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

Leon Piterman，蔚文礼(译)，邱珊娇(译)，黄文静(译)，杨 辉(译)



·世界全科医学工作瞭望·

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

Leon Piterman1，蔚文礼(译)2，邱珊娇(译)2，黄文静(译)2，杨 辉(译)1

全科医生；社会支持；老年人

PITERMAN L.斗牛犬不仅是澳式足球冠军[J]. 蔚文礼，邱珊娇，黄文静，等，译.中国全科医学，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.

作为一名被公认和长期备受折磨的澳式足球西部斗牛犬队的支持者，我仍然为其华丽且当之无愧地获得冠军而自豪。

这是一个实例，来自球迷大众的嫉妒不等于是普遍的民众情绪。澳大利亚人喜欢失败者和澳式猛将。西部斗牛犬征战了62年，人们都感觉到我们这些铁杆球迷理所应当地沉浸在此次夺冠的辉煌成就里。狗狗们不仅仅是俱乐部的吉祥物，我希望下面的案例可以说明这一点。

比亚的故事

当我第一次见到阿特里斯时，她刚七十岁出头，她跟我说：“叫我比亚好了”。比亚是第二次世界大战的遗孀，靠政府发放的军人遗孀抚恤金生活。她转到我的诊所来就诊，是因为30多年来一直照顾她和家人的全科医生退休了。

比亚知道自己有心脏病、支气管哮喘、高血压。她给我看了一个装着药和雾化吸入器的特百惠箱(塑料贮藏盒)，药箱里装着各种药物，帮助我给她做出诊断。给比亚看病不是一项困难的任务，但让我感到惊讶的是，她的常规处方中有一瓶500 ml的鱼肝油。我尽职尽责地按照常规处方给她开药，她的药费由退伍军人事务部(联邦政府的一个部门)支付。我觉得可以用更好的现代复合制剂来为比亚治疗便秘，但她坚持要求按照常规处方开鱼肝油。

某个冬季潮湿寒冷的周一上午，比亚非常焦虑地给我打了一个紧急求救电话，说她肚子痛得厉害，已经两天未排便了，这对她来说是不正常的。应比亚的电话要求，我去她家出诊。我知道，文献中并未报道过鱼肝油的副作用。到比亚家后，我受到一条华丽而温顺的红色猎犬的欢迎。我给比亚做了检查，她在发热，左髂窝压痛明显，非常痛苦。而在我给比亚做检查的过程中，她的狗看起来很悲伤。我觉得比亚可能有憩室炎，必须住院治疗。我建议她带上常规服用的药物，不过可以把鱼肝油留在家里。

我在感叹她有一只多么漂亮的狗，也担心如果比亚住院了没有人来照顾它。比亚突然泪流满面，跟我说：“我儿子杰克会来照顾劳伦斯(狗的名字)。但这不是我如此悲伤的原因。我不得不告诉你，医生，这些年开的鱼肝油都不是我吃的，都是给劳伦斯吃的。你注意到了吗，它的毛发多漂亮啊，这是鱼肝油的作用”。

比亚恢复得很快，1周后出院，和她心爱的劳伦斯在家团聚了。我对这个病案做了反思，我觉得很有必要继续给她开鱼肝油。如果从比亚的幸福角度来考虑，迎合和满足她给狗狗吃鱼肝油的做法，无疑是符合成本-效益原则的。

珍妮弗的故事

珍妮弗90岁，长期存在的主动脉狭窄开始成了大问题。她稍微用力就会气促，半年内因为心力衰竭住院3次。另外，珍妮弗还患有慢性阻塞性肺疾病，这段时间处于稳定期，还有严重的骨质疏松。

最后一次住院时，她看了心脏专科团队。专家们建议她接受经导管主动脉瓣膜置换术，她和她的女儿与专家探讨这个手术的利弊。幸运的是，我对这个手术也有一些了解。我的家人在与珍妮弗相似的年龄也曾做过这种手术，而手术给我的这位家人增加了5年无症状生存时间。我最近还参加了一个心脏病学会议，在会上有好几篇论文介绍了通过股动脉或肱动脉进入主动脉瓣的新的手术方式的成功率。所以，我强烈建议珍妮弗接受这个手术。

