Nineteenth Century Medical Guide

Chapter 121 118.
According to the modern concept of trauma, emergency treatment of trauma patients should follow the ABC principle [1].

In the 19th century, everything was lacking, so there must not be so much attention. Carvey can examine the current situation and adapt to the situation without strictly following the order.But the principle is the principle, the order can be changed, and none of the three things ABC can be missed, and the things that should be checked must be checked.

The bullet does not have eyes, and the location where it enters the body is also very ambiguous, in the middle of the upper abdomen.Carvey didn't know the bullet's angle of entry, and he didn't have a radiological examination in his hands. He needed to rule out the possibility of the bullet's trajectory rising into the chest cavity at the first time.

Gunshot injuries are very troublesome, especially the bullets in the 19th century lacked kinetic energy and were lead bullets. After entering the human body, the bullets would rotate and turn, forming an irregular blind cavity.

If it really hit the lungs and it would cause hemothorax, then Olgi would be really hopeless.

After quickly finding two damages to the liver and spleen, Carvey began to probe upwards for the diaphragm.Fortunately, the shooting angle of the bullet was not tricky, it only made a hole in front of the left outer lobe of the liver, and it didn't even penetrate the liver.

Now Olgi's breathing is fine, A and B in ABC are normal, only one C is troublesome.

The liver and spleen are solid organs in the abdominal cavity, and there is a large amount of blood in them. Once trauma causes contusion and laceration, it is often accompanied by a large amount of blood loss.No matter who it is, after seeing the uncoagulated blood in this belly, they know that Olgi can't last long. 【2】

Although Carvey has never seen a bullet penetrate the liver, liver contusion is a very common surgical emergency in his eyes. Hemostasis is the first priority, but at the same time considering that the operation cannot be completed in a short time, he still needs to give Orr Kyrgyzstan expansion. 【3】

"Who is free to get some water, clean water!"

Kavi put gauze under the broken spleen first, and squeezed the organs to help compress it. At the same time, he did not forget to ask someone to prepare other things: "Where do you have running water here?"

"There are in the theater."

"Take two water bottles to get water." Carvey used another piece of gauze to pinch a corner to stop the bleeding from the bullet hole in the liver. "After getting the water, bring some salt and baking soda. Just use the kitchen."

Locard didn't know why Carvey did this, but Hills seemed to understand something.

In his eyes, Carvey's surgery was meticulous and clean, and he couldn't do without water no matter before, during or after surgery.Especially in abdominal surgery, water can be used to wash the stomach, just like the appendix that Sears missed before.

Water is easy to understand, but what about salt?What about soda?

"Water can flush the abdominal cavity, so what is the salt used for? Isn't soda used to make bread?"

"The operation hasn't been done yet, what's the stomach?" Carvey didn't bother to explain, so he found a nurse and said, "If you're fine, go and get something."

The nurse was a little dazed, and the previous order could still see the purpose, but the request now made had no idea what Carvey wanted to do.She glanced at the two surgeons in this hospital, meaning to ask whether she should do what Carvey said.

But the problem is that Locard and Hills are also very confused. The operation needs to be done by Kavey, but the request is really weird.They don't understand why he always likes to use other things for an operation that can be solved with a scalpel, forceps and some surgical instruments.

Before it was alcohol and bleach, now it's salt, soda and water.
They were not afraid of the failure of the operation. Even if Olgi died directly in the office, it would not be unacceptable, because the injury was indeed too serious.But if he was able to live, but was finally killed by Kawei's itching operation, it would be too aggrieved and tiring.

Just like that, the three of them froze there for a while, not knowing how to answer the conversation.

"If you want to save people, you have to be obedient. If things come late, don't blame me if you die." Kawei pressed the bleeding from the liver breach with gauze, and touched the first hepatic portal【4】with his fingers, " Come, Locard pinches the gauze, Sears give me the crow's beak pliers."

If the liver was a knife wound, Carvey could still suture it, but now that there is a breach defect, things will become very complicated.

The bullet will not only produce a trajectory in the liver, but may also cause necrosis of the tissue around the trajectory.Carvey had no way of judging the evolution trend of the tissues around the ballistic trajectory with the naked eye in the early stage, so he could only cut off all the affected left outer lobe of the liver once and for all.

The abdominal cavity is a forbidden area of ​​surgery, and the liver is even more restricted within the forbidden area.There are rich blood vessels here, as well as hepatic ducts, bile ducts, various ligaments, gallbladder, duodenum, etc. They don't even know how to divide the liver, let alone perform liver surgery.

