godfather of surgery

Chapter 989 Massive Bleeding
Director Zhang's level is quite good, especially under the conditions of a grassroots hospital. He can independently perform some major operations, such as radical surgery for liver cancer and other digestive tract tumors. This is of great significance in a remote county like Nanqiao. Transportation in mountainous areas is inconvenient, and it takes at least two or three hours to send patients to a municipal tertiary hospital. Therefore, solving the problem nearby can reduce a lot of financial pressure on patients. This is also the reason why Shipo County People's Hospital has been able to develop.

The patient was a fifty-year-old male with advanced colon cancer. He had already developed obvious intestinal obstruction, so he had to undergo surgery. Due to financial constraints, and because the reimbursement rate for the New Rural Cooperative Medical Scheme was the highest in township-level hospitals, his family decided to ask the old director to help him stay in Guandu Hospital for the surgery.

After the abdominal cavity was opened, Director Zhang's hands were nimble, showing his expected level of skill. He quickly found the location of the tumor, used his fingers as a separation tool, and began blunt separation, turning the abdominal cavity upside down. After several separations, Director Zhang quickly found a breakthrough to separate the tumor.

"Surgery is a matter of practice. There is no special trick. How old were we when we graduated from technical secondary school? We were 18 years old! At the age of 18, we started to use the knife. What a concept. Nowadays, doctors in their thirties start to use the knife. Do you think you can compare with us in experience?"

Director Zhang was teaching Li Min while performing the operation. Old Zhang was very confident in his surgical skills and he believed in experience. In Director Zhang's opinion, papers, new technologies, and evidence-based medicine were all bullshit. Manual skills were the essence of surgery. Traditional surgical methods were the most reliable, and decades of clinical experience were better than anything else.

"I've been to the provincial capital for further studies before, and I've seen young doctors perform surgery. Their hands holding the knife looked like chicken claws, and it was frightening to watch."

“If you start practicing in your thirties, can you really do it well?”

Director Zhang continued teaching without caring whether Li Min responded or not.

"Director Zhang! How about having dinner here today and frying a local chicken with tea oil?" The old dean suggested when he saw that Director Zhang looked relaxed.

Director Zhang refused directly: "After this operation, I have to go to Shizikou Hospital for a thyroid surgery. He is a relative of a colleague in the logistics department of our hospital. Let's have dinner next time."

Director Zhang is an easy-going person who doesn't beat around the bush, so after he said that, the old dean didn't mention the matter again.

Li Min seemed quite relaxed as an assistant, and he could easily assist in tying knots and cutting threads. In the past, Li Min would not be qualified to be an assistant and had never seen this kind of operation, let alone be an assistant. But now Li Min is no longer the same person as before. This kind of operation is nothing in Li Min's hands, but just an ordinary operation, which Professor Yang has positioned him as a skilled one.

The proficiency that Professor Yang requires is not ordinary proficiency. Although the training time is not long, I am still Professor Yang’s direct disciple.

About ten minutes into the operation, Director Zhang slowed down his movements. He touched the pulsating abdominal aorta, then the tumor. "Oh my god, the tumor is attached to the abdominal aorta. Let me check on the inferior vena cava."

The inferior vena cava in the abdomen is also adhered to the tumor. What should we do? The wall of the inferior vena cava is thin. If it is not separated carefully, once heavy bleeding occurs, there will be no rescue measures at all.

Director Zhang looked rough on the outside, but he was very thoughtful. He stopped the separation and started looking for a new breakthrough. His hands were very flexible and he quickly felt something thick and string-like, which he squeezed.

"Could this be a blood vessel? How can there be such a thick blood vessel?" Director Zhang said to himself.

Li Min looked at the position of Director Zhang's hand. This was a bundle of blood vessels that supplied the tumor. There were adhesions between them and the surrounding areas. Judging from the feel of the hand, it was undoubtedly a bundle of blood vessels. It was obviously not Zhang Yidao's style to retreat when faced with this difficulty. Zhang Yidao's reputation was accumulated through one operation after another, not just a random reputation.

Since this is the vascular pedicle, Director Zhang decided to break through from here, otherwise the operation could not proceed further. He also has his own method, which is to trust his own feel. He uses his fingers and tissue scissors to cooperate with each other, repeatedly touching with his fingers, and then using the scissors, advancing little by little, cutting through mountains and building bridges across rivers. This is Director Zhang's strategy.

"How much blood do you need?" asked Director Zhang.

The old dean moved a stool and sat in the corner: "Six units. It's not convenient for our grassroots hospital to get blood. We can only prepare this much."

6 units are enough for ordinary surgery, and ordinary surgery may not require any blood at all. However, this kind of surgery involves large blood vessels, and in case of bleeding, 6 units will not be enough.

