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February 07, 2008

救急医療崩壊Q&A

Q1:医者が「たらい回し」という言葉に敏感になっているのはどうしてですか?

A1:「たらい回し」というと,救急車が患者の受け入れ先を求めてA病院→B病院→C病院→・・・と,無駄にあちこち走り回っているような印象を受けますが,無線も携帯電話もありますのでそんな馬鹿なことはしません。救急車は患者発生の現場に留まり,あちこちの病院に電話をしています。「このような患者がいるらしい」という情報が伝言ゲームのように回されるわけでもありません。一カ所から各病院に電話をして立て続けに断られることを「たらい回し」と呼ぶなら,ゴールデンウィークの部屋をとろうと浦安のホテルにつぎつぎ電話して予約がとれないことも「たらい回し」になります。「たらい回し」は,マスコミが医師を貶めようとして用いる枕詞です。なぜかマスコミは親の仇かのように医師を敵視しています。コンプレックスでもあるのかと疑いたくなるほどです。高校時代に数学や理科で医学部志望者に及ばなかったことによるルサンチマンだとしたら滑稽です。間違った日本語を使って,自らの国語力の低さも世間に晒しているのですから。しかし,マスコミの影響はすさまじく,国民の多くが実際に救急患者の「たらい回し」が起こっていると思いこんでいるようです。新聞とテレビしか情報源がない高齢者だけでなく,ネットで情報収集ができる人でも自分のブログに「たらい回しをする医者は許せない」などと書き込んでいるのがよく見られます。

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Q2:「たらい回し」が誤用なのはわかりました。では,なぜ救急患者の「受け入れ拒否」が起こっているのですか?

A2:またしてもホテルを例にしますが,宿泊予約を取ろうとしても「あいにくその日は満室です」と断られた場合,「ホテルに宿泊拒否された」とは言わないはずです。正確には救急患者の「受け入れ不可能」と呼ぶべきです。

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Q3:では,なぜ救急患者の「受け入れ不可能」が起こっているのですか?

A3:先に来た救急患者の治療に追われている,満床でベッドがない,専門外,などの理由です。

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Q4:ベッドがなければ,そこらへんのソファに寝かせればいいじゃないですか?

A4:ベッドというのは単なるスペースのことを言っているのではありません。緊急入院しなければならないほどの重症患者では生体情報モニター(心電図や血圧を測定・表示する機械)や酸素なども必要ですし,手厚くケアしてくれる看護師も必要です。ベッドがないということは,患者さんのケアを充分出来ない状態のことです。逆に言うと,6人部屋のベッドのひとつが空いていたとしても,重症患者を受け入れられない場合があります。当直医は通常一人です。先に来た患者さんが重体の場合はその処置・治療にかかりきりになります。その場合,空きベッドがいくらあったとしても,次の救急患者は受け入れられません。

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Q5:例え自分の専門外でも,いったん受け入れて応急処置し,その後別の病院に搬送してはどうですか?

A5:それをして,結果が悪いと訴訟で負けるのです。以下のサイトにわかりやすくまとまっています。
http://www.snow-flake.jp/archives/1296/
http://blog.m3.com/yabuishitubuyaki/20070423/1
http://kenkoubyoukinashi.blog36.fc2.com/blog-entry-220.html
“加古川”“心筋梗塞”で検索すれば,もっと情報が得られるでしょう。

追記(2009年2月)
専門外の患者を引き受けたばっかりに書類送検された眼科医もいます。
http://s03.megalodon.jp/2009-0123-1422-16/www.nikkansports.com/general/news/f-gn-tp0-20090123-453023.html

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Q6:結果が悪くて民事で訴えられる可能性は,他の職業でもあるのではないですか?

A6:医療では,懸命に努力したにもかかわらず,患者さんが死亡すると逮捕されることがあります。福島県立大野病院の件がその例です。

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Q7:大野病院の件は救急患者ではなく,入院患者だったのではないですか?

