生死的智慧：柯文哲 (Wen-je Ko) at TEDxTaipei 2013

外科醫師，現為國立臺灣大學醫學院附設醫院創傷醫學部主任，亦是國立臺灣大學醫學院教授，專長為外傷、急救、器官移植等。曾至美國明尼蘇達大學進修，擔任外科研究員，研究人工肝臟。回國後，建立器官移植小組，以心臟移植為目標，為了增加成功率，柯文哲自美國引進葉克膜技術，也建立了標準器官移植程序，經由衛生署推行到全國，為臺大醫院史上第一位專責重症加護的醫師。

Dr. Ko Wen-Je is the Attending Physician and Chairman of Department of Traumatology at the National Taiwan University (NTU) Hospital. He is also an Associate Professor and a senior ICU staff specializing in external trauma, critical care, and organ transplants.

Dr. Ko had completed his research fellowship at the University of Minnesota where he focused on the study of artificial liver. After completing his research abroad, Dr. Ko returned to Taiwan to lead an organ transplant team targeted at improving the success rates of heart transplants. It was then that Dr. Ko introduced the Extracorporeal Membrane Oxygenation (ECMO) technique to Taiwan. Other notable contributions include establishing a standardized procedure during transplant surgeries, which has since been advocated by Taiwan's Ministry of Health and Welfare.

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They asked me to talk about “positive destruction.”

So I thought why not just talk about myself?

I am probably the one

that has seen the most deaths

among the doctors in Taiwan.

So I think I can share something about life and death.

There's a joke:

the most famous doctors in Taiwan is Dr.(?).

You might know this joke

After Shao Hsiao-Ling accident happened,

a person went to Chi-Mei Hospital in Liu-Ying

to see a doctor named Mo

The staff in the hospital said

that there's no Dr. Mo.

"There is , " said the person.

"His name is EcMo!

He saved Shao's life!

It’s easy to understand ECMO actually.

Venous blood

passes through a pump,

which is an artificial heart,

and then passes through an oxygenator,

which is an artificial lungs,

and in the end, goes back to the body.

It is a temporary replacement of Cardiovascular Function.

it’s look like this.

It’s a machine

operating as an artificial heart

As a matter of fact,

ECMO has been used for a long time.

National Taiwan University Hospital

has used ECMO since 1994.

Now everyone in Taiwan knows it because of Shao ’car accident.

It’s similar to the old saying” One can study for ten years in obscurity,

but as soon as one passes the examination the whole world pays attention “

It became famous

due to the media.

There are successful cases with ECMO of course.

his man is a backup dancer for Jay Chou.

He suffered an Acute myocarditis one day.

so his heart stopped.

Why did I put the slide,

and why did I take a picture of him?

His eyes opened wide,

staring at the screen.

The lines on the screen were all flat

His heart stopped,

because of Acute myocarditis.

The heart stopped beating.

This is his biopsy of cardiac muscle,

ranging 100 under the microscope.

It’s not clear enough

when it ranges in 100.

And it’s crystal clear ranging 400.

Those blue spots are lymphocytes.

Obviously, it’s a serious Acute myocarditis.

The heart was soaked in lymphocytes

and it stopped.

He stared at the screen

He stared at the screen.

His heart ‘d stopped for nine days,

however, with heart and kidney transplant,

he could dance again in a month.

It's a miracle in modern medicine

In modern medicine records,

he’s the one that is still alive after the longest CPR treatment.

4 hours.

He’d been done CPR on his way from Kuo-Tei Hospital to NTU Hospital.

When they installed ECMO at NTU hospital,

they found out he’d been injected 100 cardiotonics.

So his iliac artery and vein

were narrower than pencils

So when they opened the wound

trying to put ECMO in

,they were unable to put the tube in.

They had to do the CPR again,

until he was sent to the OR.

They had to saw the chest

to put ECMO.

It’s just like magic.

It is a miracle in modern medicine without saying.

A man ‘s heart had stopped for 9 days.

