Nineteenth Century Medical Guide

This meeting, which started more like a farce, finally got on the right track in the face of a super high death rate.

"It's a long-term job to treat burns well, and it's far from just covering them with gauze."

Caveiro listed several requirements that need to be fulfilled: "First of all, the first point is anti-shock. As soon as the wounded is admitted to the hospital, a reliable venous access should be established as soon as possible, and fluid rehydration should be started immediately. The method has been mentioned before. The liquid is poured into the body through the infusion bottle and the rubber tube. The valve can be used to control the flow by knotting.

But the burn itself needs a large amount of fluid replacement quickly, and often does not need to be knotted. I have also written the calculation formula here, please remember that children are different from adults, and you must pay attention when calculating! "

Carvey took out several black-and-white photos taken by the reporter, in which were patients with extensive burns who were successfully treated, and everyone was hung with saline.

Under the pressure of Holt and Carvey, everyone gradually accepted the common sense of fluid rehydration for burns, began to record these common senses and prepared to put them into practice after returning to the hospital.

"Remember all these?"

"take note of it"

After hearing this, Carvey erased all these words, tables and mathematical formulas with an eraser, and then said: "Remember them firmly, and you can use them next time you encounter them. Remember to give priority to rehydration, and every hospital has them ready. A little needle and rubber tubing, which is needed for surgery anyway."

"Well, I can use it next time I meet it. Next time? Huh???"

"Wait, what do you mean you can use it next time you meet, what about this time? Can't you use it this time?"

"It really can't be used, the infusion period has passed." Carvey explained, "The last wounded person should have been sent to the hospital yesterday morning, and it has been 24 hours since now. Infusion now will increase the burden on the body and accelerate death. "

It is beyond their comprehension to use large doses of rehydration to support the treatment of burns. Now there is an opposite concept of "more harmful than the specified time", and almost everyone's brains are stuck in unison.

Carvey said that the reperfusion injury caused by delayed fluid resuscitation is indeed a difficulty. 【1】

The theory is boring and difficult to understand, and it is impossible to explain it clearly with the existing medical knowledge system. It can only be explained with examples: "When I was working with my father in Italy, patients with severe burns would say that their throats were sore and thirsty, and it was difficult to drink water. Difficult to relieve. We later found out that the body needs a lot of water, which is the kind of water similar to blood, that is, water with salt added.
Remember, it is 0.9% NaCl, the water needs to be boiled and then covered and cooled. "

Carvey emphasized the concentration of normal saline and the importance of high-temperature disinfection again, and then began to tell them the "case": "The infusion is very effective. The earlier the infusion, the more fluid infusion can increase their survival rate. But In one case, a patient died shortly after the infusion ended."

"How did you die?"

"We did an autopsy, and used a lot of staining and microscopy." Carvey said, "Because my father and I did not have a solid foundation in physiology and pathology, we only found swelling and damage in various tissues and organs of the corpse. We don't know why."

There was no sound in the audience, only Huot and Cedieu, who were sitting in the back row, applauded lightly: "This special phenomenon needs to be studied."

"In fact, those patients who urgently need to correct the shock have almost died within 24 hours."

Carvey told the truth without hesitation: "The rest we count as 35% with the second highest survival rate. Some of these surviving wounded are in extremely dangerous situations, and rehydration will not help at this time. And For others who are lucky, the burn area is often not large, and after the early stage, there is not much difference between whether to replenish fluids or not."

There are many strict indicators for reperfusion injury caused by delayed resuscitation, and the corresponding drug protection mechanism is also a product of modern times, which is not suitable for the 19th century.

What Carvey can do is not to complain and criticize their early solutions, but to let them learn from their failures.

"Delayed infusion is a big taboo. Next, we have to talk about the second leading cause of death."

Carvey circled on the second of the previous five words, "breathing": "If you have time, you can try to do an autopsy of the dead and wounded, and you will see that many people have very obvious swelling inside the throat. Their The airway was severely obstructed due to the edema caused by high-temperature burns, and he was suffocated to death."

