼吸輔助袋。

Those records brought back memories of Doctors and nurses trying desperately to save or resuscitate patients, of bedside vigils and prayers by Doctors and nurses alike, of nurses singing hymns accompanied by guitar at the patients’ bedside to comfort them, of medical staff taking valuable time to witness to patients at the bedside, to inquire about their spiritual condition. These words also were sometimes recorded in a chart: “The patient accepted Christ today!”The notes of a Doctor may not just contain information about the patients, but between the lines may be a window on his/her soul, revealing confidence, fears, doubts, failures, triumphs.

這些紀錄回憶著醫師、護士拼命救治或急救病人、病床前的值夜與禱告、護士的聖詩伴隨著吉他在病床邊安慰病人、醫療人員找時間在病床邊向病人傳福音作見證來尋問他們的心靈狀況。以下的文字也會被記錄在病歷上「病人今天接受耶穌基督」。醫師字裡行間的文字不止記錄病人的內在世界，但文字間的言外之意也成為自己靈魂的窗口，反映出他們自己的信心、害怕、懷疑、失敗、勝利。

I could not bear to throw away many of those charts, even those of the deceased. I’m sure I saved more than were necessary. How could I discard them? It would be like abandoning old friends…

我無法忍受丟掉這麼多的病歷，即使病人已死。我確定我留下的病歷超過需要保存的。但我如何能丟呢？這像是遺棄老朋友一樣。