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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The host (from TEDxTaipei) invited me to speak about “Positive Destruction.”

After giving it some thought, I thought I might as well share my own story.

Among all the physicians in Taiwan,

I am probably the one ER doctor who has seen the most cadavers.

I've seen many cases of life and death.

Perhaps that's why I'm suited to share such stories on this stage.

There's a joke about

the most famous physician -- Dr. Yeh

here in Taiwan.

After Shao Xiao Ling's (Taichung First Lady) car accident,

a patient went to Chi-Mei Hospital in Liu-Ying city

to seek a doctor named Yeh.

The staff in the hospital said

that there's no Dr. Yeh.

"There is, " said the patient.

"I was told that his name is 'Yeh Ker-Mo' (ECMO: Extra-Corporeal Membrane Oxygenation).

This Dr. Yeh was the one who saved Shao Xiao Ling's life!"

Speaking of ECMO, its concept is quite easy to understand.

You divert the blood flow from the femoral vein

and pass it through a pump,

which serves as an artificial heart.

The blood then passes through a membrane oxygenator,

which acts as a pair of artificial lungs.

Afterwards, the blood re-enters the body.

So, ECMO is a temporary substitute of a human's cardiovascular system.

This is how an ECMO machine looks like.

You now have a machine acting as an artificial heart

that pumps blood to the oxygenator and back to the body.

As a matter of fact, ECMO technique

was already available and widely used

at the National Taiwan University (NTU) Hospital

since 1994 prior to the first lady's car accident.

It was only since her incident that folks in Taiwan are aware of the ECMO technique.

It’s similar to the saying: "One can spend decades painting in relative obscurity,"

"but the world only sees the artist's finished masterpiece."

That's just my personal opinion.

ECMO became a household term due to its overexposure from Taiwan's media press.

here's no doubt that ECMO technique has its relatively successful cases.

One prominent example is the case of singer Jay Chou's backup dancer.

One day, this patient was admitted with fulminant myocarditis,

and was undergoing cardiac arrest.

I would like to show you a photo of him at the time,

with the patient lying on his hospital bed.

The eyes of this patient were wide open,

and were staring straight,

reading the flat lines showing on the ECG screen.

As a result of fulminant myocarditis,

the patient's heart stopped beating.

He suffered a cardiac arrest.

This is a biopsy of his cardiac muscle

magnified 100 times under the microscope.

Even under this type of magnifying power,

it's still quite hard to see.

However, magnified 400 times will be much clearer.

Those blue spots are lymphocytes.

From here, we can see a serious case of fulminant myocarditis.

Lymphocytes infiltrated his entire heart,

which caused sudden cardiac arrest.

The patient stared at the screen,

as it displayed no signs of a working heart.

After the ninth day,

after a heart and a kidney transplant,

She returned to dance in less than one month's recovery.

It was a great miracle in modern medicine.

In modern medical records,

this patient holds the longest record for CPR survival:

4 hours.

CPR was performed on him from Cathay General Hospital to NTU Hospital.

When physicians tried ECMO technique at the NTU hospital,

they found that over 100 doses

of cardiotonic drugs

were already given to him.

When an incision was made

to insert an ECMO tube,

the patient's veins and arteries were too narrow.

Therefore, CPR had to be conducted again

until he was in the operating room.

Surgeons had to saw open the patient's chest

to insert ECMO tubes from the top.

The entire procedure sounds surreal right now.

Every time I recall this case, I always say it's a modern medical miracle.

The fact that a man‘s heart had stopped for 9 days.

And after enduring heart and kidney transplants,

a 4 hour CPR,

he could still survive.

Here is anthother patient case.

The headline reads ”World's First:

Miracle of Taiwan".

Man without heart for 16 days.

In this case, the patient is a 56-year-old man.

He had a tooth decay.

Bacteria from the cavity went into the blood,

and spread to the portions of the heart.

It caused a pus buildup.

The patient went to a different hospital

where the surgical team opened up his chest,

and began to eliminate

infected tissues of the heart.

The team continued to remove

more affected tissues

until not much of the muscular organ was left.

So what can the team do now?

Transfer this patient to NTU hospital.