Director Zhang paused for a moment to think about the next step. When it comes to complicated operations, Director Zhang always takes one step at a time. He has experienced many dangerous operations over the years, but he was able to turn each one into a safe outcome.

If this tumor is to be completely removed at present, the adhesions to the aorta and inferior vena cava must be separated. The risk is too great, so we can only take a step back and leave the tumor close to the blood vessels in place, while removing most of the other parts of the tumor. This can solve the symptoms of tumor compression and achieve the goal.

Director Zhang continued to separate the tissue, using his fingers and tissue scissors in coordination. He was very skilled and experienced. After a lot of effort, Director Zhang separated the cord-like thing as a whole. At this time, sweat was already slightly on his forehead. "Damn, this is quite tricky. Let's reduce the scope of resection, remove most of the tumor, relieve the compression symptoms, and ignore the rest for now. How do you think?"

Director Zhang asked Li Min, and also asked the old dean, that this was the surgeon's usual practice, and he would discuss with everyone when encountering difficulties. Li Min felt that since the tumor was so rich in blood vessels, it would be safer to do a full resection. If a partial resection was done according to Director Zhang's idea, it would inevitably involve the interior of the tumor. With so many alienated blood vessels inside, hemostasis would be a big problem. The township hospital was short of various rescue equipment and could not handle the accident.

Therefore, Li Min decided to either give up the surgery now or perform a complete removal of the tumor. He wanted to compromise by performing a partial resection to relieve the symptoms of intestinal obstruction. The idea was good, but this would fall into a trap. It would be difficult to stop the bleeding during the operation, and heavy bleeding would endanger the patient's life.

"It is safer to perform a full resection. If a partial resection is performed, the bleeding from the tumor cross-section cannot be controlled. If you do not plan to perform a full resection, it is better to give up the surgery now." Li Min gave his own advice. Medicine is a factual science and human life is at stake. There is no room for hypocrisy. Therefore, Li Min would not agree with Director Zhang's point of view just to please him. He must express his own opinion.

Originally, Director Zhang discussed with everyone to find a way out. He raised the question, everyone agreed, and that's how it was done. But now Li Min disagrees.

Director Zhang looked up and stopped what he was doing. "The adhesions are too severe, involving large blood vessels. I'm afraid it will tear the blood vessels and cause disastrous consequences. The patient is only in his fifties, not too old. It's better to be safe than sorry. Let's be conservative."

"I don't think it's possible to be conservative now, unless we stop the operation and close the abdomen now." Li Min was also straightforward. He had a straightforward personality and was educated in this way at Sanbo Hospital. There was no such thing as social etiquette at the critical moment on the operating table.

Director Zhang hesitated, feeling a little reluctant to close the abdomen. Based on his experience, he thought that partial resection should not be a big problem, but he was still cautious: "Well, turn on my phone, turn on the password - find Director Peng's number, and I'll tell him about the situation."

Director Peng is the director of general surgery at a regional tertiary hospital. He is from Nanqiao County and is visiting his family there. Last night, Director Zhang and Director Peng had dinner together. Generally speaking, as a department director, who doesn’t have his own “backer”? County-level hospitals usually get close to experts at regional hospitals through further studies or recruiting, and maintain a stable relationship, so that they can save the day or clean up the mess in case of any problems. The “backers” of regional hospitals are usually provincial hospitals, and the “backers” of provincial hospitals are the top hospitals in the country. Many doctors in provincial hospitals are masters and doctors who graduated from these hospitals, and their own mentors are their “backers”.

The circulating nurse helped to call Director Peng, who briefly explained the patient's condition on the phone, and then instructed the doctors in the audience to take photos of the CT scans and medical records, package them, and send them to Director Peng's email address.

It is quite common for patients to temporarily seek advice and guidance from a "backer" when encountering difficulties on the operating table, especially in primary hospitals, because the preoperative diagnosis is one thing and the intraoperative diagnosis may be another. In some cases, surgery cannot be performed due to difficulties and the abdomen is directly closed. This "opening and closing operation" means nothing is done. There is nothing that can be done about it. Of course, doctors will try their best to avoid this "opening and closing operation".

Director Peng responded very quickly and called back after more than ten minutes: Try not to perform a partial resection. Although there are no CT images with angiography, it seems that the tumor has a rich blood supply, and it will be impossible to stop the bleeding when the section is cut.

The logic is very simple, just like when there is heavy intrauterine bleeding during childbirth, when there is really no other way, you can only do a hysterectomy.

Director Zhang thought about it, and planned what to do next. No one took action, and everyone kept their hands outside the operation area. Suddenly, a large amount of blood gushed out of the patient's abdominal cavity. Director Zhang was quite experienced, and Zhang Yida was not called that for nothing. He grabbed the upper part of the abdominal aorta, and Li Min immediately used a suction device to suck out the blood. It took a while to wash away the blood.

