Nineteenth Century Medical Guide

Chapter 458 454. Plan 0 and Plan 3
There is no subjective judgment or absolute correctness in surgery or in medicine as a whole.

All we have to do is to be fully aware of every stage of the disease and always think of the coping methods needed for each possible situation. Then, according to the objective changes in the disease and the difficulties that may be encountered in the future, we will constantly change the treatment plan derived from rich experience and evidence-based medicine.

The implementation of these plans requires a combination of hardware conditions, personal knowledge reserves, and some flashes of inspiration.

In fact, to be honest, it is just like playing cards. Play the right card at the right time and leave the other party with no cards to play.

It is naturally very satisfying to win with a good hand, but there is no need to be discouraged when you get a bad hand. It is normal to have a bumpy process. You just need to end it before the disease takes the patient's life. The feeling of pushing yourself and the opponent into a desperate situation step by step, and finally winning the victory with a better move is also intoxicating.

If you lose, you don't need to blame yourself too much, and you are not qualified to blame yourself. Reviewing, summarizing, sharing the battle situation, and learning from experience are the fate of doctors. Only by integrating everything into the tide of medical development and focusing on the future can you have a chance to win.

After his rebirth, Kavi has been adjusting his position all the time and feeling the development of medical care.

There were many patients that he felt helpless about, and he had no idea where to start. There were also many patients that he felt were just so-so, and he could just make an incision and be done with it. He had adjusted treatment plans for many patients, and he had also "self-developed" treatment drugs and surgical instruments, and of course he had also seen many patients leave.

But no one had ever made him feel the battle was as complicated and tense as Fisher had. It was so tense that both sides tried their best and it seemed that everything was tied up with each other, leaving no room for any leeway.

In the end, what matters is the illusory element of luck.

Although Fisher had a skull base fracture and cerebrospinal fluid rhinorrhoea at the beginning, because the amount was not large, Kavey adopted a conservative treatment approach and kept him lying down, hoping that his body could repair itself.

In fact, more than 90% of cerebrospinal fluid rhinorrhoea has small leaks and can heal on its own.

Unfortunately, Fisher's sneezing widened the fracture and further tore the dura mater, causing more and more severe rhinorrhoea. This situation is very difficult to repair on its own, and it may take months or years. Even if it is repaired, it is likely to recur.

Considering that there were no qualified antibiotics on hand, continuing conservative treatment would be equivalent to allowing the brain to communicate with the outside air, and infection was the inevitable outcome, so he decisively chose surgery.

Surgery requires precise positioning of the leak. Incorrect positioning or blind surgical exploration will not only lead to failure of diagnosis and treatment, but also cause unnecessary pain to the patient.

In fact, before Plan 1 and Plan 2, there was Plan 0, which relied on symptoms for positioning.

Although it is not 1% accurate, as long as the symptoms are typical enough, it can still be accurately located. At least it is more reliable than the explosion simulation in Plan .

From the sagittal lateral view, it can be concluded that the cerebrospinal fluid flow changes with the position of the head.

First of all, the most typical symptom of rhinorrhoea is loss of smell, indicating that the leak is located in the anterior cranial fossa, near the olfactory nerve (I). If there is a problem with vision (II), the leak will move back to the tuberculum sellae, sphenoid sinus or posterior ethmoid sinus. Loss of sensation in the distribution of the trigeminal nerve (V) indicates the middle cranial fossa. Cochlear vestibular dysfunction (VIII) and facial paralysis (VII) indicate the posterior cranial fossa.

It looks very detailed and clean, but it is not so easy to do clinically. The wooden board that pierced Fisher's eyeball disrupted everything. He not only had problems with his sense of smell, but also vision. The skin trauma on his face caused by the explosion also caused many abnormal sensations.

Even the sensation in the distribution area of ​​his supraorbital nerve disappeared, indicating that there was also a leak behind the frontal sinus.

Considering that skull fractures do not necessarily cause these symptoms, and the presence of these symptoms can only confirm that the fracture has damaged the nerves, but not 0% that there is a cerebrospinal fluid leak. In addition, Fisher's symptoms are too confusing and lack a single meaning, so Kavey kicked option off the list from the beginning.

Without the most convenient and cost-effective option 0, he only had options 1 and 2 left.