And he was still alive,

after 4 hours CPR,

heart ,and kidney transplant.

This is another case.

It reads that ”first in the world,

miracle in Taiwan,

a man lived without heat for 16 days.

This is a 56-year-old man.

He had decayed teeth.

The bacteria went into the blood,

arriving at the heart.

The heart then festered.

The operation team in the hospital

opened his chest,

and was like

“Well, it looks not well here. Cut it off.

And it looks not fine here, either. Cut it off too.”

In the end,

the whole heart was cut off.

What should we do?

“Well, transfer to NTU hospital”

I always say that NTU hospital is the line of defense in Taiwan.

Well, we still had to do it.

In the previous case, the man’s heart cannot beat.

And here,

we got a man even without a heart.

It was cut off, after all.

When he was transfer to NTU hospital,

they had to use two ECMOs

because he had no heart.

Look at the screen,

two ECMOs.

It’s really incredible I have to say.

He had no heart,

so ECG showed flat lines.

There is no heart after all.

This is his CT result.

There should have been a heart

in his thorax.

However, there was no heart.

There were only tubes.

After 16 days,

they did the heart transplant surgery.

Cardiologist surgeon Dr.Wan showed me this.

He said that when he was doing the surgery,

he should have seen a heart in the thorax

after opening his chest.

But there were only tubes

connecting to the ECMO.

The patient had no heart at all.

And after the surgery,

he was discharged.

This is The Straits Times in Singapore.

A friend of mine sent me the e-mail from Singapore.

He told me that we were in the newspapers.

16 days without heart
.

A person had lived for 16 days without heart.

But after receiving heart transplant,

he still went home healthily.

This is the other case.

He’s a 26-year-old aboriginal.

He went swimming when he was seriously drunk.

He thought he was Li Bai I guess.

But the pond was really dirty.

He choked on water.

As a result, he suffered from serious pneumonia.

It was terrible.

He’d relied on ECMO for 117 days.

Look at his lungs.

This is a serious pneumonia,

due to choke on water.

This is called cute respiratory distress syndrome.

The lungs became white.

He had used ECMO for 117 days.

We can see clearly from this picture.

His respiratory minute volume

had not exceed 100 c.c

for almost one month.

But he still recovered.

So

in the previous cases,

the man lived without heart,

the man with heart that couldn’t beat,

or the one’s lungs did not work,

they all rode out with the use of ECMO.

Even though they’d waited for 9 days

or even 100 days.

They are still alive

after heart

and lungs transplant.

It is really incredible.

To be honest,

with the media

and those successful cases,

ECMO seems to be really famous

around the island.

Of course there are successful cases,

such as the cases I’ve mentioned

and Shao.

However,

The media usually

only writes the successful ones.

They don’t write failure ones.

So we usually can’t see them.

As a Critical care medicine doctor,

I am absolutely to see the successful cases.

Nevertheless, there are unsuccessful ones.

This baby was one and half months old.

He suffered from Congenital Heart Disease.

After heart transplant,

he still could not live without a heart-lung machine.

So

they used ECMO

connected to his heart.

But not in three days,

his feet turned black.

Let’s zoom in.

Look at his feet.

So now, as a doctor.

You had to make the call.

Are you going to save his life,

by having his feet amputated.

Or will you just give up

let him go?

No matter what you do, you will suffer from pressure.

But if you can’t make the call,

This one is definitely much more difficult.

This is a 7-year-old boy

suffering from pneumoniae septicemia

It resulted in cute respiratory distress syndrome.

So they used ECMO.

After using ECMO,

there was complication.

His limbs all became black.

He stared at you with his eyes open wide

consciously.

He could even ask for water when he was thirsty.

But as a doctor,

you have to make a decision.

If you’re going to save him,

you have to cut off his limbs

all his limbs.

And if you give up,

you have to turn off the ECMO.

Now think of this:

two roads diverged in the yellow woods.

The patient is conscious.

Well, the doctor is conscious, too.

