小學生的腎臟守護者──謝從賓

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1999 / 4月

文‧張瓊方 圖‧邱瑞金



台北縣市的學童不一定都記得他的名字,但許多學生都曾經被他「看」過腎臟。

怳T年來,台北市立婦幼醫院小兒科主治醫師謝從賓,利用工作之餘,巡迴各小學,義務為學童及老師做超音波檢查。因為這項篩檢,讓許多學童和老師得以早期發現身體的異樣,早期治療,謝從賓因此成為許多師生的「救命恩人」。

「謝醫師已經很老了,他義務為我們做檢查,這種精神很了不起,」就讀敦化國小六年級的林子傑這麼形容今年五怢虓部B滿頭白髮、態度親切和藹的謝從賓。

民國七怳誚~,市立婦幼醫院小兒科醫師謝從賓,自掏腰包買一台手提式超音波,開始到各小學為學童做腎臟超音波篩檢。

謝從賓指出,多年來腎臟疾病一直是國人怳j死因之一,「不論是腎臟移植或洗腎病人,肉體上都要承受相當大的痛苦,」他說,除了生理上的痛苦外,在未實施全民健保前,腎臟疾病常給病人帶來沈重的經濟負擔。如今實施全民健保,將洗腎納入健保給付,對健保來說也是一筆龐大的醫療支出。

「有些腎臟疾病是可以『預防』的,」小兒腎臟專科醫師謝從賓指出,大約有百分之二怐熊Э旭I竭源自幼童時期,如果能早期發現、早期治療,對某些病人是有幫助的。

因此,謝從賓選擇從「預防」著手,開始為小學生做腎臟疾病篩檢,以期及早發現、及早治療。

早期發現、早期治療

事實上,自民國六怳T年起,台北市教育局每年都會為國小一年級及四年級學童做全身健康檢查和尿液篩檢。全身健康檢查項目包括:視力、聽力、耳鼻喉、牙齒、心臟、生殖器官等。

而篩檢腎臟疾病的方法,通常使用尿液、血液、超音波顯影三種。其中血液篩檢也很難在早期發現腎臟病變,往往要腎臟損傷到相當程度,甚至只剩下四分之一功能時,才能由血液中檢驗出來。

尿液篩檢,一般來說並無法發現腎臟結構的異常情況,因為尿液異常的原因很多,例如:有時候站太久、運動、發燒等都會引起蛋白尿,因此許多初次檢查有問題的學童,再作複檢時往往沒有問題。因此,謝從賓選擇使用超音波做篩檢工具。

謝式超音波篩檢

超音波檢查通常得平躺、在受檢部位塗抹乳膠,相當費時費事,原不適用於大規模的篩檢,但經謝從賓簡化之後,不僅方便、快速,經費也很低廉。

首先他改變檢查的姿勢,讓學童捲起背部的衣服,站著接受檢查。此外,他將乳膠裝在容器內,用超音波探頭沾稀釋乳膠檢查,節省不少擠壓、塗抹的時間。

配合學童的身高,謝從賓就坐在小學生的椅子上,一個看完緊接下一個,一天看二、三千個學童不成問題,平均下來,一個學童受檢時間還不到怓簂薄C

超音波照出腎臟的形狀像個盤子,根據影像中腎臟的大小、形狀、位置、輪廓、腎盂的變化、和鄰近器官的關係,專業經驗豐富的謝從賓可以很快的評估孩子腎臟是否正常。「現在儀器顯像清晰度不錯,只要很快看一下是否正常就可以了。」

「黏黏的!」是受檢學童對沾在身上乳膠的一般反應,除此之外,沒有任何不舒服的感覺。謝從賓指出,超音波是一種「非游離輻射線」,連孕婦、胎兒都能做,小朋友使用更沒有安全上的顧慮。

說不盡的感謝

怳T年來,經由謝從賓的義務篩檢,總共發現數千位腎臟異常的學童,楊美華的大女兒就是其中一個。

楊美華指出,七年前,由於謝從賓到女兒學校做篩檢,發現她大女兒的腎臟一大一小,學校通知她帶孩子去醫院覆檢。

幾經檢查後發現,孩子的膀胱輸尿管回流造成腎臟萎縮。經過輸尿管重植手術後,情況已不再惡化,現在孩子已經就讀國中二年級了,每半年還要回醫院做一次追蹤檢查。

「六年來我放在心裡的感謝,一直沒有機會說出來,」楊美華說,謝從賓濟世的大愛,讓她非常的敬佩與感動。

楊永福的女兒也在小學四年級時被篩檢出有腎積水的現象,經過治療已痊癒。在敦化國小擔任輔導室主任的楊永福指出:「不論站在學校或學生家長的立場,我都非常感激他!」今年敦化國小特別製作了一個感謝狀送給謝從賓,教導學生們要學習謝醫師的精神,要學會感恩,然而,「這些都不足以表達我們對謝醫師萬分之一的感謝,」楊永福說。

