Perth的街景與建築，邊走邊拍，此城給人慵懶，隔離，漫活的感覺

遇見台灣蝴蝶蘭，出境前的邂逅

第十屆澳洲緩和照顧年會合併第八屆的亞太安寧緩和會議於2009 年9月24-27日在西澳珀斯(Perth)盛大舉行，開幕儀式 的Flag Ceremony，安年兄(黃安年醫師)舉著中華民國國旗穩健上台，場面令人動容。老郭我有幸能記錄下這一刻。國旗將在2:11從我座位那排出現，要把它看完喔。

If I'm not wrong, it is the oldest Christian church in Europe. Correct me in case to the contrary.

2006年10月1日我在伊斯坦堡參加歐洲腫瘤內科醫學會年會期間，把握機會飽賞這座全歐最古老的教堂喔。當年的Gala Dinner即設在據說是歐洲最古老的教堂內，大家都知道土耳其是伊斯蘭教的，能夠保留這座基督教堂實在是這座教堂的地位吧！我們在此歐洲最古老的教堂裡欣賞兩小時的知名交響樂團的演出，全場只有我這位台灣人。

Meet me in Perth, West Australia, late this month.

Hi, guys, I'm going to attend an International Palliative Care Conference held in Perth of West Australia between 23rd and 27th this month.
Wish I can meet up with you there. Telephone number the same.
Could someone tell me how to make the most from this trip since this is the first time for me in Perth?
I plan this trip early in this February. Before visiting a new city, I will buy a best seller novel either with a story surrounding this place or the author is closely attached to the city, trying to get a glimpse of or set up a good imaginative impression of the very city. For Perth, I've read the novel, Cloudstreet (1991) by Tim Winton. Frankly speaking, the novel is readable but to me, a little bit boring. Sorry to say that. Probably right before that novel, the previous one, The Secret Supper by Javier Sierra, was a automatic page-turner. Of course the story is nothing to do with Perth.
Shall I get a new copy with story surrounding Perth and interesting enough to be carried along the trip? Suggest one to me, please, if you could.
Anyway, see you.

The Eton Scale: a tool for risk assessment for constipation. | Practice | Nursing Times

The Eton Scale: a tool for risk assessment for constipation. | Practice | Nursing Times

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原來迷上連續劇也可協助診斷出乳癌

原來迷上連續劇也可協助診斷出乳癌。前天我的乳房外科同事轉來一位女性乳癌病人。她的媳婦陪在她身旁。我細問病人她是如何發現乳癌或者乳癌是怎樣被發現的呢?原來她是 娘家 這部連續劇的忠實觀眾，劇情中的一位女主角，請參見附圖中的家系和關係圖中名叫賴惠君的。我沒看這部戲，不過據民視娘家官網的網友留言，好像是賴惠君的先生有外遇，娘家是她永遠的靠山，後來又不幸罹患乳癌第二期。

我們這位病人也是看到劇中惠君自己觸摸到右乳房有腫塊，她也跟著自己觸摸看看，立即發現自己竟然也有如劇中的乳房腫塊。待劇中女主角進行切片，病理報告驚傳乳癌，我們這位病人也趕緊來本院就醫。巧合的是癌症分期同樣是第二期。

自己觸摸進行乳房檢查我們醫學上稱作BSE (Breast Self Examination)乳房自我檢查。如果接受醫護人員檢查稱作CBE (Clinical Breast Examination)臨床乳房檢查。在西方先進國，近年對於是否要鼓勵女性作BSE已有反對意見，主要是既引起女性焦慮又無太大存活差異等因素。