珍妮弗的丈夫已经去世，但她并不孤独。她有鲁佛斯，一条16岁的拉布拉多犬，鲁佛斯是家中不可缺少的成员，在珍妮弗的生命中占据着重要地位。珍妮弗最关心的是，在接受手术的过程中，谁来照顾鲁佛斯，鲁佛斯的听力越来越不好了，而且后腿有关节炎。珍妮弗曾经和朋友们做过短期的跨省旅行，88岁的时候坐过太平洋游轮。外出期间，都是她的女儿凡妮莎照顾鲁佛斯，这次她的女儿也同意这样做，所以珍妮弗同意接受这次手术。

手术后5 d， 我收到了医院的信息，说手术顺利，珍妮弗恢复得很好，已经准备出院回家。我打电话给她的女儿，但得到了一个悲伤的消息：鲁佛斯已经去世了。鲁佛斯患上了皮肤感染，导致败血症，在24 h内死亡。凡妮莎非常伤心，她正准备去医院把这个坏消息告诉她的母亲。

珍妮弗出院回到家，知道这个消息后伤心欲绝。凡妮莎陪伴了她几天。虽然医生们向凡妮莎保证她的母亲目前状况良好，但她不能放下母亲不管。珍妮弗仍然说自己气促、乏力，经常哭泣，夜间不能入睡，她为鲁佛斯的死而自责。

在接下来的几周里，珍妮弗明显情绪低落，沉浸在悲伤中不能自拔。珍妮弗以前一直非常独立，但最终她同意搬进养老院。心脏手术在技术上是成功的，但患者并没能完全恢复。

有大量证据表明，宠物会给主人的生活带来好处，尤其是年迈的主人，或者独自生活的主人。孤独是老年人最大的苦恼之一，在失去配偶的老年人中尤其如此。虽然政府可以为其提供日常生活支持的经济补贴，但无法替代宠物给老年人带来的生活支持。也许，现在就是纠正的时候了。

志谢：特别感谢原文出版者《The Medical Republic》同意将此文编译后刊登于《中国全科医学》。

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.

(本文编辑：王凤微)

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.

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10.3969/j.issn.1007-9572.2017.22.002

2017-06-17)

【编者按】 澳大利亚的全科医生具有行业自律性，体现在其自行制定行业标准、自主进行资质考核及自主执业等方面，也体现在《The Medical Republic》这一共享平台上。Leon Piterman是医学学士，医学博士，教育学硕士，英国医生学会会员，澳大利亚全科医生学会会员，Monash University副校长、全科医学教授，从事全科医学临床服务近40年；研究兴趣为慢性病管理、心理健康、医学教育；曾获澳大利亚勋章，医学部医学教育奖，澳大利亚全科医生学会研究奖，香港全科医生学会研究奖等；获多项澳大利亚卫生和医学研究理事会等大型研究项目，发表科学文章和著作章节120余篇，是《全科医学中的精神病学》合作著者。Leon Piterman教授建议我国的全科医生应培养“共和”思想，以为全科医学领域提供更多的平等交流机会。目前Piterman教授定期为《The Medical Republic》撰写文章，本刊深受“医学共和”思想的启发，特邀本刊编委Monash University杨辉教授对Piterman教授的文章进行编译，并进行连载刊登！本期Leon Piterman教授为我们讲述了两例老年患者与宠物的故事，指出孤独是老年人最大的苦恼之一，经济支持和单纯的诊疗不足以给老年人以慰藉，宠物的陪伴或许为老年人提供了无可替代的生活支持。因此，Leon Piterman教授建议全科医生，在为该类老年人提供诊疗服务的同时，也要关注其情绪和心理健康，敬请关注！

1.3168 Monash University,Melbourne,Australia

2.518003 广东省深圳市，罗湖医院集团黄贝岭社区健康服务中心

注：本文首次刊登于《The Medical Republic》