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復活節彩蛋活動去哪裡玩

再過幾天就是復活節了，大家有沒有什麼活動安排呀？我家上個星期日去參加我們醫院組織的撿蛋活動，二貝收穫了一整筐彩蛋，三貝比較低調只撿了一個便說我已知足（但是後來打開彩蛋看到裡面有糖果便又想要更多，幸好二貝願意分享從自己的筐裡拿出幾個給了三貝）。一起參加活動的還有幾個同事的小孩和幼兒園的小朋友，撿蛋結束之後又一起去公園玩兒了半天，和朋友共度時光的快樂遠遠超過了彩蛋數量。 復活節的兩三個禮拜之前社區裏就會有陸續組織撿蛋和復活節兔兔互動活動。復活節雖然傳統意義上來說是個宗教節日，但是為小朋友們準備的這些活動純屬玩耍，慶祝春天的到來。那麼我們帶著孩子去參加的時候有什麼注意事項嗎？我想到了幾個小貼士，供大家參考： 查看活動信息，時間地點，組織者，活動內容等。一般來說市政區政的活動大約1個月前會在官網刊登具體消息。像新港和劍橋市政府每年都會組織在市中心公園草坪上撿蛋。父母工作的單位若是當地比較大規…

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從疑問題到選擇題

三貝，吃蘋果嗎？No！ 吃香蕉嗎？No！ 你要不要出去玩？No！ 那你想看電視嗎？No！ 三貝又開啟了No模式，無論你問什麼問題，回答都是一個堅定的No。各位孩子已經大些了的爸爸媽媽想必經歷過，兩三歲的孩子都有一段時間熱衷於「唱反調」。 心理學上可以理解為，孩子剛剛曉得了自我的獨立性，「我」和「他人」是分開的有獨立意識的個體，只有我才能決定我要做的事。我不需要按著別人的意圖去做，所以別人說什麼，我的默認回答就是「不」。說不的過程也是試探邊界，看看爸媽能接受（忍受）我多少個不。在不斷的試探中慢慢形成對這個世界的了解和與人相處的規則。 孩子的No其實是給父母一個讓孩子認知邊界的機會，父母可以有效的利用每一次No去幫助孩子形成認知模型，哪些No是可以的，哪些是行不通的。 比如前天我去幼兒園接三貝，他正在和小朋友追著玩，看到我來一臉掃興的樣子。 跟媽媽回家嗎？No！ 媽媽帶你去…

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核聚變與屁蛋

週末外面下雨，二貝和三貝在家看電視。是個教育節目，Brain Candy（大概可以翻譯為「頭腦棒棒糖」吧），加拿大出品的很有童趣的啟蒙教育系列，每集十分鐘左右的長度，用孩子們無法拒絕的挖掘機怪獸卡車之類來解釋數學加減乘除，ABC認字，和一些科學理論知識。 這集講的是星星的誕生，做怪獸卡車改裝的星際旅���火箭飛到星雲裏去，看氫原子和氦原子高速碰撞，引發核聚變。 看到關鍵時刻，兩個氫原子嘣一聲釋放巨大能量造出一個氦原子，熒屏一片輝煌，繼而看到金光閃閃的由兩個圓形合在一起的氦原子還在微微的震動。 這時候二貝一語道破天機，「是個屁蛋子！」

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如何打造幸福童年

坊間流傳著心理學家Alfred…

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0歲到18歲兒童免疫接種流程

昨天剛剛帶四貝五貝去打了六個月的嬰兒疫苗。其實一個月以前去檢查的時候就應該打的，但是當時小傢伙們不是得流感了嘛，流鼻涕發燒，身體狀況欠佳，醫生說現在打了疫苗也未必有好的免疫反應，因為那些白血球都被徵去和流感作鬥爭了，你們等著好了在來打吧。這次一人打了4針，外加口服糖漿一劑。因為有幾針是組合疫苗，所以這次一共預防的疾病竟有九個之多。四貝五貝還算勇敢，扎針的時候都沒有哭，等著扎完了才尋思過味兒來，哭了幾聲。 疫苗的發明確是現代醫學的奠基石之一，為防止兒童期傳染病擴散，降低嬰幼兒死亡率做出了重大貢獻。可是疫苗種類繁多，父母帶孩子去診所接種，往往不知道打了什麼。這裏我列出北美兒童必打的疫苗和接種流程表，讓做父母的一目了然，心裡有底。 注意這只是普通健康兒童的常規接種流程，有慢性疾病（比如慢性肺病，囊性纖維化，或免疫疾病等）的兒童需要特殊考慮。如果寶寶錯過了常規接種的時間，需要追趕補打疫苗，又…

