Nineteenth Century Medical Guide

Chapter 9 9. Noisy, Dirty and Crowded
A modern hospital is a place to treat patients and save lives. The first impression given to people should be that it is clean and tidy, but these inherent impressions are completely divorced from reality.

In fact, no place can be clean as long as it is inhabited.

The reason why modern cities are clean is nothing more than perfect garbage disposal and sewer systems.European cities in the [-]th century were not modern, so they were not as beautiful as people thought. Chaos and mess were synonymous with them.

And the hospital is a highly densely populated place, and this situation will only get worse.

It is still the time when winter and spring are turning over, and the fat mice have swaggered out of their burrows, looking for food in the corners under the beds of each house.If the time goes back another month, when the weather gets warmer, those Xiaoqiang hiding in the crevices will come out in groups to bask in the sun. (1)

A hospital is one such place.

Although the wards in the old days were noisy, dirty and crowded, this familiar scene made Carvey immediately recall his own job—doctor.

In the past, it would have been considered too modest for him to call himself that. Even if those titles were not used, he would have to add the prefix "Director" to make sense.But now Carvey is just an assistant, not even as good as the assistant physician back then.

After all, the latter still has a certain degree of professionalism, and it takes several years of specialized study and practice exams.

The identity contrast was too sharp, and Kavey couldn't adapt for a while. When introducing himself, the word "doctor" just blurted out.

The [-]th century was an era when all doctors wore formal clothes to enter and exit wards and operating rooms. The overcoat on him looked dirty, and it was impossible for normal people to equate him with doctors.

"Sorry, I was a little excited just now."

Carvey re-introduced himself: "My name is Carvey, Carvey Hines, an assistant recommended by Mr. Ignatz to come here, and I work in the surgical ward."

The little nurse was wearing a pale gold dress with a white apron on it, and she probably looked about 20 years old.Seeing Carvey like this, she didn't care too much, she just nodded and pointed to a hospital bed in the distance and said, "Since it's an assistant, go and follow, they are doing rounds."

Rounds
The original meaning of the translation of the little nurse's words was indeed ward rounds, but when Carvey looked intently, he didn't see a trace of what the ward rounds should look like.

The three young men were all dressed in black formal attire, tall and straight, and their manners were gentlemanly and elegant enough.If they were walking on the street, Carvey believed that their posture would never be bad, and they would definitely attract the attention of all the girls.

But this is not a catwalk show, but a ward round!

They did not conduct physical examinations, did not communicate with patients verbally, did not have stethoscopes on their bodies, and did not carry the patient's medical records.At most, I just asked a few words with the family members on the side, and then hurried to the next bed.

"How is it more casual to go through the motions than night rounds?"

Carvey muttered something in a low voice, and suddenly reached out to the little nurse just now: "Where is the medical record?"

"Medical records?"

"It's my first time here, of course I have to look at the medical records before rounds."

"The medical records are placed on the doctor's examination table."

In fact, it's not that the little nurse misremembered the rules, after all, it's what the head nurse repeatedly emphasized.It was really Kawei's actions and tone that could not be refused, which made her feel like she was being questioned by a superior doctor, so she responded naturally.

"Bring it to me to see."

"Okay, wait a minute."

After she handed all the things into Carvey's hands and relaxed, she realized that the patient's medical history should not be handed over to an assistant.

However, it was too late. Just when the little nurse knew that she had made a mistake and wanted to actively seek ways to correct the mistake, Carvey had already remembered all the conditions of the 13 patients in this ward: "Thank you, I see It's over."

"so fast?"

"The hospital admission record is written on it, and there is nothing difficult to remember." (2)

The little nurse just took it as a self-esteem joke. There are 13 patients with different types of diseases and different priorities. It is so easy to remember.What's more, the writing of the medical records was all written by Ignatz, which was full of various professional terms, and was still written in complicated and difficult Latin.

Even those young doctors have to look at it for a long time before they understand the meaning, how can an assistant understand it.

The little nurse wanted to take advantage of her qualifications for coming to the hospital a week earlier and scold him, but she didn't expect that Kawei didn't give her this chance, and ran to a hospital bed not far away in the blink of an eye.