客氣的醫師

雖說超音波檢查沒有安全上的顧慮,但一直以來,謝從賓這項腎臟篩檢必須透過教育局去函各學校,並在家長的同意下實施。

到各小學作篩檢,謝從賓都須事先與學校健康中心護士接洽,安排時間,因此各校健康中心護士對這位「客氣」的醫生都印象深刻。

除了少數偏遠地區的小學校外,台北縣市多數的學校,謝從賓都去篩檢過,其中不乏重複造訪的,更有主動邀請謝從賓前去篩檢的。

「已經是第三次了!」在敦化國小健康中心擔任護士怳C年的王淑芬說,放寒假前謝從賓剛為敦化國小學童做完超音波檢查,而這是抴X年來謝醫師第三次來敦化做檢查,王淑芬說,謝醫師每次來除了為學生做腎臟篩檢外,還會順便幫老師們做腹腔超音波檢查,「但是他很客氣,總說自己不是專家,只是順便幫我們看一下而已。」

然而,這「順便」一看已使不少老師因此受惠。

華江國小健康中心護士謝秀麗指出,曾有一位三抪釭漕k老師被謝醫師發現肝臟有腫瘤,後來經檢查證實是惡性腫瘤,已經開刀切除了。

此外,吳興國小與木柵實踐國小二位老師的腎癌也是在第一期時被謝從賓發現;正義國小一位老師的生殖系統惡性腫瘤、文聖國小一位老師的膀胱癌……,都是因早期被謝從賓發現,因此預後情況良好。

「老師們歲數較大,因此腫瘤、病變的機率比學生高,」謝從賓說。

腎臟病在台灣

如此付出心力、怞h年來從不曾停歇,謝從賓累積的「收穫」也是無人能及的。

根據謝從賓怳T年來篩檢上百萬名學童的發現,台灣學童腎臟異常的比例約在千分之五左右,情況包括:單腎、水腎、一側腎臟較小、腎囊腫、腎結石、異位腎……等等。

「一個醫生,一輩子頂多看到一、二怑茬瘚ヵf人,我卻看了不計其數,」謝從賓多年來對學童進行篩檢發現,大約一千到一千五百個人當中,就有一人是單腎(單側腎臟不發育),這項結果與國外報告相近。

除了得到國人腎臟異常的發生率外,謝從賓的超音波篩檢結果,也發現小兒腎囊腫從前被認為很少,是因為很少有症狀而未被發現而已。

此外,許多腎疾在早期發現、早期治療,就能避免惡化或減少發生併發症的機會。像阻塞性的尿路病變,早期加以治療,就可以避免腎功能惡化;一側腎臟較小的人發生高血壓的機會較大,如果早期發現,便能提醒當事人注意血壓的變化;而單腎的人,由於腎臟負擔較大,也要注意飲食中蛋白質和鹽的含量,避免發生慢性腎衰竭。

由於生殖與泌尿系統在胚胎發育時,有極密切的關係,謝從賓也因而由腎臟問題追溯出許多生殖系統問題。

例如,單腎常合併雙子宮、雙陰道,且常會在缺腎那一側造成陰道阻塞。這種病例,謝從賓已發現了五抴X例,在目前全世界共兩百個病例中,是最大的系列。

希波拉底的誓言

多年來,謝從賓的門診和工作時間都配合小學生的作息。「別人不喜歡星期六工作,我剛好相反,盡量把醫院的工作安排在星期六,」謝從賓說,星期三、六下午他在醫院做特別門診,也是因為小學生這兩天下午不上課,可到醫院做複檢。

然而,一天為二、三千位學童做腎臟超音波篩檢,持續抴X年不間斷,對謝從賓而言,其實是相當耗費體力的工作。

問他為什麼願意付出這麼多時間和體力,滿頭白髮的謝醫師只是靦腆地說:「每個醫生受醫學教育時,都讀過希波拉底的格言:『病人的病情是你所要顧慮的。』」如今他所做的,不過是盡一個做醫生的本分而已。

身體上勞累不打緊,更煩人的是行政手續。雖然是免費的義務篩檢,謝從賓還是得獲得衛生局、教育局、學校、學生家長的同意。早期他曾聘請助理護士幫忙,為了節省開銷,之後便一個人利用時間包辦所有工作。

主管台北市中小學童健康檢查業務的教育局第七科科員江嘉律指出,謝從賓每年都會來函,因為這項檢查對學童有正面的幫助,因此教育局站在支持的立場,樂觀其成。但是基於經費的考量,腎臟超音波篩檢目前尚無法列入教育局例行的健康檢查項目之中。

大家一起來!