It seems that NTU hospital is the last line of medical defense in Taiwan.

NTU hospital has to take patients in.

In the first case, the case was cardiac arrest.

This case is more extreme.

This is a man with not much of a heart left.

It was almost all surgically removed.

When the patient was transferred to NTU hospital,

because of the state he was in,

our medical team had to use two ECMOs.

Look at this slide.

There are two ECMO devices.

This one is even more unbelievable.

Since he didn't have a heart left,

so the ECG displayed a completely flat line.

There's not much to explain here.

This is his CT scan result.

Theoretically,

there should have been a heart in his thorax.

However, the heart is missing here.

There are only tubes.

After 16 days,

our surgical team performed a heart transplant surgery on this patient.

Cardiologist surgeon Dr. Wan showed me this.

Dr. Wan said during the surgery,

he opened the patient's chest

and had expected a heart in the thorax.

However, there were only plastic tubes

connecting to the ECMO.

The patient had no heart at all.

And after 16 days, the heart transplant surgery was completed.

The patient was discharged later.

Here is the Straits Times of Singapore.

A vendor I know sent me an e-mail from Singapore.

He told me that we were featured in the Straits Times.

16 days without heart

A person had lived for 16 days without a heart.

But after receiving heart transplant,

he still went home in good shape.

This is a third case.

He’s a 26-year-old aboriginal Taiwanese.

He went swimming even when he was seriously drunk.

Jokingly, he probably thought he was Li Bai the poet.

The pond he swam in was really unsanitary.

He choked on water.

As a result,

he caught a severe case of pneumonia.

He’d relied on ECMO for 117 days.

Look at his lungs.

After he ingested unclean water,

his condition worsened to a severe case of pneumonia.

This is called acute respiratory distress syndrome.

The lungs became abnormally white.

He lived on ECMO for 117 days.

We can see clearly from this slide.

For one entire month,

the patient's ventilation volume

did not exceed 100 c.c.

But the patient still recovered.

In short,

in the these three medical cases,

in the these three medical cases,

the patient undergoing cardiac arrest,

or the patient with lung failure,

with the help of ECMO,

no matter whether 9 days later

or even 100 days afterwards,

after a heart transplant

or lung transplant,

their lives were saved.

It is really incredible.

To be honest...

In recent history, ECMO has retained

a high level of awareness

thanks to the media presses in Taiwan.

The reason why folks know about ECMO,

is because of past success cases,

and also because of the first lady in Taichung,

and famed astrologer Nick Yen.

However,

the media usually

only reports on the successful stories.

Reporters don’t write failed cases.

Hidden from the public eye.

As a critical care physician,

I am certainly glad to encounter successful patient cases.

However, there are cases that are not as successful.

This baby was one and half months old.

He suffered from a congenital heart disease.

After undergoing a heart surgery,

the baby still could not live without a heart-lung machine.

So, we hooked the baby up to an ECMO.

The ECMO was inserted in the baby's heart.

After the procedure,

in three days,

the baby's feet turned black.

Let’s zoom in.

Look at his tiny, blackened feet.

So now, as a physician,

you have to make a decision.

Should you amputate his tiny feet

to try to save his life?

Or should you just give up

and let him go?

These types of decisions are incredibly stressful to make.

But if you can’t make the call,

then the next case is more difficult to gauge.

Here is a 7-year-old boy

suffering from streptococcus pneumonia.

His condition worsened to acute respiratory distress syndrome.

So the medical team decided to employ ECMO technique.

After using ECMO, however,

there were complications.

His limbs all turned black.

His adorable eyes would look at you,

his conscious in a clear state.

He could even ask for water when he was thirsty.

But as a doctor,

you have to make incredibly hard decisions.

If you want to save him,

you have to cut off his limbs first,

and continue with further medical treatment.

And if you give up,

you have to turn off the ECMO.

Now think of this:

Between life and death,

when the patient is in a conscious state,

of course, the doctor's mind is clear, too.

How would you ask the boy?

"Hi dear"

"If you want to live"

"I will need to amputate your limbs."

"Or you'd rather give up,"

"and rest in peace?"

How do you communicate this type of life and death decision

with a 7-year-old?

This is the line of work I have to deal with

as a critical care physician.