Airway obstruction is easier to identify than shock. These directors in the audience have poor theoretical knowledge, but rich experience.

On this point, they shared the same feeling: "Indeed, several wounded were fine when they first arrived, but suddenly they couldn't breathe for some reason, and they died within a few minutes."

"I have it here too, and it's a pretty tricky situation."

"We tried to use an airway dilator, but some people had injuries and adhesions in the mouth, and the insertion effect was not good. Maybe the front end has not entered the throat, and the person passed out."

"Haven't you considered tracheotomy?" At this moment Holt suddenly asked, "It's the same as treating diphtheria, choosing surgical means to cut the airway, and using artificial tubes to connect the lungs to the outside world."

"This"

"Wouldn't it be crazy to do that?"

"Besides, tracheotomy takes time, we don't have that fast speed."

Carvey had a general understanding of their ideas, and took out several simple puncture introduction pictures from the stack of documents in front of him, and distributed them to them one by one: "Everyone can choose to do cricothyroid membrane puncture directly as shown in the picture. , located between the thyroid cartilage and the cricoid cartilage."

This technique is no secret in Viennese surgical circles.

Including Ignatz, there are at least five or six director-level surgeons who have mastered the skills of tracheotomy and puncture.

It's just that there are only a small number of patients who need direct incision and puncture, and there is almost no emergency system, so under the halo of large-scale surgery, this practical first-aid method is not well-known.

“It is possible to enter from this location”

"This is probably the medical progress brought about by the utilization of anatomy."

France has a history of tracheotomy for decades, and it is also the country with the most tracheotomies in Europe. Of course, the death rate has always been very high.Most of the failure reasons were summarized by Carvey in this less than 3-page report, and the correct corrective plan was given.

"Although this is a mature surgical procedure for the Vienna surgical community." Carvey said in a sincere and rigorous tone, "But you guys still need a lot of practice if you are new to it. Don't use it directly if you are not proficient enough." Clinical, if you really have to, please complete it boldly, even if you fail, don’t blame yourself too much.”

They all understand the truth,

"The Viennese surgical community?"

"Are the surgeons in Vienna well-versed in tracheotomy?"

"I don't dare to do research, but the success rate of tracheotomy in the past six months has been above 70%." Carvey paused for a moment, and then calculated the probability, "It is indeed more than 70%. open it."

"This is impossible!"

"As far as we know, Austrian surgery has not performed tracheotomy, so how could it have such a high success rate."

Kids who own toy cars aren't jealous of adults who own real cars, but rather their peers who own higher-level toy cars.The feeling of being deprived of the sense of superiority accumulated over the years is very painful.

The chief doctors in front of them are at this stage. The first surgical crown, which has been working hard for decades, was mercilessly slapped to the ground by Kawei, and almost stepped on both feet.

"But the success rate of cesarean section in Vienna is higher than that of tracheostomy."

"That's different!!!"

"This is the birthplace of modern tracheotomy. The success rate in the birthplace of surgery is actually lower than 50% all year round, and it is easily surpassed by other countries."

"Stop talking, what a failure!"

Unlike the step-by-step development in Vienna, Carvey compressed the results of more than half a year into one month in Paris, and the density and impact far exceeded the former, which naturally caused this strange reaction.

"There's not much to say about this section. It's the second most common tube in first aid for burns, the artificial trachea." Carvey quickly skipped the tracheotomy, "The next thing I'm going to talk about is the urinary tube."

"Catheterization?"

"Why do you need to catheterize your body if you don't have enough water?"

"It's not for catheterization, but to monitor the amount of urine. The amount of fluid entering needs to be equivalent to the amount of urine. When the amount of urine decreases, it can be judged that the human body is very dehydrated."

Carvey briefly mentioned one sentence, and then focused on the surgical operation: "Urinary catheterization is an important inspection item for the chief doctor of the Main Palace Hospital, Mocier. It has been carried out for several years, and there is nothing much to say about the specific operation process. There is not much urine, so we will ignore the timing.