"What are you doing? If you don't understand, don't move." Director Zhang scolded him, because everything was fine just now and he had stopped the operation. When this happened suddenly, he thought it was caused by Li Min's private operation.

Li Min immediately explained: "I didn't move anything just now."

The other assistants and the doctors in the audience just saw it. Everyone stopped working. Li Min's hands were on the protective bag on his chest and he did nothing. Director Zhang pinched the blood vessel and did not pursue the matter any further.

"Large vessel clamp."

Although Director Zhang does not have the theoretical knowledge of blocking the abdominal aorta, he has experience, which is his unique skill. Once bleeding occurs and the cause cannot be found, he will first cut off the main switch and then slowly look for the cause to avoid foolishly looking for bleeding points everywhere and wasting a lot of time.

Experience is experience, and the theory of experience is different. For example, when blocking large blood vessels, there are certain requirements for blocking at what plane, for how long, and how to block them. However, Director Zhang did not know these things. He only knew that doing so could stop the bleeding.

"Let me see where the bleeding is. The blood is so bright red, it must be the aorta. Other blood vessels would not be so dangerous, but where is the rupture?" Director Zhang freed his hands to look for a blood vessel.

At this time, Li Min had already determined where the bleeding was based on the way it just appeared. He gave his own suggestion: the rupture is on the back side of the connection between the cord and the aorta that you just touched. The cord just now was a blood vessel that supplied blood to the tumor that was directly separated from the aorta. It may have been affected when it was separated, and some tears have occurred. Now it is just that the blood pressure has broken through the weak point under high pressure.

Director Zhang was a little annoyed by Li Min's constant giving of guiding opinions: "Theory is theory, and there is a big gap between theory and practice."

Even though it was so bloody, you were still able to accurately determine the bleeding point, and what you said sounded as if it were real. However, Director Zhang still reached out and touched the place where Li Min said, but didn't touch anything.

Now it involves the tearing of large blood vessels, which is probably beyond my ability. Before, I could directly close the abdomen to deal with it, but now there is no other way. I can only bite the bullet and deal with it. At least I have to stop the bleeding, otherwise the patient will die from blood loss.

Director Peng called again: "How is it now?"

"There is heavy bleeding now. I don't know where the bleeding is, but it is for sure on the aorta. I am pinching the upper part of the abdominal aorta to stop the bleeding and see if I can find the bleeding site and then repair it." Director Zhang was afraid of heat. Now his forehead was sweating and his back was wet. The circulating nurse kept wiping his sweat.

"Torn aorta?" Director Peng was startled. "Lao Zhang, I'm still in Nanqiao, not far from you. Do you need help?"

Director Peng is the director of a regional tertiary hospital and has been a good friend of Director Zhang for more than ten years. He didn't beat around the bush at this point. If the aorta was really injured, he didn't know how serious the injury was. If it could be fixed with a few stitches, Director Zhang might be able to handle it. But if the tear was severe, Director Zhang wouldn't be able to handle it with his level. Dealing with large blood vessels is not something that doctors in ordinary hospitals can do. Even if Director Peng came, if the case was really serious, he probably wouldn't be able to handle it.

Director Zhang wished for it: "That's great. The patient's vital signs are stable. I'll wait for you to come over."

"Don't panic, young man. A surgeon must have good psychological quality." Director Zhang gave Li Min some on-the-spot education, but Li Min did not panic. Director Zhang himself had sweat all over his forehead.

In fact, this was a bit of a setback. We thought it was just an ordinary abdominal tumor and that we could call it a day by removing the tumor and clearing the lymph nodes. We didn't expect it to be so complicated. Director Zhang still hasn't figured out how the aorta was torn.

"Director Peng from the City Central Hospital is visiting relatives in Nanqiao. Let's wait for him to come and check if the patient's blood pressure is okay." Director Zhang said as he turned around and went out to let the circulating nurse wipe his sweat.

The anesthesiologist immediately reported the blood pressure, which had just dropped a little, but is now normal. Fortunately, Director Zhang blocked the aorta in time.

"I learned a new trick today. Many people don't know how to deal with this situation. Simply pinching off the aorta can stop the bleeding. It works every time." Director Zhang took a break and waited for reinforcements. As long as the bleeding stopped, the patient's vital signs could remain normal.

"The blocking time of this part cannot exceed half an hour. Moving the blocking part down 5 centimeters can extend the blocking time to 45 minutes. We'd better finish the battle within 45 minutes. Otherwise, let me take a look." Li Min volunteered.

Director Zhang was quite disgusted by his attitude of thinking he was an expert after only a few days of training: "You come? There's a life on this stage."

If Director Zhang hadn't known that Dr. Li was a "good doctor", he would have definitely scolded him. He has only been training for a short time, less than a year, and he is pretending to be an expert here. He is really ignorant of the world. He thinks I have been using surgical tools for decades for nothing.