謝從賓表示,他很快就要退休了,退休後是否還繼續為學童做腎臟超音波篩檢?「有機會的話,我希望能做多一點、久一點,」謝從賓說,他很希望退休後能專心地從事篩檢工作,花三、五年的時間,擴大為全省的學童做篩檢,但是這項工作必須要有經費來源和政府的支持,能不能完成,目前誰也不敢說。

無論如何,怳T年來謝從賓的腎臟超音波篩檢模式與結果,不僅已建立了可貴的醫學資料,同時也是一種可供參考、遵循的篩檢模式,只要有腎臟醫生願意接替,他更歡迎「大家一起來」。

p110

腎臟疾病是國人的怳j死因之一,然而,百分之二拑Э旭I竭源自幼童時期,及早治療對某些病人很有幫助。

p112

每次義務篩檢,謝從賓都坐在小學生的椅子上,讓學童採站姿接受超音波檢查,一個早上下來,可以篩檢二千多個學童。(謝從賓提供)

p113

多年來巡迴各小學篩檢的結果,也讓謝從賓累積許多相關的資料、報告,對於台灣腎臟病的基礎研究貢獻良多。

p114

現代孩子們的身高、體重雖較以往有長足的增長,但若無固定健檢,身體上若有異常狀況,並不容易得知。

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近期文章

EN

The Guardian Angel of Kids' Kidneys- Sheih Chung-pin

Chang Chiung-fang /photos courtesy of Diago Chiu /tr. by Robert Taylor


The schoolchildren of Taipei County and City may not all remember his name, but many of them have had their kidneys "looked at" by him.

For the past 13 years Dr. Sheih Chung-pin, a consultant pediatrician at the Taipei Municipal Hospital for Women and Children, has been spending his spare time visiting the elementary schools of Greater Taipei as a volunteer to do ultrasound scans on pupils and teachers. This screening has alerted many children and adults to developing medical conditions, allowing them to seek early treatment. Hence many regard Sheih Chung-pin as their savior.

"Dr. Sheih is very old. For him to volunteer to give us check-ups is really marvelous." This is how Lin Tzu-chieh, a sixth-year pupil at Tunhua Elementary School, describes Dr. Sheih Chung-pin, a grey-haired, amiable man in his fifties.

In 1987 Dr. Sheih, a pediatrician at the Taipei Municipal Hospital for Women and Children, bought a portable ultrasound scanner with his own money and began visiting local schools to give the children kidney examinations.

Dr. Sheih says that kidney disease has long been one of the ten leading causes of death in Taiwan. "Both kidney transplant patients and dialysis patients have to endure considerable pain," he observes. In addition to this physical suffering, before the introduction of universal health insurance in Taiwan kidney disease was a tremendous financial burden for patients; now that dialysis is covered by National Health Insurance, it is a substantial item of the system's expenditure.

"Some kidney disorders can be prevented," says Sheih. He notes that some 20% of kidney failure cases have their origins in childhood, and early discovery and treatment can benefit many patients.

This is why Dr. Sheih decided to concentrate on preventive work, by screening elementary-school children for kidney disease.

Early detection, early treatment

In fact, since 1974 Taipei City Government's Bureau of Education has been providing annual physical check-ups for first to fourth-year elementary school pupils. They include examinations of the ears, nose, throat, teeth, heart and reproductive organs; vision and hearing tests; and a urinalysis.

The three most common methods used to screen for kidney disease are urinalysis, blood tests and ultrasound scanning. But blood tests are unlikely to reveal developing kidney problems in their early stages. Abnormalities do not generally show up in blood tests until the kidneys are severely damaged, with as little as only a quarter of kidney function remaining.

Urine tests also cannot usually detect structural abnormalities in the kidneys, because there are many reasons for a positive test. For instance, standing for long periods, strenuous exercise or fever may all give rise to protein in the urine. Hence in most cases where a child has a positive initial test, the follow-up examination does not reveal any problem. This is why Sheih Chung-pin decided to screen children by ultrasound.

Ultrasound, Sheih style

Ultrasound scans are generally done with the subject lying down, and a gel is spread on the area to be examined. The procedure is elaborate and time-consuming, and for this reason unsuitable for large-scale screening programs. But Sheih Chung-pin has simplified the procedure, not only making it quicker and more convenient, but also far less expensive.