In order to avoid the side effects of coloring positioning, Kavey chose the laborious explosion simulation. After finding that the results were not satisfactory, he switched back to the coloring positioning of Option 2.

The first step of the staining method is to inject methylene blue into the subarachnoid space, and then the dye will be discharged through the cerebrospinal fluid circulation along the leak, which takes about half an hour. What Kawi has to do is to place a dyed cotton pad at the possible leak, and as long as he encounters methylene blue, he can determine the location of the leak.

The leaks are all located in the nasal cavity. Putting foreign objects into the nasal cavity is highly irritating and requires anesthesia. In the 19th century, when there was no safe local anesthetic, ether was used for general anesthesia.

When Fisher successfully inhaled ether and fainted, the operating table was adjusted to a head-down-feet-high position. Payon and Landreth cut the cotton pads into small pieces on the operating table nearby, then hung sutures on them, and finally Kavi used vascular clamps to insert them into the nasal cavity.

Landreth used a small retractor to dilate his nostrils. Because there was not enough light, Kavey could only judge the position by feel and the distance the forceps entered: "Who can tell me where these cotton pads should be placed?"

Cotton pads were inserted into Fisher's nasal cavity one by one. It seemed simple, but for the audience, the question raised by Kavey still existed.

"You have to put a piece on the top of your nose. Above it is the cribriform plate. If there is a fracture, it must pass through there."

Someone immediately picked the simplest one and said it. The result was not precise enough, but at least it was an answer. With this as an inspiration, others also expressed their own ideas.

“There must also be a patch of sphenoethmoid recess where the sphenoid bone and ethmoid sinus meet, where the sphenoid bone and ethmoid sinus can be monitored.”

"There is also a place near the nasopharynx, where the Eustachian tube is, where you can put a piece, okay."

Mond, who had just been refuting Kavi's actions, stood up again. He put the medical record booklet that he had just rolled up into his suitcase. He seemed to lack some momentum without anything in his hands, but the amount of saliva in his mouth was just as much.

"Just now, Dr. Kavi mentioned that the Eustachian tube is a possible leak site. What's the point of you talking about the Eustachian tube now? Everyone knows that it should be placed around the Eustachian tube? But the problem is that the Eustachian tube opens on both sides of the nasopharynx. How do you put it? Can it be pasted on?" "If it can't be pasted, you can use some water stickers."

Mond was amused. "Do you really not understand, or are you pretending not to understand? Have you studied anatomy? Did you see the area of ​​the slice just now? Do you know the structure of the Eustachian tube around the nasopharyngeal opening? That's not a place to dip the cotton pad! The area around it is uneven, and it's on the side. The cotton pad is only the size of a fingertip. It will fall off after a while if you put it there."

The man was a little embarrassed by his retort and wanted to say something to save face. But Mond didn't give him a chance at all: "I think you took it for granted and thought that just sticking a thin sheet on it would be enough. You didn't think that the cerebrospinal fluid circulation takes a full half an hour as Dr. Kavi said. You have to wait that long.

The nasopharynx is so deep inside that you can’t see it at all. You can’t take it out in advance to see if it’s stained and then stick it back. This is clearly something that must be done in one go! You also have to put it in a place where it’s easy to fall off, which is just asking for trouble!!!”

“I’m just trying to answer one.”

"Listen to what I have to say, including those half-baked people sitting in the same audience with me!" Mond became more and more excited as he spoke. While stopping him, he expanded his attack to the entire venue. "When you were answering questions, did you ever think about the possibility of failure? Did you just do it because you thought the logical relationship was fine? Did you think you wouldn't get into trouble?
Let me tell you what will happen if it fails. Once it fails, the original dye is absorbed by the veins of the central nervous system and enters the systemic circulation. There is no dye in the cerebrospinal fluid. What should I do if I want to redo the leak identification? I need to inject the dye again and wait another 30 minutes!

You think it's okay? It's only 30 minutes? Dr. Kavi just said that methylene blue is harmful to the body and it is not something that can be put into the subarachnoid space for a long time and multiple times. How dare you just put it in there without caring whether it is correct or not."

Kavi did not stop Mond.

His attention was focused on the vascular clamp in his hand and the nurse who was sitting next to the operating table and constantly monitoring Fisher's vital signs. Although it was not so obvious, he could still feel the nurse's nervousness.

