This doctor has a system

Chapter 390 455. Non-mainstream method (ask for a monthly pass at the end of the month)
"Professor Gao, are you so good at echocardiography?" Director Ma asked. He felt that Gao Feng was too capable. He also knew a little about ultrasound, but he could only look at pleural and abdominal effusions. Cardiac ultrasound is still relatively complicated for laymen like them.

It's not that they can't learn it, it's that they have specializations in their professions, which are not their business.

However, this has also brought about a series of problems, the most direct of which is that you can only read the report when encountering something.

But how can I put it, medical knowledge is too vast. If you want to learn everything, you may not learn anything in the end. And generally, reports rarely make mistakes.

This patient delayed a lot of time, so everyone quickly moved on to the second case.

This is a COPD patient who has been using a non-invasive ventilator for 13 years and was recently hospitalized due to an acute exacerbation.

The patient's surname is Zhou. Mr. Zhou's life has been quite bumpy. He has a bachelor's degree. The undergraduates of that era are not the same concept as the undergraduates of today.

After graduation, he was assigned to the municipal party committee as a secretary to senior executives. His things were packed away, but his father did not agree.

"You are the first college student in our village, how can you do the work of waiting on others!"

"Go to the factory and become an engineer!"

This was the fifth intubation in his life. Compared with the previous times, he was not successfully weaned off the machine this time. He had a tracheotomy and continued invasive ventilator ventilation.

"Every time after taking sedatives, the patient feels particularly uncomfortable when he wakes up. Last time, he even developed atrial fibrillation."

Mr. Zhou felt that there was nothing wrong with being a secretary, and many classmates envied him. He communicated with his father and said that this secretary was different from the one he thought of.

We should even lower the oxygen concentration, maintain the oxygen saturation at about 93%, and use a little hypoxemia to ensure the driving of the respiratory center.

Three months later, the results of the investigation were announced. Death was the most important thing. Naturally, the factory director was not punished. Xiao Zhou was removed from his post and laid off early.

During that time, not only did he make money, but he also met his true love, and the two soon got married. Getting married at that time was easy and not that complicated.

The factory director and the other five people were killed on the spot, and the lucky Xiao Zhou lost his right arm.

Knowing that he was coming, the factory director led a group of people to sweep the couch to welcome him.

While my wife was making dumplings, she suddenly fell to the ground. After being sent to the hospital, she was diagnosed with cerebral hemorrhage and died two days later.

At this time, college students are so rare that it is not an exaggeration to say that they are half literary stars. Since the establishment of their factory until now, they have not seen a single college student. The person with the highest academic qualifications is the factory director, which is considered a junior college degree.

The warehouse where the steel was stored was in disrepair, and it was a frame structure. After being hit, it collapsed like dominoes.

After that, Xiao Zhou never encountered any big storms in his life. He just suffered from hypertension, coronary heart disease, and chronic obstructive pulmonary disease step by step.

At that time, it was not very popular to draw big cakes. The manufacturer meant it sincerely when he said this, and no one else had any major objections.

"What's the good thing about being a county magistrate?" said my father, "I want to be an engineer. Engineers sound great and you will be able to build cars and tanks in the future!"

But at this time, the first tragedy in life occurred.

"That's not necessary," the nurse said. "The owner of the car was already dead when the ambulance arrived."

Xiao Zhou got started quickly. He studied mechanical manufacturing in school. Although the knowledge in books was far behind Western countries, it was undoubtedly something advanced here.

The car hit someone and then rolled over under the bridge. When the firefighters took apart the shattered car, they found that the owner's head was hanging on the steering wheel.

But at that time, there were no car or tank factories in the city. The most high-end one was a tractor factory.

"Where's the car owner? I'm going to kill him!"

Just when he was full of good hopes for the next life, the second tragedy happened.

When Xiao Zhou was inspecting the warehouse with the factory director, something went wrong. The forklift driver may have been distracted and kicked the accelerator into the wall.

"It's been amputated." The latter said to him. "Your left lower limb was smashed to pieces by the car. There is no way to save it."

Due to his shrewd mind and daring to venture into things, Xiao Zhou quickly earned his first pot of gold. He first flipped sunglasses and then started a BB machine business.

If we can continue like this, maybe we can build a large-scale machinery manufacturing factory.