Because Dr. Mosier is now living in Vienna, if necessary, you can go to the Main Palace Hospital to ask the current acting director of urology, Dr. Guillon. "

When it comes to catheterization, the faces of these directors finally look better: "How is the catheterization technology in Vienna?"

"It's really not as good as France. We don't even have a specific urology department." Carvey said like coaxing a child, "In this regard, Vienna needs to learn from Paris."

"Surgical technology is like this. Everyone learns from each other and learns from each other. Today you are one step ahead, and tomorrow I will be a little bit ahead. Only in this way will there be progress."

It seems that the atmosphere in the venue has eased a lot, but there are still two people with bad faces.Because in their eyes, the words just now are more like a kind of pity for the weak by the strong, which is more unacceptable than simple backwardness.

"It's ridiculous to think that the surgical techniques of France and Austria are at the same level just because they are ahead of one catheterization technique."

Holt held the quill pen tightly, feeling angry in his heart: "Everyone is content with the status quo, and they don't think about why Mosier stayed in Vienna! Can they perform bladder cancer removal? Can they rebuild a new bladder for Mr. Erdem What???"

"Okay, okay, keep your voice down and say a few words less, so that it won't be good for them to hear you."

Cedieu has been shown by Kawei to lose the motivation to struggle these days, and it is clear that this paralysis is not all a bad thing, "The most important thing now is to deal with the wounded, at least let those who survived the shock survive well .”

Severe burns can cause systemic damage, and only after the test of shock and airway obstruction can one have the opportunity to face the burn wound.

And that's the focus of today's meeting.

"The next thing I'm going to talk about is wounds. To save time, I'll also talk about infection." Carvey looked at the time again and took out a stack of burn photos. "Take this wounded person as an example. His left arm was burned. Severe, basically deep second-degree and third-degree burns, accounting for 6% of the total area.

On the premise that the vital signs were stable, we performed two debridements. This is a photo. "

They have heard about debridement for a long time, which is a variant of preoperative disinfection, and Carvey mentioned it many times in the surgery demonstration.But they didn't expect the debridement technique to be so violent, and even somewhat anti-human.

"This Dr. Carvey, this is too much."

"Will the patient be able to take it after cleaning the wound like this?"

"I think it's much better than amputation without anesthesia," Carvey said again, "Generally, ether anesthesia is used for debridement, normal saline + hydrogen peroxide for disinfection, and ya tablet tincture and morphine are used for pain blockade after waking up.

Although I personally do not advocate the use of ya tablet tincture and morphine in large doses, and even strict control should be imposed on these two types of drugs, but the current situation is special, and they must be used when they are needed. "

This set of wound treatment photos was the same as the previous cricothyroid membrane puncture photos, and was passed on by Kawei.After debridement and scab removal, the battered arm was finally covered with pieces of fish skin.

"Is this fish skin?"

"Shouldn't it be covered with gauze and paraffin oil?"

"Fish skin is easier to deal with, and the effect is better." Carvey explained, "After debridement, we perform scab removal and debridement on the joint wound, and then cover the corresponding fish skin dressing. Don't worry, after animal experiments , the processed fish skin is non-irritating and toxic, and has better elasticity and air permeability than gauze.

Today is the first day of use, and it already has a very good pain relief effect, at least the morphine has been stopped. "

"Can it stop the pain?"

"We can judge the difference between fish skin and paraffin oil gauze from the pain relief effect, good adhesion rate, stretch resistance, and degree of exudation."

An example of a fish skin dressing is Alphonse's left arm, which is now covered with three specially treated fish skin dressings, which are then pressure-wrapped with gauze.

Normal people always find it weird to see the fish skin that is randomly cut by themselves and their own skin stick together.But the cool touch did ease the pain to a considerable extent, which reminded Alphonse of Li Ben beside him.

After all, the opponent was wasted so much time, the duel was quickly put on the agenda.

At nine o'clock in the morning, while the burn emergency meeting was still going on, the French cook and Li Ben walked into a grove in the suburbs of Paris