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恐龍與哺乳動物

三貝：媽媽妳是媽媽三角龍，我是寶寶三角龍。 我：好啊。 三貝：現在妳是媽媽劍龍，我是寶寶劍龍。 我：哦， OK。 三貝：妳是媽媽霸王龍，我是寶寶霸王龍，嗷！ 我：嗷！ 三貝（湊過來，星星眼看著我）：寶寶霸王龍要吃boobies。 我（一本正經）：霸王龍是恐龍，恐龍是爬蟲類，爬蟲類沒有乳房，不能吃boobies。 三貝：霸王龍沒有boobies？ 我：沒有。爬蟲類都沒有boobies，只有哺乳動物才有boobies。 三貝：那妳是媽媽哺乳動物，我是寶寶哺乳動物。寶寶哺乳動物要吃boobies，可以嗎？ 我：好吧好吧，寶寶哺乳動物過來吧。

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孵恐龍蛋

二貝從朋友那拿來一顆恐龍蛋。孵恐龍蛋這個項目我們是第一次做，但是之前在書中看到過，對過程心中有數。（Eggasaurus 這本書很有趣，將一個小男孩抓住商機將自己的愛好發展成多元商業帝國的創業故事。） 看說明書，說得放在盛���清水的盆裏，幾天後會孵出恐龍來。即刻照做，之後便是漫長的等待。二貝每天早起，放學後，和睡覺前都要看一眼。真是個訓練耐心的好方法。 爺爺走過來看到一個大盆放在台上，問：這是啥？ 我答：恐龍蛋啊 恐龍蛋？爺爺一臉不可思議：真的還是假的？ 我不禁笑起來：恐龍蛋，你說真的假的呢⋯⋯ 三天後，蛋稍有裂紋。又過一天冒出個黃黃的尖尖，也看不出來是什麼。二貝最先發現，興奮地跟所有家庭成員宣布：孵出來了，奶奶，爸爸，媽媽，三貝快來看！奶奶看過說，是個尾巴吧⋯⋯ 又過了兩天，蛋殼裂得多些，可以看出原來是一個頭上的冠子，這隻也許是副櫛龍？答案在一個禮拜後就會揭曉。stay…

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老子的為父母之道

太上下知有之其次親而譽之其次畏之其次侮之信不足焉有不信焉悠兮其貴言功成事遂，百姓皆謂我自然 道德經，第十七章 這幾句話是老子評價君主的。意思是說： 最好的統治者，民眾只知道他的存在（也有版本作「不知有之」意為民眾並不知道統治者存在，或者說感覺不到任何統治行為，因為聖明的統治者施行無為之治，不言之教）；次一檔的，頌揚德行給予民眾恩典，受到民眾的尊敬和愛戴；再次一檔的，實施嚴厲的法律刑典，被民眾畏懼；最下等的統治者則只會陰謀巧計，遭到民眾的嘲笑和辱罵。 統治者不誠信，民眾也就不相信他。最好的統治者悠閒悠哉，很少發號施令。事情辦成功了，百姓卻說「我們本來就是這樣嘛。」 先且不說放眼看當代的政客，各國元首，大多是最後兩檔子的人，要麼是報刊漫畫的笑柄，要麼使民心惶惶，人人說話時口是心非，我們只談如何把這幾句話運用在親子關係上。 對於孩子來說，雙親算是統治者一樣的存在嗎？這個比喻未免太言…

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(via 寶寶鼻塞怎麼辦，這一招輕鬆處理)

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Consult etiquette

July means new interns. Freshly minted MDs in crispy white coats disperse throughout the hospital. They pick up their list of five or ten or twenty patients, and proudly sign their names on the electronic medical record as the “responsible provider”. They are excited to type various orders in the computer, from q4 hr vitals, to rectal enemas, to daily renewal of restraints, because for the first time, they don’t need any body to co-sign them. With this infusion of positive energy, also comes a deluge of pages ringing on the waistline of everyone else. It seems like every patient under the care of an intern is getting consults to every specialty in the hospital. Of course I’m making overarching exaggerated statements, but it really seems that way.      

