10月4日， 《Intensive Care Medicine》在線發(fā)表了一篇有趣的短文：Intensive care medicine in 2050: the future of ICU treatments（2050年的重癥醫(yī)學(xué)：未來的ICU治療），作者是Jean-Louis Vincent與Arthur S. Slutsky及Luciano Gattinoni 三位最大牌的老教授。

在這篇只有10個自然段的文章中，開篇是這么說的：It’s unlikely that any of the three of us will still be around, but we can imagine how our children would describe their experience if they were admitted to the ICU in 2050. Here is what they might say:

2050年的時候我們老哥仨已不可能在了，不過我們倒是能夠想象那個時候我們的孩子將如何描述他們?nèi)胱CU的體驗，他們可能會這樣說：...

第二自然段：“The hospital is definitely smaller than in the past with lots of ICU beds, but very few other beds. And, it looks more like a five-star hotel than a hospital, with nice shops and restaurants in the lobby—it makes you forget you’re in hospital. My ICU room is fantastic! Really spacious, with a comfortable sofa for my family who can visit anytime....

說的是ICU的環(huán)境如同五星酒店般寬松，室內(nèi)有巨大的電子屏，可以顯示包含生命體征、檢驗、影像等一切的信息，包括將患者與世界各地同樣病況的患者進行聯(lián)結(jié)，當然還有醒目的紅鍵， 能夠及時聯(lián)系護士。

第三自然段：In the past, I remember the phlebotomist used to visit regularly to take blood for various tests, but now I’ve got a percutaneous sensor that measures almost every lab test. Everything seems to be non-invasive. I remember all the tubes and lines that patients used to have to monitor their heart rate and function—...

無創(chuàng)檢驗以及大量對呼吸、循環(huán)、微循環(huán)、代謝的傳感器監(jiān)測以及基于閉環(huán)監(jiān)測的持續(xù)液體反應(yīng)的監(jiān)測系統(tǒng)以便于縮血管與正性肌力藥物的持續(xù)滴定治療。

第四自然段I remember lots of my dad’s patients used to have tubes in their trachea to help them breath, but they hardly use those anymore! I need help breathing, but just have a special helmet, which is very comfortable. In really severe, acute cases, there’s an intubating robot that can insert an endotracheal tube already connected to the respirator, which sits out of the way in the closet! I’m also receiving extracorporeal lung/renal/metabolic support—this is an impressive system that, by passing my blood through an external system, oxygenates it and cleans it of CO2, urea, potassium, inflammatory mediators, and other products that my failing kidneys can no longer eliminate, and replaces them with a caloric mixture including specialized nutrients, all in one smooth passage.

氣管插管已經(jīng)很少應(yīng)用，取而代之的是特殊的頭罩式（Helmet）吸氧裝置，只有極少的重型病人可經(jīng)機器人進行插管，插管本身已經(jīng)與呼吸器連接。當然還有各種體外肺、腎、代謝支持裝置...

第五、六自然段：A weird-looking machine just scanned my chest for about a minute and then showed these amazing pictures and videos of my lungs on that huge screen. ...

They do quite a lot of surgical procedures here, but there are hardly any surgeons: all surgery is done remotely with surgeons only present in case of exceptional technical breakdown. ...There are also fewer nurses than in the past, but they are very well trained; they follow protocols and regularly practice and rehearse on simulators.

能夠替代過去笨重的CT、MRI的新型3D的肺部床旁掃描...關(guān)于外科治療，幾乎均由遠程手術(shù)取代，氣管鏡以及血管內(nèi)操作也是由機器人完成。感染科醫(yī)生將監(jiān)測治療規(guī)程，計算機負責抗菌藥物及其劑量的選擇，如愿的第一步治療常常是針對耐藥病原的疫苗接種。貌似醫(yī)生和護士大量減少，不過這些家伙都是受過極佳訓(xùn)練的家伙——他們能依從規(guī)程、規(guī)矩行醫(yī)并且常先模擬排練...(危通注：我有點搞不清楚，這種情況是否真的代表受過良好訓(xùn)練——ICU有排演的機會嗎？)

第七自然段：You might think this all sounds a bit inhuman, but it’s not at all. Although there are fewer doctors doing procedures and interventions, the ones that are present are much more available to talk to you, to explain, answer questions, and reassure me and my family. After all, they tell us that the word “doctor” comes from the Latin word docere that means “to teach” and that is now their primary role. In fact, one of the doctors explained to me how my treatment was specifically tailored precisely for me. Somehow they match the therapies I receive to my genetic code so that I get the optimal therapy with the minimal side effects. And apparently, they have this huge database of all the patients’ results and outcomes for the past 25 years, so that they can see if anyone else had the weird syndrome I had, and then figure out the best way to treat it. I was also happy to sign a form that all patients sign, agreeing that virtually any treatment I get will be part of a clinical trial, and that all major hospitals are linked as part of a clinical trials network. Apparently, this approach has really advanced medical care. Clinical trials that used to take years are now done in the matter of a few weeks, and the results can be better individualized. They call this large network-based medicine and it replaced the old evidence-based medicine.