但是我的經驗是在台灣有很大比率的乳癌是因BSE發現的，所以在台灣應該要推廣BSE。

乳癌個人化醫療和量身訂「治」

每一位乳癌病患都是獨特個體，無論體質、病情、預後和患者對治療模式的自主選擇都不盡相同，醫師必須提供周密、嚴謹、和專屬的診療計畫，以提高治療效果，同時減少治療帶來的副作用，這就是所謂的量身訂「治」的個人化醫療。
個人化醫療也需要有高階的醫療設備和技術，光田醫院很榮幸宣布我們的乳癌團隊擁有專為乳癌患者量身訂治的技術和設備如：哨兵淋巴結生檢(SLNB)、高階正子電腦斷層(PET-CT)、乳房磁振照影(Breast MRI)、影像導引靶向放射治療(VMAT-IGRT)和癌症分子生物標記檢測(molecular biomarkers)等。我們的乳癌團隊中有乳房外科、專精乳癌內科治療的腫瘤內科、放射腫瘤科、核子醫學科醫師以及國內少有的、經驗豐富的哨兵淋巴結判讀的病理科醫師。
乳癌術後的復發風險評估必須正確，否則會導致「過度治療」或「治療不足」的後果，前者有可能產生不必要的時間浪費、承受不必要的副作用；後者則會造成癌症復發的後果。
如何防止過多或不足的治療呢？這其實有賴於團隊運作上的默契，與適時由各專家提供診治上的意見。現在正是體現癌症個人化醫療的時代，我們必須和患者站在同一陣線上迎接一切挑戰。

98年度癌症診療品質認證注意事項

1. 清楚敘明人員執掌以區分角色與權責
2. 不可一項任務切割為多人負責。(如：癌登資料品質管控設有專責人員一名、社區服務設有專責人員一名)。
3. 負責人需熟知其職責。例如：社區服務之業務可能包含癌症篩檢及癌症預防，屆時應彙整院內所有相關業務並於癌症委員會上報告，且在癌症會議記錄中呈現。
4. 院內同儕審查機制相關資料＝治療指引遵循率、病歷書寫品質監測、團隊會議、併發症討論會議或臨床病理討論會議可以是併發症討論會、臨床病理討論會議等類似會議，重點在於這些會議應有監測機制且實地運作，討論的結果內容定期於全院性委員會中核備即可。
5. 同儕複閱後除於複閱單上簽名外，亦需彙整複閱結果並回饋至相關人員進行改善，方達到同儕複閱之意義。
6. 基準2.4乃資料庫之內部品管審查，2.5則為癌症委員會對資料庫正確及完整性之外部稽核
7. 基準2.5的審查精神在於提報正確的癌登資料至TCDB。故若對癌登欄位有爭議時，各院需建立討論機制(例如：提交多專科團隊會議討論)，並將結果彙整供相關人員參考。
8. 各醫院追蹤個案之結案定義由各院自訂。
9. 病理切片皆採外包診斷（例：委託台北病理中心），則需提出該受委託檢驗單位之複閱機制及相關紀錄證明。
10. 有部分醫院直接使用NCCN制訂之指引做為院內版本，然而部分治療項目國內目前健保尚未給付，醫院若確實經過討論，應註明該項目健保尚未給付，列為可選擇項目，基準之精神在於希望院內透過共識討論制訂適合自己院內使用之診療指引。
11. 治療計畫書上應呈現以「病人為中心」之完整治療模式，且在主要治療前即完成，而非治療後才以補填方式完成。
12. 證明治療規劃（計畫）書是經由多專科團隊的方法可在治療規劃（計畫）書中註明提交多專科團隊會議討論時間，不需每位團隊醫師簽名。
13. 定期召開多專科個案討論會議且有記錄，會議召開頻率至少兩週一次

Liondrive

Liondrive

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『阿公活到明天好不好？』

昨天我在大甲院區看門診，一位老先生由媳婦和一位大約五六歲的孫子陪同複診。老人家雖然有點面容滄桑但總顯得客氣和慈祥。他是一位晚期癌症病人，看診時孫子非常安靜站在病人旁邊，不但不吵也沒有一般同年齡小孩有的調皮作怪。

大甲鎮一帶我們稱作台灣中部海線。民風純樸，以前常聽說什麼海線病人病識感低，配合就診率低，醫囑遵從率差等的評語。但自從我在大甲設門診後，我體認到這裡的病人不但不像傳聞中所講的，反而表現出「最可愛」、最樂於與醫生配合一切診療。