A7:近年,インフォームドコンセント(IC)という言葉は誰でも知っているくらい普及してきました。今時,充分なICをせずに危険な治療や手術を行う医師はいないでしょう。しかし,救急患者は一刻を争う状態ですので,家族に充分な説明をする時間がありません。夜間休日の救急現場では医師は通常一人です。一人で治療しつつ,家族に充分な説明をするのはきわめて困難です。つまり,救急の現場では患者家族と信頼関係を構築する時間がほとんどありません。刑事事件は遺族の感情とは関係なく立件されるはずですが,遺族の感情が警察を動かすことも多々あります。ICの時間はあったであろう予定手術でも逮捕されるなら,患者側とトラブルになりやすい救急では逮捕の危険性はもっと高くなります。

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Q8:いいわけは聞き飽きました。当直医は救急患者を受け入れる義務を果たさなくていいのですか?

A8:病院の当直は入院患者の急変に備えて泊まるもので,院外からやってくる救急患者を診察・治療する義務はありません。当直料という手当はもらえますが,それは「自宅ではなく,病院で寝る」ことに対する手当です。寝ることが前提だからこそ,翌日は朝から通常勤務となっています。つまり,当直医が院外救急患者を診るのはボランティアであり,慈悲の心,皆さんが大好きな「仁術」によるものです。
詳しくは,
http://anesthesia.cocolog-nifty.com/freeanesthe/2007/09/qa_e211.html
http://anesthesia.cocolog-nifty.com/freeanesthe/2007/09/post_c607.html
http://ameblo.jp/med/entry-10065702840.html
http://goose.jugem.jp/?eid=72
http://archive.mag2.com/0000145665/20050423080000000.html?start=40
をどうぞ。
震災の被災地に全国からボランティアがやってきて,被災者のために奉仕活動をしていたとします。長期間のボランティア活動を終えて故郷に帰ろうとする人に向かって「勝手に辞めるな。俺たちの生活はどうなる。義務を忘れたか。もっと働け」と罵声を浴びせる。今の日本のマスコミとそれに踊らされた無知な国民がしているのは,まさにこれです。

追記(2009年4月)
http://pari.u-tokyo.ac.jp/column/column02.html

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Q9:いつから当直がボランティアになったのですか?

A9:院長が勝手に「救急患者を断るな」と勤務医に言うことはありますが,日本は表向きは一応民主国家ですので,院外救急患者を受け入れることを当直医に義務づける,つまり連続36時間勤務を強制するような制度は存在しません。ずっと昔からボランティアでした。交代制の夜勤の場合は話が別です。

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Q10:最近の医者はなぜボランティアをしたがらないのですか?

A10:語弊があるかもしれませんが,救命救急はドラマチックで,医師にとって本来はおもしろい仕事のひとつです。自分の力で患者の命を間一髪救えた瞬間は医師冥利につきると言えます。やりがいのあるボランティアだったので,当直を好む医師も少なくありませんでした(いやがる医師も当然いました)。つい数年前まで,「今日はどんな救急患者が来るだろうか」とワクワクしながら当直していた猛者さえいましたが,今ならそんな医師を猛者とは呼ばないでしょう。昔は,重症患者を救えなかった場合でも患者さんの家族から「夜中に精一杯のことをしていただき,ありがとうございました」と御礼を言われたものですが,現在の患者は医師の努力に対して訴訟という形で答えてくれます。ひどい場合は刑事訴追です。さらに医療知識皆無のマスコミが一方的に誹謗中傷してくれます。これらのリスクを冒してまでボランティアをしたがる者はいないでしょう。また,昔は本当の救急患者しか搬送されてこなかったので医師にとって密度の濃い勉強になりましたが,今はご存知のように軽症患者のコンビニ受診ばかりです。しかもこいつらは権利意識が強く,夜中でも最高の専門治療を要求してきます。逮捕の危険を顧みず,さらにこんなモンスター・ペイシェントを相手にしなくてはならないボランティアなど,誰がやりたがるでしょう。

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Q11:医者には応招義務があるのではないですか?