Firstly he modified the examination posture: he has the children roll up the clothes from over their lower backs, and examines them standing up. He also puts diluted gel into a small container and dips the ultrasound scanner head into it before applying the head to the body, thus eliminating the need to spend time kneading and spreading the gel.

In line with the children's small stature, Dr. Sheih sits on a child's seat to do the scans, and examines the children in quick succession. In this way he can screen two to three thousand children a day without difficulty; on average he spends less than ten seconds on each child.

From the size, shape, position and outline of the kidney in the scanned image, along with variations in the renal pelvis and the kidney's position relative to neighboring organs, the highly experienced Dr. Sheih can quickly assess whether the child's kidneys are normal. "Today's instruments give good resolution, so it only takes a glance to see whether an organ is normal."

"It's all sticky!" is most children's reaction to the gel left on their bodies, but apart from this they experience no discomfort. Sheih Chung-pin points out that ultrasound is a form of "non-ionizing radiation." It can even be used on expectant mothers and their fetuses, so there are no safety concerns about its use on young children.

Boundless gratitude

Over the past 13 years, Sheih Chung-pin's voluntary screening program has identified several thousand children with abnormal kidneys. Yang Mei-hua's eldest daughter is one of them.

Yang Mei-hua recounts how seven years ago, when Dr. Sheih examined the children at her daughter's school, he discovered that one of her daughter's kidneys was smaller than the other. Yang was told by the school to take her to a hospital for a follow-up examination.

This examination showed that the ureter from the child's smaller kidney passed too directly through the wall of her bladder, so that it was not closed by the pressure in the bladder. This meant that urine could flow back into the kidney, causing the kidney to atrophy. After an operation to reimplant the ureter into the bladder wall, the condition stopped deteriorating. The child is now in her second year at junior high school, and goes back to hospital for a check-up every six months.

"All these years I've never had the chance to say how grateful I am," says Yang Mei-hua, who finds Sheih Chung-pin's philanthropic spirit both admirable and moving.

When Yang Yung-fu's daughter was examined by Dr. Sheih in her fourth year of elementary school, she was found to have hydronephrosis (distension of the renal pelvis, which collects urine from the kidney and passes it to the ureter). After treatment she made a full recovery. Yang, who is head guidance counselor at Tunhua Elementary, says: "Both as a member of staff here and as a parent, I'm very grateful to him!" This year Tunhua Elementary had a special certificate of thanks made for Sheih Chung-pin. The teachers also tell the children to be like Dr. Sheih and to be grateful to him. However, says Yang Yung-fu, "All that isn't enough to express a fraction of the gratitude we feel for Dr. Sheih."

The modest doctor

Although there are no safety concerns with ultrasound scanning, for Dr. Sheih to carry out screening at a school always requires a letter to the school from the Bureau of Education, and the agreement of parents.

Before going to a school, Dr. Sheih first contacts the school's nurse to arrange a time. This is why all the school nurses are familiar with this "modest" doctor.

Apart from a few more remote schools, Sheih Chung-pin has carried out examinations at the majority of schools in Taipei City and County. He has visited many more than once, and some even invite him unprompted.

"This is the third time already!" says Wang Shu-fen, who has been Tunhua Elementary's school nurse for 17 years. She says that when Sheih Chung-pin went to Tunhua Elementary to examine the children shortly before the winter holiday, it was his third visit in ten years. Wang says that every time Dr. Sheih comes to the school, as well as examining the children's kidneys he also does abdominal scans for teachers. "But he's very modest-he always says he's not an expert, he's just taking a quick look for us."

Nonetheless, this "quick look" has benefited quite a number of teachers.

Nurse Hsieh Hsiu-li of Huachiang Elementary School recalls how Dr. Sheih once discovered a lump in the liver of a 30-year-old male teacher at the school. It was later confirmed as malignant and removed.

Other examples include stage one cancers in the kidneys of teachers at Wuhsing Elementary and Mucha Shihchien Elementary; a malignant tumor in the reproductive organs of a teacher at Chengyi Elementary; and cancer of the bladder in a teacher at Wensheng Elementary. These were all discovered early by Sheih, so that the prognosis for their treatment was good.

"Teachers are older, so in fact there's a greater likelihood of discovering tumors and other disorders in them than in the children," says Sheih Chung-pin.

Kidney disease in Taiwan

Dr. Sheih's 13 uninterrupted years of dedicated voluntary work has yielded other valuable results too.