診療完畢老人家起身欲離開時，一旁不發一語的孫子突然面向媽媽問道：「阿公還能活多久？」

，只聽到護士小姐回答：「小朋友很乖喔」。小孫子不但沒有移動腳步，反而提高音量地問：「阿公還能活多久？」。我非常驚訝六歲小孩竟然會脫口而出這樣的問話？他問的問題是多麼直率以及多麼迫切！

老人家彎下腰用開玩笑的語氣回答孫子：「阿公活到明天好不好？」小孫子一副憂愁的模樣。那位媳婦則拉住老人家說：「會活很久啦。」

護士想結束這個對話，我及時轉向小朋友同時拉住他幼小的手臂，認真的回答：「你很關心阿公喔。我告訴你，你爺爺的壽命是上帝決定的喔，不是醫生決定的。是上帝決定的，這樣講明白嗎？」小孫子看著我，竟然很用力的點了點頭。

兒童在經歷親人得重病對生命產生疑惑，引發悲傷的情緒，若能夠及時給予生命教育，幫助兒童面對生命無常，瞭解雖然我們不能決定生命的長度，卻可以掌握生命的寬度和廣度，以正面積極的態度接受家庭成員組成的改變是非常重要的。如果有時間坐下來陪孩童一起看描繪生死議題的繪本如「一片葉子落下來」、「阿嬤再見」、「想念外公」、「最好的朋友」、「再見，愛瑪奶奶」．．．等，能夠解除兒童對死亡的疑慮、害怕、和恐懼，對於兒童的人格成長也具有正面的幫助，抓住每一個機會教育，使每一個恐懼與焦慮能被轉化成為兒童成長的助力。

聖誕節嘉年華會我扮聖誕老公公

   

         去年我們的教會援例沿著市內的路線報佳音給民眾，大概是因為我的體型吧，我的任務是扮演聖誕老公公，背著裝滿糖果及文具的禮物袋，在飄揚著聖誕歡樂的音樂歌聲，穿梭在浩浩蕩蕩的報佳音隊伍中，想盡辦法發完袋裡的禮物。沒想到反應很熱烈，有爸爸媽媽停下機車讓她的小孩能接到來自聖誕公公的禮物，經過我身旁的車子會搖下車窗緩慢底行駛，我用塞的丟的都好，他們總是會高興自己能收到聖誕節的禮物。

Google

 

那年我在布拉格的查爾斯大橋上接受街頭藝術家的速描.

Google

Keep it up !!!

One of my patients, an old woman of indigenous Bu Nung tribe, has been afflicted with advanced breast cancer. She was often brought in by her daughter living nearby this hospital. In strict term, she is not a good patient based upon the way she takes her medicine.

Because her breast cancer tumor cells express huge quantities of hormonal receptors which means that taking a kind of oral pills that work on those receptors can shrink and kill the cancer cells, I asked her to take the oral pill day by day, not to skip even one. Initially, she did and treatment results were splendid.

However, gradually she lost her patience. After asking a leave from my clinic saying that her daughter would plan a sight-seeing trip for her to Japan, she was lost to my follow up for up to eight months. Basically without any treatment for that long period, her breast cancer worsened and spread to internal organs. She was brought back again.

I like to learn and use the language my patients are talking. Mostly, I ask them to teach me how to say greetings and encouragement in their local tongues. In order to let myself memorize and retrieve those learnings, I jolt them down in the beginning pages of the patients' medical chart. For this particular lady, I learn two important phases in Bu Nung: "U nin nang" (Keep it up! 您加油) and "Min da ma saga" (Please don't give up, you can do it! 懇請您再繼續加油).

Ultimately, she listened to me and underwent chemotherapy injection. For her, it is definitely tough.

One day after finishing a session of the outpatient visit, she was required to wait outside the clinic. She hesitated to move herself away from the chair but asked me, "Doc, say those words to me! Do you know how much strength I got from your saying those words you wrote on those front pages to me? Say it again, please."