A11:ほとけ心から救急患者を受けると,医師生命どころか人生そのものを棒に振るかも知れません。応招義務など気にしている場合ではありません。司法も,「腕に自信がないなら救急などするな」というニュアンスの判決を下しています。
詳しくは
http://obgy.typepad.jp/blog/2007/09/post_de0c.html
をどうぞ。

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Q12:「ボランティアをしない」という強い意志を持って受け入れを断るのであれば,やはりそれは「受け入れ不可能」ではなくて,「受け入れ拒否」ではないですか?

A12:「当直医が救急患者を診るのは当たり前」という洗脳がまだ解けていない医師,あるいは皆さんが好む「仁術」「慈悲の心」により,できるだけ救急患者を診ようとする医師もまだ多くいます。空床があり,なおかつ自分が専門とする疾患・外傷でも受け入れを拒否するような豪傑はまだ現れないでしょう。割り切って「当直は寝るのが普通なので,救急は一切お断りします」と言える医師が多いなら,医師の過労は問題にならないはずです。
架空の話ですが
http://anesthesia.cocolog-nifty.com/freeanesthe/2008/01/17_5b7f.html
を参照してください。

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Q13:救急患者が受け入れを断られる事件はこれからも続くのですか?

A13:はい。もっとひどくなるはずです。

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Q14:こんなことになる前に,医者たちは救急医療崩壊の阻止に向けて何か行動を起こすべきだったのではないですか?

A14:救急に限らず,心ある医師たちは「このままでは医療は崩壊する」と警告し続けてきました。このような本を上梓した先生もいます。しかし,政府もマスコミもあまり取り上げませんでした。最近になってようやく少しわかってきたような素振りも見せますが,それでもまだ諸悪の根源を医師のモラル低下にしようとしています。医師は医療が崩壊してもそれほど困らないどころか,「かえってビジネスチャンスになる」と期待している(焼け野原後の復興を考えている?)者もいるようです。医療が崩壊して一番困るのは一般国民でしょう。一番困る人が行動を起こすべきではないでしょうか。

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Q15:医者の家族が急病になることもあります。それでも困りませんか?

A15:多くの医師は今までボランティアも含め,医療に充分貢献してきました。10年に一度あるかないかの家族の一大事に際し,適切な医療を受けさせるべく,自分が持てる人脈をすべて駆使してもバチはあたらないでしょう。医師には医師の友人・知人が数多くいます。医師同士で細々と助け合ってなんとかします。どうしても専門病院への入院が必要で,そこが満床の場合,皆さんが大好きな「ソファに寝かせる」方法も我々ならできます。「ベッドが空くまではこのソファでいい。点滴や投薬,監視は俺がする。脈はずっと触れておくし,血圧は時々手動で自分で測る。何かあっても責任は自分が取る」と言えるからです。重症が集まる救急病院はベッドの回転が速い(亡くなる患者さんが多い)ので,1時間ほど耐えればベッドが空くことが珍しくありません。とにかく,なりふり構わず八方手を尽くすことでしょう。残念ながら,この方法は患者が医師の家族の場合しか使えません。

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Q16:日本医師会は救急医療崩壊阻止に向けて何かしてこなかったのですか?

A16:日本医師会は医師全体の代表ではなく,開業医が主体となっている団体です。夜間や休日の救急医療,特に二次・三次救急を担っているのは主に勤務医です。医師会は勤務医の労働環境など興味はないでしょう。高齢の開業医などは救急搬送受け入れ不可能の報道を見聞きして,あなた方と同様「最近の医師はたるんでいる」と思っているかもしれません。

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Q17:ノブレス・オブリージュというものがあります。医師は特権階級なのだから,国民に奉仕する義務があるのではないですか?