Lying on the bed was a 10-year-old boy, and his mother stood beside him with an anxious face.

It was the first time for the mother and son to meet these famous doctors. From the appearance of the "ward rounds" just now, it can be seen that the words were a little cautious.Now that I have gone to the beds below, my mother has been hesitating whether to consult with those people again.

Carvey, who has worked in the hospital for more than 30 years, can tell at a glance that the rounds just now have failed to solve their problems.In addition, Ignatz's first operation today was bed 11, so he walked over immediately: "Is there anything I can do for you?"

The mother finally found someone who could talk, and explained: "My son's leg was injured, it was very serious, and they said it would be amputated."

"Well, I know, so how can I help you?"

The mother looked back at her son who was suffering from severe pain on the bed, and felt very uncomfortable: "But my son doesn't want to have his leg amputated, and neither do I. He is only 10 years old. If he does, he will definitely lose his job, and the family has no money. "

Carvey had just seen the medical record, which clearly stated the diagnosis of "compound tibial fracture", Ignatz's own handwriting. (3)

He didn't understand what a "compound" fracture meant, but he knew very well that when dealing with such trauma patients, without the help of an X-ray machine, a rigorous physical examination must be used to judge the fracture injury.

The mother lifted the quilt from her son, revealing the badly injured left leg.

The shape of the left leg was indeed not quite right, the central bone area was deeply sunken, and the surrounding skin was swollen to varying degrees.The most critical thing is that there is a defect in the skin in the deep concave area, and there is an obvious avulsion separation between the subcutaneous tissue and the muscle fascia.

This is a crushing injury caused by the strong traction force generated by the rotation of the wheels. Modern doctors also call it "avulsion injury" or "degloving injury".

Carvey looked at a circular avulsion wound on his leg and made a simple measurement: "Wagon crush?" (4)

"Yes." The mother couldn't help but shed tears again, "When I came home from work last night, I was accidentally knocked over by a carriage while walking and crushed my leg."

Carvey nodded, and avoided the wound to do a simple inspection of his leg. The main focus was not on the fracture itself, but on the soft tissue, blood vessels and nerves around the bone.

The soft tissue check is the tension of the soft tissue of the calf, the temperature and color of the calf skin, etc.If the soft tissue is swollen, the skin temperature is elevated, the skin is red and dull, and there is severe pain, it is likely to be compartment syndrome. (5)

With the current medical level, there is no reason to hesitate. Amputation is necessary, otherwise death is certain.

The blood supply of the tibia is checked for the pulsation of the dorsalis pedis artery, and the nerves are checked for toe movement limitation and pain, and whether there is foot drop.If the blood vessels and nerves are damaged, the function of the distal limbs will inevitably be impaired, so it is not an option to keep this leg and let it be infected, and it is better to amputate it.

The child was lucky, and there were no problems with soft tissues, blood vessels and nerves.

Only then did Carvey start to focus on the fracture, and it was necessary to carefully examine the shape, length and circumference of the left leg to judge the displacement of the fracture.

Because there is no steel plate and nail for internal fixation, the scope of application of simple manual reduction and fixation is very limited.If the displacement is serious, even if it is reset, it will be difficult to heal the bone, and the final result is likely to spend the rest of life with a burden.

Now the shape of the left leg has changed, and the displacement exists, but from the outside, the range is not large, and the length has not changed, which happens to be stuck in the surgical indication for amputation.

At this time, the doctor needs to make a judgment, whether to protect or cut.

Reduction and fixation are required for insurance, which is fine. Fracture treatment has existed since ancient times, manual reduction is not difficult, and the technique of splint fixation is quite proficient.But the key problem is the avulsion wound. In such a hospital environment, with such a large open wound, infection and festering are inevitable.

But amputation does not have this problem.

As long as the embedding of the amputated stump is done well, the chance of infection at the suture line is definitely much smaller.Even if infection does occur, the rate of development is much less.

Although in Carvey's eyes they are all about the same, they are all fighting for their lives, but in the hands of Ignatz, the mortality rate of conservative treatment must be higher, and there is no problem in choosing amputation: "I personally think that Mr. Ignatz's choice There is nothing wrong with that, amputation is the safest way to minimize the death rate."