The patient's current breathing is still very fast, 29 times/min, heart rate is 98 beats, and oxygen saturation is 97%. Although the oxygen concentration was 40%, Lao Zhou still said that he was hypoxic and became restless.

"The patient's COPD is still very serious. The carbon dioxide once reached more than 115mmHg, which is beyond the upper limit, but the person is awake." The doctor in charge reported, "The pressure required by the patient is very high, with the peak pressure around 28cmH2O. There is also about 10cmH2O of endogenous PEEP.”

After working with the factory director for several years, Xiao Zhou has become a very popular deputy factory director. Under his leadership, the tractor factory was far ahead in competition with similar companies.

"Nurse! Where's my leg!" Xiao Zhou shouted in horror.

Xiao Zhou burst into tears, feeling deeply unfair about his fate.

"I will be promoted in the future. Maybe I will become a county boss one day."

However, it is obviously wrong to increase the oxygen concentration at this time. Patients with severe carbon dioxide retention should avoid high-concentration oxygen inhalation, because it will inhibit the respiratory center. An oxygen saturation of 97% is enough, and there is no need to blow to 100%.

It was then that Xiao Zhou learned that there was a disease called moyamoya disease.

Later, he had another car accident, and when he woke up in the hospital, his whole body was not well.

The wife soon became pregnant and gave birth to a fair and fat boy more than 10 months later.

"Xiao Zhou, you can just follow me from now on." The factory director patted his shoulder and said, "If you work for a few years, you can sit in my position."

"The patient has not slept for several days and is very irritable." The doctor in charge was very worried. "Currently, I can only use some sedatives."

"But the patient's heart condition is also not good. He has chronic heart failure."

"The patient has not been able to sleep well in the past few nights, complaining of feeling suffocated and having a fast respiratory rate. The effect of sputum suctioning is not good either."

The nurse hurried over to comfort him and calm him down, and the doctor also hurriedly came to the bedside.

After being depressed for a while, Xiao Zhou got back on his feet. In order to avoid the sympathetic eyes of people around him, he decided to go to the south to do business.

"What sedative did you use?" a director asked.

"Dexmedetomidine."

Dexmedetomidine is a commonly used sedative drug. It is used for sedation during tracheal intubation and mechanical ventilation in surgical patients undergoing general anesthesia. It is used for sedation during intubation and ventilator use during intensive care treatment.

Under normal circumstances, the side effects of this drug are relatively small. It may be that the patient's physical condition is not very good. The cardiology department recommends not to use this type of drug.

So now the question is, what should the patient do if he is so irritated and unable to go offline?
And staying awake all the time is definitely not an option.

Sleep is an important physiological phenomenon of the human body. During sleep, the human body's heart, lungs, spleen, kidneys and other internal organs can get sufficient rest to maintain basic physiological functions. The sleep time required by normal adults is about 7-8 hours. , clinically it is usually recommended to take a nap for about 30 minutes every day. Normal people can generally go without sleep for 16 hours, but they can also go without sleep for 24 hours occasionally.

But the patient has not slept for several days, and other problems are bound to arise if this continues.

"Sedatives still have to be used," a director said. "Let the anesthesiology department come and take a look to see if other drugs can be used."

Many people nodded subconsciously.

"I think the focus should still be on the situation of patients going offline." Director Ma said, "It's not good to be unable to get off the machine all the time. Over time, it can easily lead to other problems."

Take ventilator-associated pneumonia, for example.

"He has been unable to get off the machine, and sedatives cannot be used all the time. Will the patient be comfortable with the tube inserted?" Someone said, "It will definitely be restless and difficult to sleep."

"This will inevitably lead to failure in offline offline, which is very troublesome!"

"How about we go see the patient?" the doctor in charge asked.

Since the patient is in the intensive care unit and there are other patients there, not many people can go to see him. Fortunately, the patient has stayed at the hospital for a relatively long time, and many directors are aware of his condition.

Gao Feng followed the doctor in charge to see the ill-fated Mr. Zhou.

He was lying on the hospital bed sickly, with one hand and one foot fixed to the bedside by a restraint belt. The endotracheal tube was connected to the ventilator, and his eyes were full of bloodshot eyes.

Seeing the person coming, Mr. Zhou's eyes lit up, and he tried to raise his left hand vigorously.

"Don't move, old man." The nurse said quickly, "The doctors are here to consult you. You have to cooperate."

When the patient heard this, he no longer exerted any strength with his left hand and opened his mouth as if he wanted to say something.