A friend of mine, who is in the last weeks of her fellowship thus soon to be attending, recently has been getting bombarded with inappropriate pages for non-urgent consults in the middle of the night. Being a responsible and the sole representative of her specialty at night, she promptly calls back the numbers on the pages. She then finds discombobulated and clueless interns at the other end of the line, not able to tell her any useful information about the patient, instead merely asking her to “please come see them”. Why are they calling the consult? Because it is on the “to-do” check list next to their evening sign out. Why are they calling in the middle of the night? Because they have to get all the items on the list ticked off by the morning. Thanks to the diligent interns compulsively engaged in scut work, dozens of specialist residents and fellows are losing faith in humanity from fragmented sleep. Am I implicating the loathed and no-longer politically correct sense of hierarchy in medicine? Yes, and take solace that my friend, soon, as an attending, will not need to answer every consult page herself. But I can just as well bring out the justice-for-all principles of efficient resource utilization, teamwork, shared medical decision making, patient-center care... all the good stuff that is supposed to make hospital a happier safer place. 

Whatever the labels I can slap on to justify my motivations, I feel an urge to spell out the previously implicit etiquettes on consults. Some of them are passed on to me from my senior residents when I was an intern. Some are told to me by specialists on the receiving end of my calls. Some are what I tell others when I became the specialist. Some are common sense. I will suggest that consult etiquette be a routine part of intern orientation. We have all been there, and there’s no need to keep making the same mistakes. My friend may be nice enough to still go see the patient after a vague consult request, but many will not, and may even harbor a negative image of the requester and care team, and write it up in a, god-forbid, safety report. 

So how can you sound competent, efficient, caring, and convincing on your consult calls? How can you not only get your point across but also make the consultant merrily jump to their feet to come help take care of your patient?

Know the basic info of your patient At minimum, you should have the patient name, medical record number, age, gender, and location (floor and bed) ready when you pick up the phone. Location is particularly important because you want your consultant to be able to find the right patient. Know why your patient is in the hospital. What are they admitted for? How sick are they?

Have a good reason for the consult.  Consultants work the best on solving well-defined, singular problems. They are not good at embarking on an exploratory intellectual journal with you. Formulate your consult into a short, simple question that is not “Can you come see them?” Instead ask, “What antibiotics is best to treat this multi-drug resistant infection?”, “Does this patient need dialysis?”, “Why is this patient thrombocytopenic?”, “How should I adjust the insulin pump?”, “What tests do I need to stage this cancer?”. If you are consulting a proceduralist, have a procedure in mind that you want them to do. The proceduralist may have their own opinions about the type and indication of the procedure to be performed, but they will gladly come assess the patient and determine for themselves. The most frustrating consult requests are to “help manage” common chronic conditions like hypertension, COPD, diabetes, and osteomyelitis. There isn’t really a yes/no question or a definitive answer the consultant can give for the patient, and the consultant is stuck with the patient for the rest of the hospitalization. They may enjoy billing for the two-line note on the patient every morning, but most of the time, they’d rather see the patient dropped of their long list. 

Do you homework and give data to back up your reason for consult.  If you ask a consultant to help you with a problem, they will frequently ask back what have you done toward finding a solution. Don’t ask general surgery to do an appendectomy on a patient with right lower quadrant pain without an ultrasound or CT scan to show enlarged appendix. Don’t ask hematology to work up anemia before you’ve ordered a smear. Worse yet, don’t call a consultant before you’ve personally laid eyes on the patient and done a thorough history and physical. 

Make sure you are calling the correct specialty.  With the way medicine is becoming, hyper-specialization in inevitable. So everyone has their turfs and boundaries. This has several implications. First, there might be multiple consult teams in a department. Don’t call the thyroid pager for diabetes, even though both are endocrinology. Don’t call the chronic pain pager for acute pain, even tough both are anesthesiology. Second, some body parts are shared between departments. Facial trauma may be split between plastics, oromaxillofacial, and ENT. Spine may be alternating between orthopedics and neurosurgery. Double check you are calling the department covering the body part that day. Third, know what your patient’s problem is and which specialty will treat that problem. The other day a woman came in vomiting blood and the emergency room resident reflexively called GI. It turns out she was throwing up blood because she was in DIC from a retained product one day after an unsuccessful abortion. A few routine history questions and blood tests would have clarified the source of her problem and gotten her to an OB several hours sooner. Calling the wrong consult can actually mean life and death. 

Don’t consult a specialist for things you can do yourself.  Associated with the hyper-specialization phenomenon is that physicians have become less and less confident about managing things outside of their silo across the board. This translates to generalists not being confident about anything at all. We forget the purpose of the grilling in med school and internship is to make us comfortable managing, or at least initiate the management of, the common ailments. You don’t need a cardiologist to treat hypertension, a pulmonologist to treat COPD exacerbation, a neurologist to work up a headache, or a psychiatrist to evaluate the patient’s decision-making capacity. I know we are all defensive and afraid that we might miss something. But why do we exist at all if our purpose is to make phone calls all day? Don’t call a consult for “help with diagnosis and management” until you have exhausted your own knowledge base. The consultants really have better things to do. 