A17:医師に特権などありません。医師は税金を払わなくていいと思っている人がいるようですが,それはありません。医師優遇税制も田舎の小さな個人医院程度でしか適用できず,一般的な開業医や病院には関係ありません。医師の窮状を理解してくれる人は少なく,警察・司法・行政・マスコミ・モンスターペイシェントのいずれにも迫害されており,四面楚歌です。すぐに「赤ひげ」という架空の人物を例に持ち出す人がいますが,自分に余裕がない状態でノブレス・オブリージュなどできません。それに,ノブレス・オブリージュや仁術は強制されて行うものではないはずです。

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Q18:それでも,急病や大けがでは医者が頼りです。国民はどうすればいいのですか?

A18:この国の政治家は,国民の健康や福祉よりも道路建設のほうが大事だと思っています。こんな国に生まれた身の不幸を呪うか,そんな政治家しか選ばなかったことを後悔するしかありません。一方,「今までの日本の医療がすばらし過ぎた。今後は普通の先進国並みになるだけ」という考え方もあります。WHOは日本の医療を総合一位と評価しましたが,それも過去のものとなるでしょう。イギリスやアメリカの悲惨な医療事情は有名ですが,カナダもひどいようです。http://obgy.typepad.jp/blog/2008/02/post-1341-3.html
いや,カナダが普通なのかも知れません。

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Comments

ブログ紹介、ありがとうございました。
ホント、マスコミが間違った言葉の使い方をするから、一般の人まで真似しちゃって、困りますよね。
言葉を扱うプロなんだから、もっとしっかりしてもらいたいです。

Posted by: Dr. I | February 12, 2008 at 09:20 PM

Dr.I様,こんにちは。

いえいえ,こちらこそ。

これからもよろしくお願いいたします。

Posted by: 管理人 | February 12, 2008 at 11:08 PM

どうもこんばんは。都筑てんがです。
報告が遅れましたが、トラックバックさせて頂きました。

自分のトコも、「救急受け入れ問題FAQ」を作っていますので、もしよろしければ、読んでみて下さい。

「救急受け入れ問題FAQ」を作りませんか?
http://punigo.jugem.jp/?eid=447

なるべく専門用語を廃して、ゆとり脳の人にも分かるような文を書けるようになりたいなぁ…と考えてますが、自分自身も、医療に関する知識が足りないため、うまい文章が書けなくて難議してます。

今の医療の現実を説明するのって、本当、難しいですね…。

Posted by: 都筑てんが | February 19, 2008 at 09:04 PM

都筑てんが様,こんばんは。

トラックバックありがとうございます。私も先ほどTBさせていただきました。

本当に,一般市民にもわかりやすいように書くのは難しいですね。飽きずに最後まで読んでもらうためには順番も考慮せねばと,最近思うようになりました。その一方,「どんなに噛み砕いて解説しても,DQNどもには理解できないだろう」と諦めている自分がいます。

Posted by: 管理人 | February 19, 2008 at 11:54 PM

ブログ検索サイト(テクノラティ、Yahoo!ブログ、他)で

「病院 たらい回し」
「病院 たらいまわし」
「病院 救急 受け入れ」
「病院 救急 赤ひげ」
「病院 仁術」

などといったワードで検索すると、未だに、この問題が医師のモラルの問題だと思っている人間が多い現実に涙が出そうになります。

…まぁ、FAQ作成のための良い材料にはなるんですが、なんだかなぁ…という感じです。

Posted by: 都筑てんが | February 20, 2008 at 11:07 PM

都筑てんが様,こんにちは。

マスコミの巨大な影響力に対してはなす術がありません。ブログを持っている人はインターネットでいくらでも正しい情報を得られますが,その人たちでさえこの低レベル。
新聞やテレビでしか情報を得ない人々の洗脳ぶりは推して知るべしでしょう。

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