Gao Feng felt anxious. It was very painful to have the tube inserted, and the patient was still awake.
This is undoubtedly a great torture.

Thinking that the patient had been intubated five times, he instantly got goosebumps.

Mr. Zhou's tracheotomy caused air leakage when he spoke, so his voice was very low. The doctor in charge quickly put his head up.

"He said it was very uncomfortable and painful. He couldn't sleep all night and didn't want to live anymore."

Everyone was silent when they heard this.

Whether the patient can die or not actually does not depend on him or her, nor does it depend on the doctor. The decision-making power is still in the hands of the family.

"I have repeatedly communicated with the family members, but they still requested active treatment." The doctor in charge of the bed also felt helpless.

The patient lost his wife early in life, and he raised his son by himself. He has not remarried for so many years. The relationship between father and son is very deep, so the son cannot accept the consequences of losing his father.

"He is too selfish." Someone whispered, "Does he know that the old man suffers too much like this?"

Gao Feng carefully looked at the parameters of the ventilator. The peak pressure was around 28cmH2O. This was too high. The patient must be very uncomfortable. It was strange that he could fall asleep without sedatives.

The current oxygen concentration is 38%, the blood oxygen saturation is 95%, the heart rate is 89 beats/min, and the respiratory rate is 23 beats/min.

After returning to the demonstration classroom, everyone discussed with each other for a while. When Director Ma saw that it was almost done, he motioned for everyone to start speaking.

"I think we should have a good talk with the family," said an older director. "We must learn to accept death calmly."

"The patient has had tubes inserted so many times, and every time he is weaned off the tube, it doesn't seem to go smoothly. He is still so old, and the value of treatment is very low."

"And the patient himself did not have a strong desire to survive. I remember that he refused to enter the intensive care unit while he was awake."

"That's true." The doctor in charge of the bed said. The patient entered the intensive care unit for intubation at the request of his family after he became comatose.

Next, several people expressed their opinions, but the content was somewhat unsatisfactory and many methods were not very applicable.

Gao Feng felt that what the older director said was more substantive. In this case, the best outcome is actually to go see Marx happily. If you hesitate for one second, you will suffer for one more second. .

But if the family doesn't accept it, then there's nothing we can do.

"Professor Gao, do you have anything to say?" Director Ma asked.

"I have some ideas in my mind, but it may not be suitable." Gao Feng hesitated.

"You tell me, let's see if it's suitable." Director Ma said with a smile.

"Can we increase the patient's oxygen concentration?" Gao Feng said, "It is now 38%. How about raising it directly to 50%?"

"what?"

The scene suddenly fell silent.

"Professor Gao, this is inappropriate!" said the bedside doctor. "Such a high oxygen concentration may further aggravate the patient's carbon dioxide retention."

Mr. Zhou was originally admitted to the intensive care unit for intubation because of carbon dioxide retention. If the carbon dioxide retention worsens again, it will definitely affect the respiratory center.

"What will happen if carbon dioxide retention worsens?" Gao Feng asked.

"She will be in coma." The doctor in charge replied subconsciously.

"Can you fall asleep then?"

It must be the kind that can sleep well and can't wake up even if you shout.

"But."

"Director Ma, that's what I think." Gao Feng said, "Excessive carbon dioxide makes it impossible for the carbon dioxide to drive the respiratory center to breathe spontaneously. Spontaneous breathing will be lost, and of course the patient will fall asleep."

"He hasn't been able to sleep a wink in the past few days, and his spirit is about to collapse. At this time, I think it is most important for the patient to have a peaceful night's sleep."

"What a great idea!" The older director couldn't help but slap the table. "By inhaling high-concentration oxygen, we artificially cause respiratory depression to achieve the purpose of sedation."

"I believe the side effects of oxygen are definitely less severe than the side effects of sedatives."

Long expiration, slow frequency, and low ventilation are the ventilation principles for patients with severe COPD. Because it is harmful for patients who are depressed to breathe hard. It will affect the patient's exhalation and aggravate the excessive residual volume in the lungs.

It is best for such patients to use analgesics and sedatives to calm them down and breathe slowly.

But since the patient has been intubated and is in an intensive care unit with complete monitoring equipment, and sedative drugs cannot be used, it may not be an option to make the patient coma after inhaling high-concentration oxygen.

(End of this chapter)