Don’t call non-urgent consults at night.  What is urgent? Ask yourself, is the patient dying? Is the patient losing a limb? Is the patient going to deteriorate to the point of dying or losing a limb in the next 6 hours if not seeing by this specialist? If the answer is no, wait until the morning. Don’t send a page to “just get this patient on the list for tomorrow”. Teams change and there is no guarantee the groggy and irritated night consultant will pass the info onto the day consultant. Along the same line, all non-urgent consults should be paged between 8am and 3pm. No one wants to receive a new consult at 5pm, because it means staying late to see the patient, or burden the night team with unnecessary work that should have been done during the day. Also don’t send a page during the shift-change hours. It will increase the likelihood of your page bring lost and never returned. 

For truly urgent consults, clearly communicate the need.  The key to do this well is to know the trigger words for the specialty you are consulting. For neurosurgery, it might be things like “expanding subdural hematoma” or “new motor deficits”. For orthopedics, say “open fracture” or “degloving injury”. If you really need a cardiologist to come treat hypertension for you in the middle of the night, you might want to mention “acute ischemia from increased afterload”, “uncontrolled rhythm”, or “pending heart failure”.  Usually “hemodynamic instability” grabs most people’s attention, but you may be asked what are you doing to stabilize the patient, and why are you not calling a code. 

On an optimistic note, I’m going to reframe the scut work of calling consults into an exercise of interdisciplinary communication and learning opportunity to collectively generate the best plan for patient care. Responsible consult practices, we can make it happen. 

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For most anesthesiologists, the concept of "long term care" equates to operating room cases lasting >3 hours. - Angela Bader, MD

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Money is behind a lot of the changes, societal, cultural, philosophical.

George Battit MD on anesthesia safety

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Boston in fog

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Kayaks of Charles River

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四月四日ハーバード広場雪

地下鉄の入り口で跪いてるホームレスの人を見た 手の前には乾いたコーヒーの跡が残っている紙コップ 側に立つダンボールに「人間としての親切さを求む」と書かれてある 斜め上に伸びるトンネルから吹いて来る風はやたらに寒い この風にこの人は一日中当たっているのだろう そう思うと僕は恥と罪悪感に満たれて エスカレーターを走り登って地上へ逃げ出した

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足跡

足跡，是我小學的時候班上每週一次通訊報的名字。小比賀先生用鉛筆工工整整寫在藍格子稿紙上，再拿去教務室影印，發給學生，上面記錄著每週課堂上教的東西，班級裡的活動，節假日的來去，遠足的費用，有時還有學生們寫的作文習作，拿回家裡給家長過目的。小比賀先生微胖，橢圓的臉上帶著副金絲眼鏡，個子挺高的，當時也就三十出頭，剛結了婚，還沒有做爸爸，卻在我們小孩子面前擺一副長老相，用只有古希以上的人才使用的『わし』（老朽）自稱。有一次先生忘了課本還是什麼在教務室，教務處長親自送到班上來，先生鞠躬道謝，說『わたしのです』（是我的），聽起來倒像害羞的大姑娘，幾個調皮的男生立即模仿，搞得全班哈哈笑起來。小比賀先生的字是圓圓的，沒有稜角，沒有筆鋒的那一種，應該接近於圓哥特式，和他人一樣，隨和的。通訊報的報頭也是他自己設計的，四個粗體的圓潤的平假名『あしあと』，底下幾個可愛的腳印。

初到日本，插班五年級，第一個禮拜上學回來，帶了份『あしあと』，卻不知上面寫了什麼。還好本文的內容摻差著一些漢字，查個字典還都明白了十有八九。只是這通訊報的名字，很長一段時間在我心中是個謎。因為是平假名的，字典上也沒有看到恰當的漢字填上去，也許是那時候家裡的那本簡明日漢實在太差了。小姨的日語最好，因為她之前在東京讀語言學校，但她也被這方便兒童的平假名難住了。先生選的名字，想必是有美好意義的，會不會是兩個詞合在一起的新造詞呢？我和小姨揣測著，『あし』也許是明天『あした』的縮寫，『あと』是後面，那麼報紙的名字就是明天之後，未來的意思吧，一種對小學生的期望？但是怎麼的還是感覺無法信服。後來索性不想了，每週照樣拿報紙會來，報頭漸漸地退到背景裡去了，成為了一種模糊的，美妙的，謎。