這段很有意思,說的是盡管執(zhí)行操作的醫(yī)生護士極大地減少了，但總有一位總是陪著患者聊天、解釋回答并安定家屬——這是因為拉丁語中的“doctor”就是“to teach”的意思——這也正是這些doctors正在依從的。此外，基因編碼、精準醫(yī)學(xué)以及大數(shù)據(jù)已經(jīng)呢夠味患者選擇負作用最小的理想化的個體治療并預(yù)測預(yù)后，或者發(fā)現(xiàn)患者是否存在特殊肚餓綜合征。而患者將非常樂意簽署一切知情同意書或者表單（危通注：真的嗎？），這是因為多數(shù)醫(yī)院都是臨床試驗研究網(wǎng)絡(luò)的成員，相關(guān)的研究結(jié)果也不會像過去耗時幾年，而是數(shù)周即可完成，而結(jié)果將更為個體化——這種基于大型網(wǎng)絡(luò)的醫(yī)學(xué)模式取代了老式的循證醫(yī)學(xué)。

第八、九、十自然段：Of course, there are still some disciplines where human contact is very important, like obstetrics and pediatrics… and intensive care. But it’s certainly well organized—I’ve been really impressed—physician assistants are available to complement the other staff… and there are even robots that can tell stories or otherwise distract and encourage the patients!

對于老年及兒科患者以及ICU，人們之間的接觸非常重要，而這些也都被良好地組織起來，包括護士助手以及會講故事的機器人統(tǒng)統(tǒng)都有...

The older doctors and nurses tell us that in the past ICU patients were often sedated, and some even paralyzed. That’s really difficult to believe. Today, only alcoholic patients may need sedatives (unless they give them some alcohol, as they say it makes more sense). And bed rest is no longer considered a benefit—patients are only allowed to stay in bed at night, unless you’re in shock or in coma. As soon as my shock was resolved, a physiotherapist introduced me to Jim (or is it Gym?), my personalized robot, and explained how “he” would help me exercise and walk with me—we even get out into the landscaped garden surrounding the ICU when the weather is good!

鎮(zhèn)靜和肌松治療的湮滅，床邊主動以及基于機器人的被動活動的增加....

Anyway, I’ve got to go—they’re calling me for my lung transplant, using a lung made from my own stem cells! Speak later.”

打斷一下，我馬上要做肝移植——新肝臟當然是來自我本人的干細胞，等會聊...

這篇類似科幻小品的文章點明了未來ICU治療幾種可能或者說發(fā)展趨勢：

其一：必然是智能化，將導(dǎo)致醫(yī)療機器人的廣泛應(yīng)用，而人力成本的大幅減少，人工主要集中于某些特殊行業(yè)——此店是否適用中國值得懷疑

其二：診療的Protocol化， 一切按照程序與規(guī)程進行，但這是否有好處也值得懷疑—— 未來醫(yī)學(xué)的最主要的挑戰(zhàn)就在于如果傳統(tǒng)的醫(yī)生對患者的訓(xùn)練模式如果真的變成醫(yī)生對仿真人的訓(xùn)練的話，經(jīng)過這樣全程訓(xùn)練的醫(yī)生是否能夠真的應(yīng)付實際有千變?nèi)f化的病人，這個問題實際的本質(zhì)就是在追問——對于任何一種疾?。ɑ蛘哒f對患有同一疾病的不同患者），究竟是否存在針對其的普適而又深刻的protocol？如果沒有，那么protocol化就是在害病人，在簡單化，幼稚化問題；如果有，那么人工智能或者編程化要進化到什么程度才能出現(xiàn)合理的規(guī)程？

其三：基于基因和大數(shù)據(jù)分析的新的醫(yī)療模式的產(chǎn)生，包括干細胞、精準醫(yī)療、網(wǎng)絡(luò)醫(yī)學(xué)模式以及大數(shù)據(jù)預(yù)后因素分析等......盡管精準治療的目標是個體化，但是否能實現(xiàn)真正的個體化以及個體化治療是否真的能帶來收益最大化都是值得考驗的——尤其是個體化治療與上述protocol化出現(xiàn)矛盾的時候怎么辦？

實在說，現(xiàn)代醫(yī)學(xué)的未來發(fā)展中重要的矛盾之一很可能就是 個體化與程式化的矛盾！

其四：無創(chuàng)化，毋庸置疑肯定會是大趨勢

其五：人文化、輕松化

其六：參與及互動度的大幅增加

......

當然，寫了上面這么多，其實都真的不是我想說的！

不知道你在通讀原文的時候，或者在看到我簡單翻譯的那些你能認識的中文文字的時候，有沒有發(fā)覺——在上面的科幻的圖景中，重癥醫(yī)學(xué)與其他專科的區(qū)別——無論是專業(yè)操作還是就醫(yī)環(huán)境，學(xué)科之間的差異好像都在消弭！

是的，現(xiàn)代醫(yī)學(xué)的發(fā)展好像真的是要碾壓一切的現(xiàn)有模式！對于重癥醫(yī)學(xué)而言，未來很可能發(fā)現(xiàn)不了重癥醫(yī)學(xué)專業(yè)醫(yī)生與其他專業(yè)醫(yī)生的區(qū)別，包括就醫(yī)的環(huán)境。又或者是另外一種場景—— 未來若是單系統(tǒng)功能障礙或衰竭，很可能就由各?？埔詿o創(chuàng)、人性及protocol化的方式自行解決，只有發(fā)展為最嚴重的多臟器衰竭的階段才可能進入ICU——可是這個時候，還能無創(chuàng)化嗎、還能人性化嗎、還能protocol化嗎，深表懷疑？

我不知道最終的答案，因為我經(jīng)歷西方重癥醫(yī)學(xué)訓(xùn)練已經(jīng)是快8、9年前了，至于現(xiàn)在它在西方發(fā)達國家發(fā)展為什么樣子我不知道，那些經(jīng)常出國的可能比我知道的還少，所以我覺得不如在這里寫下來我的感覺—— 上面幾位我深深尊重與服膺的統(tǒng)領(lǐng)本專業(yè)近半個世紀的世界級的老漢怎么現(xiàn)在突然一起變得這么“迷蒙”和“理想化”了呢?

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