The enlightenment of liver surgery in the true sense was in 1888, when the left and right lobes of the liver were distinguished by the shunt of the portal vein. In the same year, a doctor performed a tumor resection of the left outer lobe of the liver.

If Carvey's surgery is successful, the time can be advanced by 22 years.

He and Locard switched places, took the crow's beak forceps and a scalpel given by Hills and slowly began to separate the connective tissue near the portal of the liver: "There is too much bleeding from the liver, and Olgi can't lose any more blood." , I now need to block the hepatic portal vein."

What followed was something that the two had never seen before. Lockard and Sears couldn't help but put their heads together and opened their eyes wide to see what happened.

"So who's going to get the water?" Carvey fiddled with the surrounding tissue with pliers in one hand, while taking the time to take a pulse: "The heart rate is 120, and the blood loss is estimated to be more than 1000ml"【5】

There is no need for Sears and Lockard to say anything more when the conversation reaches this point, a nurse immediately stood up and said, "I'll go."

Carvey immersed himself in the separation and said, "Take as much as you can, go and come back quickly."

"I see."

The nurse thought of a large kettle in the ward, and was about to go out when he suddenly stopped him: "By the way, are the salt and soda in your kitchen clean? I asked the peddler last time that the salt I bought didn't seem to be pure salt, soda The powder is also mixed with other messy things."

"Ours is a formal channel, but..." Hills was not sure, and looked at Lockard beside him, "It should be no problem."

"Forget it, I can't control that much, I have to get things over first."

"it is good."

Carvey looked at the remaining three nurses and began to assign tasks in turn:
"(Nurse A) she's gone, don't stand around stupidly, you (Nurse B), go find a kerosene stove, I want to boil water [6]; you (Nurse C), listen to his heart rate, Take care of your breathing; and you (Nurse D), help pass the equipment, we won’t be able to free our hands later.”

Soon the nurses were performing their respective duties, and the office finally had the feel of an operating room.

Olgi was badly wounded. Although the knife wound on the left abdomen was not deep, it also injured the intestines and spleen, and maybe other places were also injured.The bullet in the middle of the abdomen deviated a little to the left, hit the liver, and knocked out a gap with a diameter of about 2cm.

Considering too much blood loss, Carvey didn't have time to do other investigations. Fortunately, his spleen was safe for the time being, and he could stabilize the liver bleeding first.

"The bullet destroyed the left outer lobe of the liver, and it was unrealistic to repair it. I decided to resect the left outer lobe of the liver."

Carvey finally separated the anatomical structure of the first hepatic portal【7】, found the hepatic portal vein, made a hepatic portal blocking band with gauze strips, and then asked Locard to hang crow beak forceps on the cloth strips.Lockard was like an intern who had never been on the operating table, holding the gauze in one hand and the forceps in the other, standing there blankly not knowing what to do next.

Carvey patted the pliers in his hand with the back of his scalpel: "This is placed outside to prevent the gauze strips from being missed. Why do you keep holding it?"

Lockard let go of his hand: "."

The back of Kawei's knife changed direction and patted his other hand again: "The liver door is blocked, why are you still stuffing it with gauze? Does it look good?"

"Forehead"

Locard has been practicing medicine for eight or nine years. He has done a lot of operations, big and small. He has never felt so stupid, just like when he first entered medical school and had no concept of anatomy: "Dr. Carvey, what did you just say? Where is this liver?"

"Left outer lobe of liver."

Carvey put more force on the retractor, stretched the field of vision as much as possible, and then used a scalpel to divide the surface of the liver one by one: "The liver can be divided into five lobes and eight segments, the upper and lower segments of the left outer lobe, the left inner lobe, and the right front lobe. The upper and lower parts, the upper and lower parts of the right posterior lobe, and the caudate lobe."【8】

Locard had never heard of such an anatomical term, and the familiar liver suddenly became unfamiliar: "This"

"I'm sure, there is no such method of lobulation in the anatomy book, and can the liver really be lobed?" Sears was straightforward enough and asked, "Where did you learn it?"

"Self-taught."

Carvey said something casually, and continued to prepare for the removal of the liver lobe.

If you want to cut off a certain organ, you can't simply pinch the blood vessel and cut it off with a single knife.Because the organs are surrounded by supporting ligaments and many connective tissues, all the cut parts must be freed before cutting.

