ปรัชญาคนขับรถแทกซี่

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ปรัชญาคนขับรถแทกซี่

                ไม่กี่วันก่อน ตอนเช้ามืด.. ข้าพเจ้าได้นั่งรถแทกซี่ จากโรงพยาบาลบเอกชนกลับบ้านหลังจากเลิกเวร.. ระหว่างที่นั่งอยู่ในรถ ข้าพเจ้าก็เอ่ยปากถามไปตามเรื่อง ถึงภาวะเศรษฐกิจในปัจจุบันของปี พ.ศ. 2558 และ 2559 ว่า ‘เป็นยังไงบ้าง กับรายได้?’ คำตอบที่ได้ ทำให้ ข้าพเจ้าแปลกใจว่า คนขับรถแทกซี่ เป็นนักปรัชญาหรือเปล่า?? เพราะเขาพูดจาได้เฉียบขาด มีเหตุ มีผล มากจริงๆ

คนขับรถแทกซี่ พูดว่า ‘ ทุกสิ่งทุกอย่าง ในวงการธุรกิจ มักเป็นไปตามกฎของ demand & supply รายได้จากการขับรถแทกซี่ก็เช่นกัน..ย่อมหนีไม่พ้นจากอุปสงค์และอุปทาน..เมื่อมีรถแทกซี่ออกมาในท้องถนนมากมาย คนขับก็ต้องมีรายได้น้อยลง เป็นธรรมดา นอกจากนั้น ยังมีคู่แข่งเป็นรถพาหนะอื่นๆอีกครับ..รถตู้ขาว เข้ามาแย่งเส้นทางยาวๆ ..รถมอเตอร์วิ่งว่อนรับผู้โดยสารยามรถติดและเส้นทางสั้นๆ ..รถสองแถววิ่งเก็บเกี่ยวในระยะทางสั้นๆและกลางๆ..สารพัด สารเพ ของการแข่งขันหาลูกค้า...ไหนเลย ประเทศไทยจะมีสภาพเศรษฐกิจที่เลวร้ายลงทุกวัน จากการที่นักท่องเที่ยวต่างประเทศ ไม่ค่อยเข้ามาไทยด้วยปัจจัยข่าวร้ายๆ และยังมี..การย้ายถิ่นของบริษัทอุตสาหกรรมหนัก (Heavy Industry) ไปยังประเทศ เวียตนาม กัมพูชาและพม่า..อีกจำนวนมาก อันเป็นผลมาจากค่าแรงที่สูงและจากความเสียหายของภาวะน้ำท่วมครั้งใหญ่ในปี พ.ศ. 2554 ’

ข้าพเจ้าฟังคนขับแทกซี่จนเพลิน ก็นึกถึงเรื่องราวของการผ่าตัดคนไข้ผ่านกล้องทางนรีเวช ที่เพิ่งผ่านมา ว่า มีปัญหาอะไรบ้าง จะคล้ายคลึงกับปัญหาคนขับแทกซี่รายนี้หรือเปล่า?

คนไข้รายนี้ เป็นผู้หญิงอายุ 40 ปี มีครอบครัวแล้ว..แต่ไม่มีประวัติคลอดบุตรที่แน่นอน ข้าพเจ้าถามย้ำกับพยาบาลในห้องผ่าตัดว่า ‘คุณสุกัญญา เคยคลอดบุตรมาก่อนหรือไม่?’ การที่ข้าพเจ้าถามเช่นนั้น ก็เพราะว่า ถ้าคุณสุกัญญา เคยคลอดบุตรมาก่อน.. ช่องคลอดเธอจะกว้างขวางพอ ที่จะตัดเลาะเอาเนื้องอกออกทางช่องคลอดได้อย่างสะดวก..โดยไม่ต้องใช้เครื่องมือพิเศษปั่นและดูดชิ้นเนื้อออกทางหน้าท้อง..

พยาบาลห้องผ่าตัดคนหนึ่งตอบว่า ‘ไม่ทราบคะ..แต่เธอเคยผ่าตัดไส้ติ่ง’ คำตอบนั้น ไม่ได้ตอบคำถามชัดเจน..เพียงแต่พอบอกได้ว่า ‘ส่วนขวาล่างของช่องท้องคุณสุกัญญาจะมีพังผืด ไม่มากก็น้อย’ ซึ่งเมื่อเจาะท้องเข้าไปตรงสะดือของคุณสุกัญญา ก็มองเห็นภายในช่องท้องด้านขวาล่างของคนไข้ มีพังผืดเช่นนั้นจริงๆ แต่มีไม่มากนัก..ทำให้ข้าพเจ้าใช้Trocar ขนาด 5 มิลลิเมตร เจาะช่องท้องด้านขวาล่างอย่างสะดวกและได้ตำแหน่งที่ต้องการ หลังจากนั้น ข้าพเจ้าก็ออกคำสั่งว่า ‘เอาเตียงผ่าตัดขึ้น และเอาด้านหัวคนไข้ลงต่ำครับ’ จากนั้น ก็ให้แพทย์ทางด้านล่าง ที่นั่งอยู่ระหว่างขาคนไข้.. ช่วยกระดกมดลูกขึ้น..