In the beginning, I made decisions rather logically.

I identified everything by patients.

Gradually,

I targeted diseases, not patients.

A diseased heart, for example.

Fortunately, when I turned fifty,

I gradually realized that I should treat patient as a whole again.

To be quite honest,

I consider myself academically inclined.

When I reached my 30s,

heart transplants,

lung transplants,

ECMO technique,

youngest chief physician in NTU hospital,

chief physician of the Surgical Intensive Care Unit,

Initiated the Organ Registry and Sharing Center project,

Chief physician of the Trauma Unit.

All these were accomplished by my 30s.

During this journey,

I believed that medical knowledge was incredibly powerful.

Medical knowledge can cure everything.

But in my 40s,

there were many unsuccessful cases

with the use of ECMO.

Sometimes the families of the patients asked me,

“How come the First Lady of Taichung survived,

but my family member didn't make it?”

I don’t know how to answer such questions.

I couldn’t say because he or she was not the First Lady, could I?

Others ask me,

“why do his limbs turned black?”

If I'd known the answer,

I would have definitely prevented it from happening.

I have to admit that I don't know.

So when I was in my 40s,

I thought that

why couldn't this patient be saved?

Finally, when I was reached my 50s,

the concept dawned on me.

There's a Chinese poetry that says: "I've searched high and low for her."

"It's only when I turned around,"

"The woman I seek is just standing behind me near a lantern."

That day,

it dawned on me that

doctors are people, not God.

Doctors can only try our best.

That’s it.

I began to reason this philosophy out.

Let's look at seasons.

There's spring, summer, autumn, and winter.

Medicine has its limit.

No matter how advanced science is,

with today’s technology,

a person without a heart,

or lungs,

or liver,

or kidney,

can still live.

But can we replace our organs with devices or gadgets

forever?

Medicine still has its limits.

So I came to a conclusion.

Can gardeners change the seasons?

Of course not.

Gardeners can only make flowers

grow prettier in the four seasons.

As a doctor,

am I capable of changing nature's rules to birth, aging, sickness or death?

Well,

it's very difficult.

As a doctor,

all we can do is to enable people

to go through life a little easier when they’re alive.

That’s all.

So gradually,

I came to realize that

doctors are just the gardeners in the life's garden.

As a gardener,

when faced with the withered plants,

how to treat them is a great question.

As an expert in critical care,

how do I face death?

From a scientific aspect,

or more precisely, from molecular science,

a system undergoing physical reaction

on a molecular level

will tend to minimize energy

and maximize entropy.

So delta S (entropy) should be greater or equal to zero.

Some may ask how delta s is greater than zero.

Some believe it's from the Big Bang theory,

as it describes the state of ever-expanding universe.

So that's how delta S is greater than zero.

Or you may ask,

is anything constant in the laws of this universe?

Honestly,

I don’t have an answer to this.

There’s an old saying

"A blind man is no judge of colors."

Visually impared folks

can’t distinguish colors

so it's pointless to ask them to judge.

Does constant apply

to the laws in this universe?

Does eternity exist

in space and time?

Frankly,

I don’t know these answers.

But at least,

within the realm of our discussion

delta S is still positive.

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

In theory,

objects tends to be in minimum energy and maximum entropy,

creating greater disorder.

My existence

would mean a delta S less than zero,

which defies molecular science.

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 us 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

is always in an unstable state.

The group disrupts its surrounding.

So even if delta S for the group is negative,

because the group disrupts its surrounding,

delta S total is greater than zero

to make the equation positive.

So my existence

is to disrupt my surroundings

until one day

when I can no longer do so,

that's when I disrupt myself

so Delta S total can remain positive.

In essence, our existence is to disrupt.

When you’re unable to disrupt the surrounding,

you end up disrupting yourself.

That is the meaning of death.

It's death from a molecular science aspect.

However,

as a doctor,

I understand molecular science.

But what about the meaning of life?

One day, when I was in ICU

making my rounds

I came to realize

that humans only have two types of ending.

One is with inserted tubes.

The other is without.

Both represent death.

Death is every person's final journey.

So

what does death mean to us?

I'd like to share a contrasting viewpoint on this.