He first cut off the round ligament of the liver, and then clamped the round ligament of the liver with crow beak forceps and pulled it down gently, freeing the falciform ligament, left coronary ligament, part of the right coronary ligament, left triangular ligament and hepatic ligament, fully freeing the left hepatic ligament. outer leaves. 【repair】

"Self-taught?"

Seeing Carvey's proficient operation techniques, Hills definitely didn't believe it, but he really couldn't find anyone with this ability: "Don't be kidding, I have never seen anyone who can teach themselves."

"You can't teach yourself, is anatomy invented by God?" Carvey didn't want to waste time on this matter, "Nurse C, report your heart rate."

The nurse was taken aback for a moment, and then realized that C was referring to herself: "The amount has always been around 120."

"It's still stable." Carvey looked up at the door, and continued to immerse himself in the separation. "My father often has corpses left by autopsies in his hands. I found the liver interesting, so I tried to do an autopsy."

"But the liver is a whole piece, why should it be divided into lobes?"

"It looks like a whole piece to the naked eye, but if you look at the distribution of blood vessels, it can be divided into lobes and segments." Now that the rescue is important, Kawei can't elaborate, "Do as I said first, and wait until the operation is over." Let's talk about it, shall we?"

Freeing the hilum of the liver and the left outer lobe of the liver is very troublesome, time-consuming and labor-intensive.

Until the two pots of water, a large bowl of salt, half a bowl of baking soda, and a kerosene stove that Kavey asked for were all in place, Kavey couldn’t free the left outer lobe: “First boil the water, how much is this kettle? ?”

"About 1L."

"First boil half a pot." Carvey began to change the angle, separated the left hepatic vein, and ordered at the same time, "then put salt and baking soda in another pot of cold water."

"How much do you want?"

Carvey put down the scalpel, wiped off the blood on his hands, turned around and picked up the small spoon given by the nurse, and put salt and sodium bicarbonate into the water like seasonings in cooking: "That's it first, wait After the water boils, you mix the water on both sides back and forth."【9】

"What are you doing?" Sears couldn't understand his operation more and more.

"To mix a water temperature closer to the human body, it should be ok if the ratio of cold to hot is 1:2." Carvey didn't explain any further. He needed to separate the left hepatic vein as soon as possible, and then cut off the entire left outer lobe. "Heart rate, heart rate, Report your heart rate."

"127."

The nurse did not dare to neglect, and the reported figures made the whole office very nervous.Obviously, the large abdominal incision exacerbated the loss of body fluid, and it became more difficult to maintain blood pressure, and Olgi's heart rate began to go up.

"Speed ​​up, hurry up!!!" Carvey cheered them up, and even increased his hand speed, "Come on, Nurse B, you don't have to worry about the stove, go find an iron rod."

"Iron rod???"

"Yes, thinner, preferably something like iron wire, without sharp cuts in the front." Kavi wiped off the sweat from his forehead with his sleeve, and said, "Go, I will use it later."

Hills stopped asking questions, and stood aside with Locard, pulling the hook, doing things as ordered, while watching Kawei separate the tissue around the blood vessels.As for what are the water, salt, baking soda and the iron wire I need now, it’s useless to ask anyway.

"Nurse D, you step down, you don't need to hand over the equipment." Carvey looked sideways at the equipment nurse just now, and ordered, "Get the syringe."

"Oh."

"Take two more,"

"Understood." The nurse put down her things, left the desk, and took out several syringes from the storage box on the side, "Then what?"

"Bring it here first, and wait for the water to be reconstituted, and fill it up for spare use." Just after Kawei finished speaking, he couldn't help but look at Olgi, whose face was getting paler, and asked again: "Nurse C, heart rate! Heart rate! Don't let me remind you, this thing is life-saving, you have to report it every 2 minutes!!!"

"It is, it is 131 now"

"It seems that the limit has been reached." Carvey put down the pliers and scalpel, turned to the two nurses and said, "Don't worry about the water temperature, just mix the water together, and then inject it into Olgi's blood vessel with a syringe .”

"Just punch in like this?"

"Yes, type in."

"Can this work?"

"Of course it can work, even if it really can't, there is no other way." Carvey explained, "If you lack so much blood, you must make up for it."

"The syringe is only 1ml."

"An extra 1ml is better than nothing." Carvey glanced at Lockard and Sears, "Don't pull the hook, you two, take more syringes, don't take out the needles, the syringes pump water Relay. Get half of the pot first, as long as you cooperate fast enough, you can finish it in a while."

　The code words on duty are really tiring. . .

　　
　
(End of this chapter)