ภาพที่เห็น..คือ มดลูกมีขนาดใหญ่กว่าปกติเล็กน้อย ขนาดประมาณอายุครรภ์ 8 ถึง 10 สัปดาห์ ..แต่ที่สำคัญคือ ด้านหน้าบริเวณ lower segment ของมดลูก..มีพังผืดอัดแน่น กล่าวคือ ส่วนของกระเพาะปัสสาวะของคนไข้ยื่นเลยขึ้นมาเกาะ บนพื้นผิวมดลูกส่วนล่าง มากกว่าปกติ..ตรงนี้สิ ..น่ากลัว..โดยเฉพาะสำหรับคุณหมอมือใหม่ที่เพิ่งผ่าตัดผ่านกล้อง..ถือว่า มีความเสี่ยงและอันตรายมาก..

อะไร? ที่หมายถึงความเสี่ยงและอันตราย?? อันตรายที่ว่านั้น คือ การบาดเจ็บหรือฉีกขาดของกระเพาะปัสสาวะ (Bladder injuries) ของคุณสุกัญญา...ทำไมจึงเกิดการบาดเจ็บหรือฉีกขาดของกระเพาะปัสสาวะได้?? ทั้งนี้ เพราะ คุณสุกัญญา ต้องเคยตั้งครรภ์คลอดลูกโดยการผ่าตัดคลอดมาก่อนอย่างแน่นอน การผ่าตัดคลอดบุตรบริเวณส่วนล่างของมดลูกนั้น เราจะผ่าเปิดและเย็บปิดแผลส่วนล่างของมดลูก (Lower uterine segment) โดยกรีดมีดลงในแนวขวางของมดลูกส่วนล่าง (low transverse incision)

 เมื่อทำคลอดทารกน้อยเสร็จเรียบร้อยแล้ว ก็เย็บปิดบริเวณตรงนี้เอง โดยจะเย็บเอา Peritoneum หรือเยื่อบุลำไส้ ที่คลุมกระเพาะปัสสาวะ ไปปิดแผลที่เย็บบนเนื้อมดลูก ..ทำให้เกิดการดึงรั้งเอากระเพาะปัสสาวะไปคลุมไว้ที่มดลูกส่วนล่าง..ดังนั้น ในการผ่าตัดผ่านกล้องต่อมา พอเราใช้เครื่องมือกรีดมดลูกส่วนล่างทางด้านหน้า ก็จะทะลุเข้ากระเพาะปัสสาวะพอดี..วิธีการแก้ไขจริงๆ  ก็ไม่ยาก สำหรับคุณหมอที่มีประสบการณ์ ซึ่งจะได้กล่าวต่อไป

ในสถานการณ์เช่นนี้ ข้าพเจ้าตัดสินใจเลือกที่จะตัด เส้นเอ็น ที่ชื่อ Round ligaments  ทั้งสองข้างให้ขาดจากกันเสียก่อน โดยเลือกตัดเส้นเอ็นให้ห่างจากขั้วมดลูก (Uterine corneal part) ประมาณ 2 เซนติเมตร  จากนั้น ก็เลาะตัดแหวกเนื้อเยื่อตรงนั้น ให้เห็นพื้นล่างที่ต่ำลงไปจนทะลุไปที่ช่องว่างด้านหลัง จนเห็นลำไส้เล็กและลำไส้ใหญ่ที่ซ่อนอยู่ทางด้านล่าง.....จากนั้น ข้าพเจ้าก็เลือกตัด เส้นเอน้น็็นที่ชื่อ Ovarian ligament proper พร้อมกับตัดเอาท่อนำไข่ออกทั้งสองข้างด้วย คราวนี้ มาถึงจุดสำคัญของการผ่าตัด คือ การใช้เครื่องจี้ไฟฟ้า ตัดด้านล่างและด้านหลังของตัวมดลูกเหนือต่อเอ็น Utero – sacral ligaments เล็กน้อยในแนวขนาน (Horizontal) จนทะลุเข้าช่องคลอด ซึ่งในตอนนี้เอง ข้าพเจ้าจะเห็นขอบของท่อวงแหวนเครื่องมือสีน้ำเงิน..ซึ่งถือเป็น landmark สำคัญของช่องคลอด..  ต่อจากนั้น ข้าพเจ้ายังคงจี้ตัดส่วนของมดลูกส่วนล่างทางด้านหลัง (Posterior aspect of lower uterine segment) ทะลุเข้าช่องคลอดย้อนขึ้นไปเรื่อยๆ จนเลยมาถึง..บริเวณด้านข้างของมดลูก (Lateral aspect)..ซึ่งมีเส้นเลือดใหญ่ ชื่อ Uterine Arteries ซ่อนตัวอยู่...

