Leon Piterman，黃文靜（譯），楊輝（譯）

故事發(fā)生在一個(gè)忙碌的周六早晨，當(dāng)時(shí)正值流行性感冒多發(fā)季節(jié)。診所的候診室里擠滿(mǎn)了患者，接診員在電話(huà)里告訴我：“大家只能站著”。接診員還說(shuō)：“里昂醫(yī)生，韋伯先生正在與診所進(jìn)行電話(huà)連線(xiàn)，他是喬治醫(yī)生的一位患者。韋伯先生聽(tīng)上去很憂(yōu)慮，需要馬上與醫(yī)生聯(lián)系，但他不愿意告訴我事情的原委”。

我永遠(yuǎn)忘不了和比爾（即韋伯先生，全名為比爾·韋伯）接通電話(huà)時(shí)，他甩給我的那段開(kāi)場(chǎng)白。他說(shuō)：“醫(yī)生，如果你現(xiàn)在不來(lái)為我的岳母伊迪絲做些什么的話(huà)，那我的下一個(gè)電話(huà)就會(huì)打到謀殺專(zhuān)案組，告訴他們我殺了那個(gè)老太太”。后來(lái)，我終于弄明白，原來(lái)是比爾和他的妻子在照顧伊迪絲時(shí)遇到了極端的困難。于是，我答應(yīng)他要在午飯時(shí)間去他家做一次上門(mén)訪視。

我在比爾家的前門(mén)見(jiàn)到了他。那是一幢普通的20世紀(jì)50年代建筑風(fēng)格的雙面貼磚房，這種建筑風(fēng)格的住宅在墨爾本東南區(qū)的城區(qū)街道上隨處可見(jiàn)。在那個(gè)年代，房地產(chǎn)商會(huì)把蔬果和花卉的種植園分割出一部分，用于建造住宅。這種建筑風(fēng)格已經(jīng)被藝術(shù)家霍華德·阿克利栩栩如生地展現(xiàn)了出來(lái)，如果感興趣的話(huà)可以到谷歌上去搜索一下他的繪畫(huà)作品，現(xiàn)在他的畫(huà)幾乎和他畫(huà)的房子一樣值錢(qián)。

比爾·韋伯，72歲，身材高大，體格魁梧，年輕時(shí)可能是一名體育健將。但他的外表掩蓋了他同時(shí)患有2型糖尿病、高血壓、缺血性心臟病的事實(shí)，2年前他還接受了3次冠狀動(dòng)脈旁路移植術(shù)。比爾帶我進(jìn)到廚房，他的妻子薇拉坐在那里，淚流不止、神情凄苦。我以前沒(méi)有見(jiàn)過(guò)薇拉，但從她的雙手可以明顯看出，她患有類(lèi)風(fēng)濕關(guān)節(jié)炎。

比爾向我解釋到，他和妻子7年來(lái)一直在照顧伊迪絲?，F(xiàn)在，伊迪絲已經(jīng)96歲了，患有阿爾茨海默病，二便失禁，大多數(shù)時(shí)間都在床上度過(guò)。比爾時(shí)常會(huì)出現(xiàn)胸痛的癥狀，薇拉因?yàn)轭?lèi)風(fēng)濕關(guān)節(jié)炎而不能做事情，所以大部分搬運(yùn)沉重物品的任務(wù)就落在比爾的肩上。伊迪絲已經(jīng)在一家公立養(yǎng)老院的排隊(duì)名單上等了2年，但現(xiàn)在看來(lái)想要得到一個(gè)床位的期望與當(dāng)初剛報(bào)名時(shí)一樣渺茫。比爾對(duì)現(xiàn)在的醫(yī)療照護(hù)系統(tǒng)感到非常失望，雖然地方政府和地段護(hù)理服務(wù)組織為他們提供了家庭照護(hù)服務(wù)，但這并不能滿(mǎn)足他們?nèi)找嬖龃蟮恼兆o(hù)需求。同時(shí)，家庭內(nèi)部的變動(dòng)也是雪上加霜。最近他們的女兒離婚了，成了單身母親，需要照顧2個(gè)正處在青春期的男孩，而且兒女手頭拮據(jù)，需要經(jīng)濟(jì)支持。

我被帶進(jìn)臥室，然后見(jiàn)到了伊迪絲。伊迪絲的塊頭不小，可能有90 kg。很明顯，她缺乏定向力，意識(shí)不清。整個(gè)臥室里彌漫著小便的惡臭味。在給伊迪絲做體格檢查的時(shí)候，我注意到她的臀部有一個(gè)早期褥瘡。薇拉表示，近兩天伊迪絲的意識(shí)混亂情況越來(lái)越嚴(yán)重了。我懷疑伊迪絲存在尿路感染，應(yīng)該安排她緊急住院治療。當(dāng)時(shí)，我可以安排伊迪絲住進(jìn)當(dāng)?shù)厣鐓^(qū)醫(yī)院的公立病房，現(xiàn)在那家社區(qū)醫(yī)院已經(jīng)改成了腫瘤中心。