But how do you ask the boy,

" hey if you want to go on,

I have to have your limbs amputated,

all your limbs.

Or if you do not want to go on,

I will turn off the machine."

How do you talk about life and death

with a 7-year-old.

As a critical care medicine doctor,

let me tell you my experiences in the past years.

In the beginning,

I saw a patient.

Gradually,

I saw only a disease.

I saw a heart only.

Fortunately, when I turned fifty

I gradually saw a patient again.

To be frank,

I am good at studying.

I had done heart transplant,

lungs transplant,

ECMO

when I was about 30.

I was the youngest chief doctor in NTU hospital.

Chief of surgical intensive care unit.

I was in Taiwan Organ Registry and Sharing Center.

And I was the vice chief of Trauma Unit.

In my thirties,

I thought

medicine was such an awesome thing.

It solved everything.

But in my forties,

There are so many unsuccessful cases

with the use of ECMO.

Sometimes the families of the patients asked me,

“why was Shao saved,

while my family members weren’t ?”

I don’t know how to answer the questions.

I couldn’t say because he or she was not Shao, could I?

Or they asked me,

“why does his limbs turned black?”

If I had known,

I would definitely avoid it.

I did not know.

When I was in my forties,

I thought that

why could not some patients be saved?

Finally, when I was about 50

the principle dawned on me.

It’s like a poetry said, "for, everywhere, no trace of her can be seen.

When, all of a sudden, I turned about.

It’s her. Where lanterns are few and far between."

One day,

it dawned on me that

doctors are people, not God.

All we can do is try our best.

That’s it.

It’s just like seasons.

There are spring, summer

autumn, and winter.

Medicine has its limit,

no matter how well developed is the science.

With today’s technology,

we can still be live

without heart

without lungs

without kidney

or without liver.

But we can’t rely on machines

for our whole lives.

Medicines has its limit.

It’s just like

the gardeners

can’t change seasons at all.

All the gardeners can do

is to make the flowers prettier in seasons.

As a doctors,

can we change birth, aging, sickness or death?

Well,

of course not.

As a doctor,

All we can do, is to make people

live a little better when they’re alive.

That’s all.

So

I came to realize that

doctors are just the gardeners in the life of garden.

As a gardener,

how to face the withered plants

is a question.

As an expert of critical care medicine,

how do I face death?

From scientific aspect of death,

or precisely, from physical and chemical aspects of death.

Every physical reaction ,

or chemical reaction,

tends to achieve minimum energy

and maximum entropy.

Delta S is always positive.

Some will ask where does the relation come from?

Some people believe it came from the Big Bang Theory.

The universe is expanding due to the Big Bang Theory,

delta S is always positive.

Or

is there universality in the laws of universe ?

Honestly,

I don’t know either.

There’s an old saying

Blind men can judge no colours

Blind people

can’t talk about colours

because they can see nothing.

is there universality

in the laws of universe ?

Is there university

in the unlimited space and time .

Frankly,

I don’t know.

But at least,

among the scope we’re in

delta S is still positive.

What does it mean when we say delta S is positive?

In theory,

it should be minimum energy and maximum entropy.

So it all becomes more chaotic.

My existence

would mean a negative delta S

and this disobey the theory.

Then how should we view life and death?

Actually,

we often see ourselves only.

We don’t realize that we are in the universe.

The universe is the combination of we and the environment.

So total delta S

equals to delta S system and delta S surrounding.

So

this is an important concept.

Any organized group

are unstable.

It has to destroy the environment.

Delta S is negative,

however, it should be positive.

As a result, it will destroy the environment

to make the equation positive.

So my existence

is to destroy the environment.

Until one day,

when I can no longer destroy the environment,

can I destroy myself only.

Delta S should maintain positive,

so to exist is to destroy.

When you’re unable to destroy,

you can only destroy yourself.

This is death.

This is death from physical and chemical aspects.

However,

as a doctor,

I understand physics and chemistry.

How do I think of life?