ข้าพเจ้าใช้เครื่องจี้ไฟฟ้าชนิดที่เป็นตัวปิดเส้นเลือดด้วยความร้อน (Seal uterine vessels) ชื่อว่า  Ligature  จี้ตัดเส้นเลือดใหญ่ (Uterine arteries) ทางด้านข้างของคอมดลูก (Lateral aspect of lower uterine segment) ทั้งสองข้าง

ช่วงสำคัญที่สุดของการผ่าตัดผ่านกล้องของคุณสุกัญญา คือ การจี้ ตัด เลาะ เอาส่วนของกระเพาะปัสสาวะที่ปกคลุมทางด้านหน้า ออกจากมดลูกส่วนล่าง (Lower uterine segment) ข้าพเจ้าเริ่มต้นด้วยการผ่าตัดจากด้านข้างก่อนทั้งสองด้านดังที่กล่าวมา โดยค่อยๆจี้ตัดเลาะย้อนขึ้นไปทางข้างบน (นับจากรอยต่อของแผลผ่าตัดที่เปิดครั้งแรกด้านหลังของมดลูกส่วนล่าง).. ซึ่งมีกระเพาะปัสสาวะย้อยมาจากด้านหน้า คร่อมปกคลุมมดลูกส่วนล่าง..จากนั้น ก็ค่อยๆเลาะ จี้ ตัด..Peritonium   ตรงกลางๆ (Middle part) หรือเยื่อบุลำไส้ส่วนที่ยึดกับผิวด้านหน้าของมดลูกส่วนล่าง.. ตรงริมขอบที่ติดกันพอดี..โดยค่อยๆกรีดจี้เจาะเนื้อเยื่อ พร้อมกับให้แพทย์ที่กระดกมดลูก ช่วยดันเครื่องมือจากด้านล่าง ให้มดลูกลอยขึ้นสูง.. ซึ่งจะมีผลช่วยให้การกรีดเจาะ ..ไม่ทะลุเข้าไปในกระเพาปัสสาวะ..

เมื่อข้าพเจ้าเลาะเอา Peritonium ส่วนที่ปกคลุมด้านหน้าของมดลูกส่วนล่างได้แล้ว ก็ใช้จี้ไฟฟ้า จี้ตัดเนื้อบริเวณส่วนคอมดลูกจนทะลุเข้าไปในช่องคลอด (Anterior fornix) ..การจี้ตัดเนื้อมดลูกส่วนล่างครั้งนี้ แตกต่างจากครั้งก่อนๆ เพราะข้าพเจ้าจี้ตัดในช่วงท้ายๆของการผ่าตัด (last operation)  ภายหลังจากเลาะทางด้านข้างของมดลูก จนเปลือยเปล่า..และเห็นแนวทอดตัวของกระเพาะปัสสาวะที่ปกคลุมมดลูก จากนั้น จึงทำการกรีดจี้ไฟฟ้าไปโดยรอบพร้อมกับดันตัวกระดกมดลูก..

จริงๆแล้ว!! ก่อนหน้านั้น ตอนที่จี้ตัดเนื้อเยื่อบริเวณด้านข้าง..อันประกอบด้วยรังไข่และท่อนำไข่ ซึ่งเรียกรวมๆว่า ‘Adnexa’  ข้าพเจ้าได้เลาะตัดเอาท่อนำไข่ออกไปด้วยทั้งสองข้าง ดังนั้น พอเลาะตัดจนทะลุเข้าช่องคลอดโดยรอบ..เรียบร้อยแล้ว.. เนื้องอกมดลูกก็หลุดลอยเป็นอิสระทันที..