If you ask me what death is,

I will ask you:

what does it mean to be alive?

Everyone here in this audience

came to hear a lecture.

I hope you can do one thing when you leave.

Before falling asleep tonight,

when you’re lying on your bed,

ask yourself this question:

"What does it mean to be alive?"

Because

this question

leads us to contemplate

on the meaning of 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 one will set death

as his or her goal in life.

Therefore, life is just a process.

In this process

during one's entire lifespan

we keep searching for the answer

to the meaning of existence.

So when you’re searching for the answer to existence

that is the very answer to the question.

Death is not the goal of life.

Life is just a process.

Recently, I've been sharing the story of feces.

At one time, my advisor was going to retire.

So he said,

"I am going to retire,

treat me to somewhere fancy."

I said, "Of course."

So my advisor, another schoolmate, and I

went to the 2nd floor of the Sheraton Hotel

to celebrate in a French restaurant.

The three of us spent TWD$ 26,000.

I was astonished when I got the bill.

How could I eat something so expensive?

I’d never been to that kind of restaurant before,

so we ordered

some random and unknown dishes.

When I saw the bill,

TWD$ 26,000, I was too shocked to speak.

The next morning, in the toilet,

I examined my feces carefully.

I thought in my mind,

"I’d spent TWD$ 9,000 dollars producing this."

After careful examination, I concluded that

this "poo" looks no different from the feces I produced after dining in the NTU hospital cafeteria.

The buffet there costs TWD$ 70 only.

I couldn't tell the difference.

On the toilet, I came to realize that

all the wealth one desires

turns out to be crap.

Confucianism is the most important philosophical system in the Chinese culture.

The advantages of Confucianism are that

its philosophy is about human virtues.

Let's look at a few passages

in the Analects of Confucius.

"“If you don't understand what life is, how will you understand death?"

"If you can't yet serve men,"

"how can you serve the spirits?”

“When your parents are alive,"

"serve them with propriety;"

"when they die,"

"bury them with propriety,"

"and then worship them with propriety."

Confucianism refused to talk about life and death.

Instead, Confucius gave answers to

sacrificing life for justice

and how man holds no regret

once he understands "the way".

To a follower of Confucianism, the question of life and death

is a topic to be avoided.

He offered no direct answers.

So...

on the positive side,

he focuses on the time when he is alive.

Just avoid these big questions

and focus on the things you have at hand.

But there is one problem.

He totally sidesteps the question of life and death.

The following is what I think.

In Chinese culture,

Confucianism is the most crucial philosophy.

Back then, our forefathers didn't want to discuss life and death.

They tried to avoid the question.

There’s a saying from Sun Tzu's Art of War:

"Force soldiers to see the face of death; they will fight to stay alive."

Only when we can face death

or even face death straight up

can we begin to reflect on

what life is.

We will all die one day.

Life is just a process,

a process of searching for the meaning of existence.

That's just my humble opinion.

I think I can be considered an astute person.

My stamina is good, too.

I've biked around the entire Taiwan island on my first biking tour.

Just because I'm asute

and also in good physical shape,

can I use these blessings

to bully

or to take advantage of others?

Definitely not.

So

those who are blessed

should be grateful.

If we are very capable,

shouldn't we actively help others

and make our lives more meaningful?

Life is about "knowing gratitude" and "repaying gratitude."

When I visited Dharma Drum Mountain Monastery,

the abbot there, Veneralble Guo-Dong, shared with me

the idea of "knowing and repaying gratitude,"

as well as "being grateful, not resentful."

He said,

“I know you've been wronged,”

“but you can’t complain."

"Instead, you should make greater vows to help others in need.”

Lastly, let me share a concept

called “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 of "n" will approach zero rapidly.

What does that mean?

If what I give to the society

is greater than what I take from the society,

my "a" is greater than one.

This society will become better and better accordingly.

If what I take from the society

is greater than what I give to the society,

my "a" will be less than 1.

Consequently, this society will increasingly collapse.

I will end my speech

with these words.

"Facing hardships is not the most difficult thing."

"The most difficult thing is..."

"to facing the hardships"

"without loosing your passion for mankind."

Thank you, everyone!