One day,

when I took round in the intensive care units.

I came to realize

that there are only two kind of outcomes in lives.

One is with tubes insertion,

while the other is not.

But they’re all called death.

Death is an immutable law.

So

how do we think of death?

I have a flip point of view.

If you ask me what death is.

I will ask you:

what is life?

You guys came here

to attend a lecture.

I hope you can do one thing when you leave.

Tonight, when you are going to sleep,

when you’re lying on your bed,

ask yourself a question:

what is being alive?

Because

when you think of the question

we have to think of a question:

what is life ?

My answer to the question is this:

when you’re searching for the answer to the question,

it is the answer to the question.

Everyone dies eventually.

No when will set death

as the goal of life.

Life is a process.

We keep searching

for the answer

to what being alive is

in our life.

So when you’re searching,

that is the very answer to the question.

Death is not the goal of life.

Life is a process.

Recently, I always share the story of feces.

My teacher was going to retire,

he said,

"
 I am going to retire,

let’s go to somewhere fancy."

So

My teacher, my schoolmate and I

went to a French restaurant at Sheraton.

And it’s on me.

We spent 26,000 NT dollars.

I was too astonished to speak.

How could I eat something so expensive?

I’d never been to that kind of restaurant.

I had no idea

about what I’d ordered.

When I saw the bill,

I almost collapsed.

The next morning, in the restroom,

I examined my feces carefully.

I’d spent 9,000 NT dollars

producing it.

But I could not tell the difference

with the meals in the cafeteria, which cost 70 NT dollars,

at the NTU hospital.

I just could not tell the difference.

Then, in the restroom, I came to realize

that all the wealth you can get

is just feces.

Confucianism is the most crucial ism in Chinese culture.

Confucianism has its virtues.

It talks about human.

You can see the sayings in Confucian Analects as followed.

While you do not know life,

how can you know about death?

While you are not able to serve men,

how can you serve their spirits?

When alive,

be served according to propriety;

that, when dead,

they should be buried according to propriety;

and that they should be sacrificed to according to propriety.

Confucianism refuses to talk about death.

If you keep asking,

he would answer something about laying downing one's life for justice,

or if a man in the morning hear the right way, he may die in the evening without regret,

or sacrificing their lives to preserve their virtue complete.

Confucianism avoids

talking about death.

It doesn’t want to discuss about it

So

it is enthusiastic

about human,

and it leaves others behind.

It cares about the things you can see now.

However,

it doesn’t talk about death at all.

The following is what I think.

In Chinese culture,

Confucianism is the most crucial thought.

But we didn’t want to think of death in the past.

We avoided talking about it.

There’s a common saying based onSunzi's Art of War:

Placing somebidy on field of death and he will fight to live.

Only when we face the death,

seriously,

can we ask what life is.

We will all die in the end.

Life is just a process,

of searching for the meaning of being alive.

This is my point of view.

Actually, I am a smart person,

and strong enough.

I can travel around the island by bike.

But can I

bully others

just because I am a little smarter,

or a little stronger?

Well,

definitely not.

So

those who benefit from the society

should be grateful.

You should help others

if you’re able to.

That makes your life much more meaningful.

It’s about gratitude.

When I went to Dharma Drum Mountain,

the master talked with me

about gratitude.

Being grateful.

Being kind instead of being revengeful.

“I know you are misunderstood,” he said,

“but you can’t complain.

You should help others instead.”

At the end of my speech, let me share a concept with you.

It is “a to the power of n.”

If a is greater than 1,

a to the power of n is infinity.

If a is less than 1,

a to the power will approach zero rapidly.

What does that mean?

If what I give to the society

is greater than what I get from the society,

a is greater than one.

Our society will become better and better.

If what I get from the society

is greater than what I give to the society,

a is less than 1

Our society will become worse.

And I end the my speech,

with these words.

Facing difficulties is not the hardest thing.

The hardest thing is

facing the difficulties

without losing passion for your life and world.

Thank you very much.