การผ่าเลาะตัดเอาชิ้นเนื้องอกมดลูกออกจากช่องคลอดของคุณสุกัญญานั้น (Removal of  uterine myoma by cutting to small pieces from vagina ).. ไม่ยากเลย วิธีการ คือ เราเอาเครื่องมือที่สอดจากช่องคลอดออก (ตัวกระดกมดลูกพร้อมท่องวงแหวนสีน้ำเงิน) จากนั้น ก็ตัดเนื้องงอกมดลูกเป็นชิ้นเล็กๆ โดยเริ่มจาก ปากมดลูก และตัดดึงเนื้องอกลงมาเรื่อยๆ ..เนื่องจากช่องคลอดของคนไข้รายนี้ กว้างพอสมควร ..เนื้องอกมดลูกทั้งหมด จึงหลุดออกมา โดยไม่ต้องเลาะตัดเนื้องอกทิ้งที่ละชิ้นๆ ..เหมือนที่เคยกระทำมาในคนไข้รายอื่น

วิธีการเย็บปิดช่องคลอดจากการผ่าตัดผ่านกล้องนั้น กระทำได้ 2 วิธี วิธีการแรก คือ เย็บจากด้านบน คือ เย็บปิดช่องคลอดจากในช่องท้อง โดยใช้ตัวจับ (Needle Holder) ที่ยาว เหมือนตะเกียบ และมีตัวประคองเป็นแขนยาวๆ (Grasping forceps) เช่นกัน โดยมีแพทย์ผู้ช่วย ร่วมถือตัวประคอง (Grasping forceps) ช่วยด้วยเช่นกัน.. วิธีการเย็บแบบนี้ ต้องใช้ความสามารถที่ฝึกฝนมานานพอสมควร ส่วนอีกวิธีหนึ่ง คือ การเย็บแผลส่วนปลายช่องคลอด (Vaginal Apex) ผ่านทางช่องคลอด (Transvaginal suturing)  วิธีการนี้ ง่ายกว่า และเหมาะที่จะใช้ในกรณีที่..แผลภายในตรงยอดช่องคลอด มีพังผืด หรือเย็บยากจากด้านบน สรุปง่ายๆ คือ ถ้าไม่แน่ใจว่าจะเย็บจากข้างบนได้หรือไม่ได้ หรือกลัวว่าจะมีปัญหา..ให้เย็บผ่านทางช่องคลอด (Transvaginal suturing)   เท่านั้น กรณีของคุณสุกัญญาก็เช่นกัน..ข้าพเจ้าได้เย็บผ่านทางช่องคลอด..ซึ่งขอให้พยาบาลช่วยเหลือในการเย็บ (Assisted) ก็เพียงพอ..ส่วนแพทย์ผู้ช่วย ข้าพเจ้าบอกให้คุณหมอไปตรวจคนไข้ที่รออยู่ ได้เลย..คนไข้รายนี้ ได้รับการผ่าตัดอย่างเรียบร้อย โดยไม่มีปัญหาใดๆ เธอพักอยู่โรงพยาบาลเป็นเวลา 3 วัน ก็ได้รับอนุญาตให้กลับบ้านได้..

คนขับรถแทกซี่ทุกคน ล้วนถือว่า เป็นคนที่ได้เรียนรู้ตลอดเวลาจากมหาวิทยาลัยแห่งชีวิต เพราะพวกเขาได้ยินและสนทนาเรื่องราวกับผู้โดยสารทั้งวันทั้งคืน จึงมีข้อมูลข่าวสารมากมาย ถ้ารู้จักวิเคราะห์ ก็จะคาดการณ์ล่วงหน้าถึงเหตุการณ์บ้านเมืองได้อย่างแม่นยำ..คนขับรายนี้พูดต่อว่า ‘ในระหว่างนี้ สายตาของคนต่างประเทศถือว่า ประเทศไทยไม่ใช่ประชาธิปไตย หลายประเทศจึงห้ามติดต่อซื้อขายหุ้นกับไทย ทำให้เงินลงทุนในตลาดหลักทรัพย์หายไป ส่งผลให้สภาพคล่องภายในประเทศลดลง..คนไทยจนลงเพราะไม่มีเงินสดหมุนเวียนอยู่ในมือ และคนจนกำลังจะตายในยุคกระแสทุนนิยม โดยเฉพาะคนที่ปรับตัวไม่ทัน’..

ขณะที่กำลังสนทนาสนุก..รถแทกซี่ก็หยุดจอด ที่หน้าบ้านของข้าพเจ้า....ข้าพเจ้าลงจากรถแทกซี่คันนั้น พร้องกับจ่ายเงิน บวกค่าทิปอีกเล็กน้อย ..ข้าพเจ้าบอกไม่ถูกว่า คนขับรถแทกซี่คันนี้ เป็นนักปรัชญาหรือเปล่า..แต่ที่แน่ๆ..เขายังคงเป็นคนหาเช้ากินค่ำอยู่เหมือนเดิม...เพราะไม่กล้าที่จะปรับเปลี่ยนวิถีชีวิต..

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