Kavey found an opportunity and used his free left hand to feel Fisher's pulse, which was indeed faster than before. This reaction was not uncommon during anesthesia, and since he had just injected a tube of methylene blue into his subarachnoid space, it was probably a normal reaction.

He gave the nurse an affirmative look and then tried to find a way to shut Mond up.

6◇9◇Book◇Bar

In fact, Mond had made the basic concept clear, and the interests involved were not left out, so the rest was useless nonsense. If he was not stopped, he might even criticize the Prince of Wales who was sitting next to him.

"That's enough, Dr. Mond. You are right. That's enough."

Seeing that it was Kawi, Mond, with a red face, stepped on the brakes tactfully, put on his messy mask again when he closed his mouth, and returned to his seat. Without his attack, everyone else breathed a sigh of relief. If he really continued to curse, I'm afraid no one could resist that tongue.

Kavi also didn't like this kind of rapid-fire answer, which was filled with too much emotional output.

However, leaving aside useless emotions, the time mentioned by Mond is indeed an important factor. Not only is methylene blue damaging to the nerves, but also the ether anesthesia is injected through the nasal cavity. The craniotomy site is very close to the nose, and multiple inhalations of ether will affect the drape and even the progress of the operation.

Mond's words were very reasonable, but the operating scene, where only Kawi had expressed his opinions unilaterally, was indeed a bit lifeless.

After the cotton pads were placed, Cavi asked Holmes to lower the white curtain and announced the cotton pad positions: "I placed the cotton pads in the following locations: the front of the nose roof, the middle nasal meatus, the junction of the back of the nose roof and the sphenoethmoid recess, and below the rear end of the inferior turbinate. I think you have all learned the anatomy of the nasopharynx, and I have told you the specific locations. There is still a lot of time for you to play freely."

The positions are not as clear front and back as the frontal, ethmoid, sphenoid, and pharyngeal parts mentioned by Kavi before. The positions of the four cotton pieces are relatively concentrated, forming an upper and lower layer relationship.

Before Mond could finish his speech, he stood up again and wanted to continue, but was pushed back by Kavi: "Doctor Mond, you should take a rest first, so that others can have some participation."

"This"

Mond was very reluctant and even wanted to argue with the surgeon about the right to discuss in the surgical theater of the Hospital Main. Kavi knew this kind of person very well. No one could stop him when he got rebellious. In order to affirm his approach and cool down his emotions, blindly opposing him would only have the opposite effect. He had to give him some positive rewards.

He glanced at the wall clock, pointed at the minute hand and said, "Before the results are drawn, I will select three active viewers to give them a brief diagram of today's surgery. It includes the inspection method and surgical process, as well as possible mistakes and remedial measures.
First of all, I will give the first copy to Dr. Mond today. He successfully activated the atmosphere of the discussion in the surgical theater. I need to emphasize that surgery requires not only rigid anatomical knowledge, but also the collision of creative thinking. Maybe this collision is not so friendly, but it is necessary. I still have three copies of the atlas in my hand. Everyone, please keep going! "

As soon as these words were spoken, the venue became restless. Anyone who had seen Cavi's surgery would not be able to refuse Cavi's surgical illustrations.

Everyone was excited when they saw the intern pick up Kavi's atlas, walk through the small iron door next to him, run all the way to the auditorium, and hand such a precious thing to Mond. Hundreds of people in the entire venue had a heated discussion on the location of the four cotton pads and their relationship with the leak.

However, the person who was really anxious was not Mond, nor was he in the audience, but was next to Kavi.

"What do you mean?" Landreth must be feeling uncomfortable. "I can understand that you just sent one to Sadio, but now you are sending one to these people?"

The implication is not how noble Kavi's atlas is, but why he doesn't have it.

"You're already on stage and operating directly, why do you need a diagram?" Kavi took Fisher's pulse again and said, "You and Professor Sediyo discussed it for a long time before deciding that you would be an assistant."

"The operation is so complicated, it wouldn't be a big deal to give me an extra atlas."

"They were just sketches, not very detailed." Kavi's face became worse and worse, and he turned around and asked the nurse, "How's your blood pressure?"

"Just measured 4/84 mmHg four minutes ago."

"It's a bit low." Kavi checked the time again, then waved at Holmes, "Prepare for Plan 3."