如果是現(xiàn)在，而且伊迪絲足夠幸運(yùn)的話(huà)，她可能會(huì)被安排到大型公立醫(yī)院的“短住病房”。在那里她可以接受相應(yīng)的實(shí)驗(yàn)室檢查和治療，也會(huì)有住院醫(yī)師為她提供服務(wù)。現(xiàn)在，很多老年人被安排住進(jìn)了這種“短住病房”，但實(shí)際上，“短住病房”就是不知道“何去何從”的委婉說(shuō)法而已。

我很感激比爾請(qǐng)我到他家里去阻止了一場(chǎng)“謀殺”，但這遠(yuǎn)不及比爾和薇拉對(duì)我的感激。目前，社區(qū)老年人的數(shù)量越來(lái)越多，照護(hù)需求越來(lái)越大，上述案例中反映的問(wèn)題將會(huì)越來(lái)越突顯。60～70歲的老年人本該在退休后享受生活，但他們卻不得不去照顧年紀(jì)非常大的父母。雖然他們中的很多人存在健康問(wèn)題，但還是不得不把自己劃歸到上有老、下有小的“三明治一代”行列里。這夾在中間的一代人既要服侍80～90歲的年邁父母，又要關(guān)照30～40歲的寄居子女，有些會(huì)突然面臨家庭危機(jī)。

作為全科醫(yī)生，我們需要照顧一個(gè)家庭里的好幾代人，我們既要為他們提供急癥服務(wù)，也要為他們提供持續(xù)性服務(wù)。全科醫(yī)生的診斷和管理措施，不僅要針對(duì)患者個(gè)體，還要針對(duì)家庭和社區(qū)。隨著年齡的增長(zhǎng)，人們對(duì)家庭和社區(qū)資源的依賴(lài)會(huì)逐漸增加，因此我們現(xiàn)在就要為這些可能會(huì)發(fā)生的事情做好計(jì)劃。若非今日，更待何時(shí)？

志謝：特別感謝原文出版者《The Medical Republic》同意將此文編譯后刊登于《中國(guó)全科醫(yī)學(xué)》。

It was a busy Saturday morning at the clinic in the midst of a major influenza epidemic. The waiting room was "standing room only" when I received a call from my receptionist.

"Leon, it's Mr Webber on the phone. He's one of George's patients. He seems distressed and needs to speak to a doctor urgently. He won't tell me what it is about."

I will never forget Bill's opening remarks when we were connected. "Doctor, if you don't come now and do something about my mother in law, Edith, my next phone call will be to the homicide squad to report a murder."

I managed to ascertain that he and his wife were finding it extremely difficult to manage Edith and promised to do the home visit at lunch time.

I was met at the front door of a modest 1950s doublefront brick-veneer home. It was much the same as many in the street created during the subdivision of market gardens into residential real estate in the inner south-east of Melbourne. The style was beautifully captured by the artist Howard Arkley (suggest you Google him for picture) whose paintings are now worth almost as much as the houses he painted.

Bill Webber, aged 72, was a tall, solidly built man,possibly a sportsman in his day. His appearance, however,disguised the fact that he suffered from type 2 diabetes,hypertension and ischaemic heart disease and had triple coronary bypass two years ago.

He ushered me into the kitchen where his wife Vera sat,tearful and forlorn. I had not previously met Vera, however it was apparent from looking at her hands that she was afflicted with rheumatoid arthritis.

Bill explained that he and his wife had been caring for Edith for the past seven years. She was now aged 96, suffered from dementia, was frequently incontinent and spent much of her time in bed.

Bill was still getting chest pains, and with Vera incapacitated with arthritis most of the heavy lifting fell on his shoulders.

Edith had been on the waiting list for a public nursing home for two years, but the promise of a bed seemed just as elusive as ever.

Bill felt let down by the system. Home help from the council and district nursing were helpful, but did little to alleviate the day-to-day caring needs.

The family situation was further complicated by the recent marriage break up of their daughter who now, as a single mother, was caring for two teenage boys and needed financial support.

I was led to the bedroom where I met Edith. She was a large woman, possibly over 90 kg.

She was clearly disoriented and confused and the smell of urine seemed to permeate the room. In the course of examining her, I noted an early bed sore on her buttock. Vera felt that the confusion had got worse over the past two days.

I suspected a urinary-tract infection and felt urgent hospital admission was warranted. This was at a time when I had access to public-hospital beds at the local community hospital (now a cancer centre).

In the current climate, with a bit of luck, she would be admitted to the "short-stay unit" of a large public hospital while investigation and treatment were implemented and placement organised. Many elderly now crowd these socalled "short stay" places, a euphemism for "where to from here".

I was grateful to be able to prevent a homicide, but not nearly as grateful as Bill and Vera.

This case illustrates a problem that will become increasingly more common as our community grows older,resources for care of the elderly become more and more stretched, and people in their late 60s and 70s, who should be retired and enjoying life, find themselves caring for their very old loved ones.

Many, despite their own ill health, may fill the ranks of the "sandwich generation" where they care both for their elderly parents as well as their 30- to 40-year-old children,some of whom are suddenly facing domestic crises.

As GPs, we care for several generations within one family. We provide both acute care as well as ongoing care.

Our diagnostic and management processes focus not just on the individual, but also on the family and the community.

As we age, the dependence on family and community resources will only increase. We need to plan for these eventualities now.

For if not now, then when?