Old High School Buddies of Mine

I haven’t caught up writing again in this blog because I felt alone when doing it and always suspect I myself am the only one in and out of this blog space. This hasn’t changed until recently one of my senior high school classmates, Y.C., asked me in the phone why I seemed to discontinue writing something in the blog now. She gives me back my stamina and endeavor to maintain this blog again.
Every high school classmate reunion party has its own legacy and is full of touching stories. I first attended this party was roughly 26 years after we were graduated. Right now we’ve been sharing nearly three decades of friendship and memories from the same old time in which we could not imagine a world flourishing with internet, Wi-Fi, and SMS. What we had back then were hand-written letters, bicycles to wander around the town, and guitars to show up our egos.
Our class teacher, Mr. Guo, responsible for our performance and acting as a mentor for us, taught us mathematics. “You won’t be able to find classmates in the university that are dearer and closer than one you have now.” He said. That kind of relationship arising in those high school years is pure without any conflict interest, always looking forward to a reunion party in the unknown future when expecting the fact of separation very soon.
In the first year in the medical school, I could not afford to buy a microscope for the Histology course. I talked to S.H. studying 150 km away down south in another University. Unbelievably, he sent me money for getting a new one without mentioning repayment. After graduation, I applied for a job as an internal medicine resident. In order to sign an effective contract, a down-payment was compulsory to secure the job position. (make sure I would definitely take the job in time). For me then a poor newly-graduated, that was a big sum of money. My senior high school classmate, P.K., tackled the problem for me. Those things you won’t talk to other people owing to self-esteem issue. However, my senior high school classmates shared some of my secrets in the past. They are easily becoming someone you would turn to when you need help or are desperate.
My classmates now live in different countries with majority dwelling in Malaysia, Singapore, Taiwan, Thailand, and Canada.

我有在運動

        我們當醫生的常勸導病人要常運動，有些反應快的病人，會立即反將一局地說：「那醫生你ㄋ？您有在運動嗎？」親愛的病友們：看著啦！我有在運動喔。而且，參加2008羅氏健康盃男雙，還得到季軍！有圖為證喔！下次就拜託不要回嘴了，要說：「是！」「謝謝醫生提醒我，運動要持之以恆。」

八月份的制癌大補帖一文

本年度本院在癌症治療和診斷領域上，有明顯的進步。
一、我們啟用的新型正子電腦斷層掃描儀PET-CT，是最先進的機種，解析度可小至4毫米，除了強化診斷力，也有助於放射治療的腫瘤定位，更精準的顯示我們要瞄準的腫瘤標靶。
二、氬氦刀腫瘤冷凍消融術的引進，運用高科技，把癌瘤凍死(消融)。可以在手術室開刀時進行，也可以影像引導定位經皮穿入直接治療。臨床應用上，冷凍消融術能控制肝臟和腎臟等處的癌瘤，對肝細胞癌和腎細胞癌尤其有用。
三、本院乳癌醫療團隊也引進新型的哨兵淋巴結定位掃描儀。在過去，幾乎所有早期乳癌病人都必須接受傳統的腋下淋巴結廓清手術。但對乳癌癌細胞未轉移至淋巴結的女性病人而言，腋下淋巴廓清術無疑是多餘的且有手術過大之嫌。哨兵淋巴結是乳癌轉移至淋巴結路徑的第一站。如果此群淋巴結是乾淨的(沒被轉移)，或稱淋巴結陰性，那麼病人就可免作腋下淋巴廓清手術。哨兵淋巴結定位技術的重要性在於能協助外科醫師精確找到要做切片的哨兵淋巴結。
四、硬體上，光田醫院正在規劃的「科際整合腫瘤專科病房」將設在第一醫療大樓的五樓。此科際整合腫瘤專科病房提供營養師、復健師、社工師、衛教師、心理師甚至藝術治療師的主動聯絡(liaison)服務。病房的設計和動線都經過事先專業規劃，溫馨、舒適和整體感帶給病患和家屬輕鬆和心靈的撫慰。