Over the years he has screened around a million children. Statistically, the results show that the rate of kidney abnormalities in Taiwanese schoolchildren is around five per thousand. Conditions include solitary kidney, hydronephrosis, unequally sized kidneys, renal cysts, kidney stones and misplaced kidneys.

"Most doctors wouldn't see more than ten or 20 patients with only one kidney in a lifetime, but I've seen any number of them." In his many years of screening schoolchildren, Dr. Sheih has found a case of solitary kidney (with a fully developed kidney on only one side of the body) in about every 1,000 to 1,500 children, which is similar to the rates reported in other countries.

As well as establishing the incidence of kidney abnormalities in Taiwan, Sheih Chung-pin's screening program has also shown that renal cysts are more common among children than was previously thought. This is because there are rarely symptoms, so that many cases remained undiscovered.

Sheih says that adults with polycystic kidney disease need to be careful to avoid high blood pressure and urinary tract infections, otherwise they risk early kidney failure.

Also, the early detection and treatment of many kidney conditions can prevent their becoming worse or reduce the risk of complications. For instance, early treatment of obstructive disorders of the urinary tract can prevent impairment of kidney function; people with unequally sized kidneys are at higher risk of high blood pressure, and discovering the condition early enables them to be advised to monitor their blood pressure; and because in people with only one kidney the load on that kidney is greater, they have to take care to limit the amount of protein and salt in their diet so as to avoid chronic kidney failure.

In the earliest stages of pregnancy, the development of the urinary system is intimately related with that of the genital organs. Hence Dr. Sheih's renal examinations have also revealed many disorders of the reproductive system. For instance, solitary kidney is often associated with double uterus and double vagina, often with obstruction of the vagina on the side without a kidney. Sheih Chung-pin has discovered over 50 such cases, the largest single group among the 200-plus cases so far reported worldwide.

The Hippocratic oath

For many years Dr. Sheih has tailored the timing of his clinics and other work to the rhythm of elementary-school children's lives. "Other people don't like to work on Saturdays, but I'm just the opposite-I try to arrange as much of my work at the hospital on Saturdays as I can." Sheih Chung-pin says that one reason why he holds his referral clinics at the hospital on Wednesday and Saturday afternoons is that elementary schools do not have classes on these two afternoons, so children can go for follow-up examinations at these times.

However, doing ultrasound scans on two to three thousand children a day continuously for over a decade has been a great physical strain on Sheih.

When asked why he is willing to spend so much time and effort, grey-haired Dr. Sheih simply answers shyly: "During medical training every physician reads Hippocrates' aphorism 'Your first concern is the condition of your patients.'" All he is doing today, he says, is his duty as a doctor.

The physical strain he can cope with, but the red tape he finds more wearing. Although Dr. Sheih provides his examinations free of charge, he still has to get the authorization of the Taipei City and County bureaus of health and education, and the agreement of the schools and of the children's parents. In the early days he employed a nurse as an assistant, but later, to save on expenses, he took on all the work himself.

Chiang Chia-lu of Taipei City Government's Bureau of Education, which has overall responsibility for health checks for the city's schoolchildren, says that Sheih Chung-pin writes to them every year, and because his examinations are of benefit to the children, the bureau welcomes them. But due to budgetary considerations, it has not so far been able to include ultrasound kidney scans among its own routine health checks.

Let's all do it together!

Sheih Chung-pin plans to retire soon. When he does, will he continue screening schoolchildren? "If I have the opportunity, I hope I can do more and go on with it longer," he says. He very much hopes that after he retires he can concentrate on screening work, and over three to five years expand his program throughout Taiwan. But this would require a source of funding. "At the moment, that doesn't look very likely." On questions such as the complexity of the government bureaucracy and how funding is allocated, the old doctor is unwilling to comment very much, but his frustration is obvious.

Be that as it may, Dr. Sheih's kidney scanning work over the last 13 years has not only built up a mass of valuable medical data, but can also serve as a model for others to follow. If other kidney specialists are willing to take on the task, Dr. Sheih welcomes them: "Let's all do it together!"

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Kidney disease is one of the ten leading causes of death in Taiwan. But 20% of kidney failure cases have their origins in childhood, and early treatment can help many patients.

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When doing his voluntary ultrasound screening sessions at elementary schools, Sheih Chung-pin sits on a child's chair and examines the children standing up. In this way he can examine over 2,000 children in a morning. (courtesy of Sheih Chung-pin)

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During his many years of kidney screening work in elementary schools Dr. Sheih has amassed much data and written many reports, which have contributed greatly to basic research into kidney disease in Taiwan.

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Children today grow taller and heavier than in the past, but if they do not have regular check-ups, health problems may easily go unnoticed.

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