This is not Carvey's cold-bloodedness, it is the optimal solution under age constraints, and Ignatz has reduced the mortality rate during and after amputation to about 20%, so you can give it a try.

However, medical treatment has never been unilateral treatment by doctors, and it is also necessary to listen to the demands of patients and their families.

"I don't want amputation."

This time it was the child lying on the bed who spoke: "I am afraid of pain, and I am also afraid of losing my job. There are two younger sisters to take care of at home. I can help my mother earn an extra 400 Helle per month. Without this salary, They will starve to death."

"That needs to be prepared for wound necrosis," Carvey said, "if there is necrosis."

"I understand this. Aolat who lived next door died because of a wound that rotted." The boy glanced at his mother, and then said lightly, "I can lose a mouth when I die, it's better than lying on the bed with amputation." Be strong."

Carvey nodded. "Okay, I'll talk to Mr. Ignatz and then give the leg an assessment"

While he was discussing the treatment plan with the patient, the rounds of the three young men had also ended.

The boy's leg was badly injured and he was admitted to hospital as soon as he arrived last night.Preventing wound infection from worsening is more important than other operations, so Ignatz ranked his amputation at the top of the list today, and the time was set at ten o'clock in the morning.

After the failed cesarean section the day before yesterday, the three of them became much more cautious. Not only did they get up early for the rounds, but after the rounds, the focus of attention was all on him.

"He should be the first operation today, and Mr. Ignatz is performing the surgery."

"His medical records. Here, bed 11, named Eston, a 10-year-old boy."

"Compound tibial fracture. What I did was amputation of the tibial knee joint."

"Ms. Ignatz's amputation is well-known at home and abroad. The knife is stable and fast. I must learn more today."

"I remember making an incision under the patella, amputating the tibial plateau and the ligament muscles around the knee joint, and then using the remaining part of the flap for the final embedding."

"Indeed it is."

After reading the medical records, the three of them suddenly found that there was a stranger beside the bed in bed 11, wearing a black coat, chatting with the family members about something: "Who is that person?"

"I haven't seen it, I guess I wasn't there just now."

"It's probably a family member."

"I think it's almost time. Push people to the theater as soon as possible. We still have a lot of preparations to do. Mr. Ignatz hates others for being late, so don't be scolded by him again."

The three of them were from a wealthy family and had never worked as a cart pusher. Besides, the person sitting on the cart was a poor man.But working under Ignatz, it is unrealistic not to do it. In order to be fair, they chose to solve this problem by guessing coins.

Just as one of them took out a krona coin from his pocket, the little nurse who was working next to him suddenly said, "Just ask an assistant to push him over."

"assistant?"

"Don't physicians have assistants, and we also have assistants in our wards?"

"Yes, isn't that the one standing there talking to bed 11?"

　(1) In fact, many modern hospitals also have problems with environmental cleanliness. To see how a hospital is managed, you only need to check whether there are cockroaches in the wards. Of course, the environment has no direct relationship with medical strength.

　　(2) Medical records began in the 17th century, with simple disease content at the earliest. Later, due to the emergence of hospitalization, medical records began to show admission history and discharge history.It was not until the beginning of the 20th century that American doctors first proposed to record the development of patients' conditions during hospitalization, and finally formed the medical records that are now a headache for all doctors.

　　(3) The "compound" in the modern diagnosis does not exist, and the specific parts of the tibia are replaced, such as tibial plateau fractures and tibial shaft fractures.If the bone fragment is severe, a comminuted fracture of the tibia can be added, and if the fracture surface penetrates the epidermis, an open fracture of the tibia should be added.If the fracture is displaced, "with displacement" can be added at the end of the nomenclature.

　　(4) Circular avulsion wounds are mostly seen in calf crushing. The skin is split and avulsed in a circular shape. The width of the missing skin is the same as the width of the tire.

　　(5) A series of early symptoms and signs of muscles and nerves in the intraosseous fascia formed by bone, interosseous membrane, intermuscular septum and deep fascia due to acute ischemia and hypoxia.Also known as the 5P syndrome, pain (pain), pallor (pallor), paresthesia (paresthesia), paralysis (paralysis), pulselessness (pulselessness)

　　
　
(End of this chapter)