我的日語越來越好了，超越了小姨，和先生還有同學們交流暢通無阻，寫的作文也曾經被抄到通訊報上，還獲了縣政府頒的作文大獎，漢字考試當然是第一的，音讀，訓讀，都弄得頭頭是道，甚至幫助媽媽的日本人同事解讀劇本裡的俚語。我卻沒有用我提高了的語言能力去回想『あしあと』的意思。可能是因為班上有我這麼個國際學生，抑或這只是我的自戀，本來應該留下來教下一年的五年級學生的小比賀先生和我們一起昇到了六年級，陪我們到小學畢業。之後他轉到了城市另一端的一所小學，據說是為了離家近些，多陪陪他太太。我搬到了鄰市去唸中學，和小學的同學幾乎沒有聯繫了。過年的時候會給小比賀先生寄去一張賀卡，他也會回信，都是些客氣的話，和一兩句對我的鼓勵。我不知道我為什麼一直沒有問他通訊報的名字究竟意味著什麼，雖然這應該是一個簡單而又快捷地得到答案的途徑。直到離開日本很久以後了，我己經在大學，也有五六年沒有給小比賀先生寄賀卡了，有一天突然我腦中閃過了一個啟示，『あしあと』是『足跡』。好像晴天霹靂一樣，我震驚了。又如如夢初醒，我覺悟了。當時的那種感覺，真的是快樂。那些腳印是有道理的，有目的的被安排在報頭上的。我的老師是紮實的，領著我們一步一步走過來的，那麼的謙卑，那麼的腳踏實地。什麼明天，未來，期望，沒有那種浮誇和理想主義，我把先生的意向完全猜反了，從來沒有這麼高興認識到自己是錯的。

今夜又想起足跡，是因為無意中在網上衝浪衝到了自己大學和醫學院時寫過的博客，說來這些年我也留下了不少的足跡，數碼的，谷歌上可以追蹤的。十五年前博客剛剛興起的時候，我就申請了一個，日記形式的，幾乎每天都寫一點，很多瑣事，有時像豆腐帳，有陣子記錄了我每天吃的東西，卻也有人來看，還留言幫我打氣加油減肥的。後來說blogspot平台更好，就把博客挪了過去，繼續寫我的生活，煩惱，感慨，比之前的多了一些戲劇色彩，添油加醋的把我的喜怒哀樂發洩一番。還是有人來看，包括現實中的朋友，留言表示同情的，替我抱不平的，分享類似經歷的，無名的關心倒也感覺挺欣慰的。有人私下裏勸我，別把那麼個人的東西放到網上去，雖然我從來不透露任何人的真實姓名，認識我的人還是可以猜的到。於是把博客加密了，只限於我自己看。卻又有朋友輾轉到了我的博客網址，發現進不去，特意想我索要訪問權。偏巧是我敬佩的人，對我的生活感興趣，算是對我的一種賞識，我也跟蹤他的博客，惺惺相惜的味道，不好意思否決，只是不再寫自己那點事了，只發表些對於時事的意見，對於大千世界的詮釋。潮流變遷，所謂的大眾媒體推廣開來，吹捧人人都是專家，人人也就以為自己是專家了。我開了幾個特殊興趣的博客，分享我所感興趣的題材，比如中國漢字的起源，平面設計，醫療科普等。每個寫了兩三篇小文，但也只是三分鐘熱血，不久就被學業事業淹沒了。這幾個博客，包括個人的那個，都早已長年失修，荒廢了，今夜一看，許多連結和圖片都已經失效了，點開一個又一個錯誤信息。卻有那文章，還停留在網上，彷彿被遺棄在地下車庫的腳踏車一樣，灰塵累累，鏽��斑斑，座位已經不見了，鏈子也掉了，輪胎早已洩了氣，還停在那裡。

這幾年沒有寫什麼，而恰恰人生發生了很多值得用筆反省的事情，沒有去寫，還是覺得畢竟是私事，不值得曬出來以饗讀者。其他的主題，興趣所至，也湊集了不少，記在本子上，等待有空時坐下來推敲，卻遲遲沒有實現。博客軟件也越來越高級，照片，視頻已是家常便飯，手機也能上傳，互動更是實時零距離。現在這個博客，是前年遊歷全國各地醫院的時候建的，為的是有個地方收集我在各地的所見，照片佔多數的，也算是我的足跡。現在靜下心了，不如寫點東西，不至於使這個博客也淪落為遺孤。