Gou in the operating room to add some upgrades

Chapter 191 Fang Xian walked too fast (please subscribe)
"Is there an MRI? If it's just a CT scan, it's basically invisible."

"The content displayed by MRI is much more detailed than that of CT. CT is actually better at seeing large organ damage such as organ damage and fractures." Fang Xian did not refuse.

When you first arrive, you enter the department, not the training camp in the operating room. So you definitely have to interact with patients, have colleagues, and deal with certain interpersonal relationships.

During the training period, Fang Xian only needs to study and ponder!
Fang Xian does not need to be responsible for diagnosis, prognosis, selection of surgical methods, or the overall progress of the surgery. Fang Xian does not need to worry about it. What he has to do is work, study, and strive to grow.

"Yes, Doctor Fang, look here..." He Donglai immediately pulled out the MRI results and stepped aside.

He Donglai and Huang Qian quickly stood on the left and right sides of Fang Xian. While rolling the mouse with Fang Xian, they bent down and crawled, aiming their buttocks at the desk behind them, carefully and seriously.

In order to ensure that Fang Xian could read the pictures more accurately, He Donglai also took the initiative to help explain: "This patient suffered a blunt injury to the upper abdomen, the skin was bruised but not broken, the ribs were broken, and the MRI showed a ruptured pancreas, liver and Spleen contusion and laceration.”

"Then the shape of the abdominal aorta is intact, there is no large amount of peritoneal effusion, and damage to the large blood vessels is not considered for the time being. The shape of the spleen is irregular, there are diffuse bleeding spots around the pancreas, and there are blood clots. Look at these locations... …”

"But during the operation, arterial bleeding occurred. We still haven't fully figured out which artery the bleeding was from, and Director Fang didn't tell us. Let's review the case again and do a review of the condition in the department tomorrow."

"Now we both feel quite a headache." After He Dong finished speaking, he turned to look at Fang Xian.

It is both asking for advice and discussing.

Fang Xian just glanced up and down and said: "The characteristics of normal pancreatic tissue in MRI mainly include the following aspects -"

"The first is high contrast. As you can see, whether it is a normal pancreas or a pancreas after contusion: the pancreas usually has high contrast on MRI and can be clearly separated from the surrounding tissue, which is very helpful to us. Clinicians clearly observe its shape and structure."

"This is much more convenient than CT display."

"The second one is the same as CT, it can perform multi-plane imaging. This is the basic feature of magnetic resonance imaging, so we won't mention it yet."

"Third, the resolution of soft tissue is good. In addition to seeing the general structure of the pancreas, we can also use MRI to show the characteristics of soft tissue and see the internal structure of the pancreas, including the pancreatic duct system and pancreatic parenchyma."

"Of course, functional imaging is not necessary, and it is not used to evaluate pancreatic islet function in diabetic patients!"

"Really?" Fang Xian first found some images of normal pancreatic tissue and introduced them to the two of them respectively.

After hearing this, both of them nodded, but their brows were furrowed.

Because what Fang Xian is talking about now is actually a bit high-end.

Determining the general location of the injury based on the report is something mastered by Level 1 MRI interpretation. Only Level 2 MRI interpretation requires you to accurately locate the location of the lesion, make your own interpretation, and conduct a general qualitative analysis of the nature of the lesion.

Level 3 MRI reading requires an understanding of anatomical structures, such as the head, body, tail and fine structures of the pancreas, which requires a certain foundation of anatomical structures.

This is already the limit for the two of them.

As for what Fang Xian said, the so-called pancreatic duct system and pancreatic parenchyma are already at the level of MRI reading, and are more detailed.

But, if you have to learn, learn first and find the key points first.

Therefore, even if the two of them heard it half-understood, they digested part of it without interrupting.

"After we find the location of the injury, we need to understand its general nature through MRI reading and the patient's general medical history."

"For contusions, the doctors in the imaging department have given us instructions, and it is also shown in the report. However, the doctors in the imaging department will not give a more in-depth interpretation. These require our clinicians to do it based on clinical practice-"

"Is the patient's surgery finished?" Fang Xian interrupted.

If the patient is still on the stage, he will stop talking nonsense and talk about the key points directly.

The patient has been properly treated. When analyzing the case retrospectively, Fang Xian can go into more depth to facilitate the two of them to learn and understand.

If the patient is still on the stage and some flaws have not been discovered, it would be a waste of time to just go ahead and do the surgery.

"It's done. Director Fang just finished it when he came down. The patient has been transferred to the general surgery ward. There is no need to enter the ICU."

"Director Fang's skills are quite good." Huang Qian nodded quickly. He was in the ward and was also responsible for the patient's final fate. He also contacted the department where he was transferred and explained some detailed issues.

Fang Xian also knew that his worries were unnecessary, so he added:
"According to the instructions of the radiologists, combined with the basic theories of general surgery, pancreatic contusion refers to external trauma or damage to the pancreas, which is usually accompanied by bleeding or inflammation."

"If it's a rupture, it's a direct burst, not a bruise. That's definitely the definition."

"Brothers, don't blame me for talking too much. The main reason is that I have never lectured to others and have no experience in this area, so I try to do everything in detail. I was a student before."

This is Fang Xian's truth.

No one had discussed with him how to diagnose or read films for a long time. When Fang Xian was a specialist, it was even less possible for him to give advice to others.

As for giving guidance during operation, they only need to adapt to the situation and ensure that their operating level is at the lower limit and provide guidance.

However, the theoretical study and diagnosis-related content can naturally be more detailed so that others can understand it better.Fang Xian has no experience in this area.

"Well, it's okay, Doctor Fang continued." He Donglai and Huang Qian also hoped that Fang Xian could explain in more detail. The first priority is to understand the lectures, rather than pretending to be profound.

"Eedema and swelling: After trauma, the pancreas will definitely experience edema and swelling, which may appear as an increase in the size of the pancreas on MRI. Is this easy to understand?"

"Whether it is a surgery or a sprain, swelling will occur. Swelling is a three-dimensional change in volume. It can be seen with the naked eye, and the MRI will definitely not miss these changes, right?"

"So, whether it is the pancreas or the swelling after blood vessel damage, there will be thickness migration with other normal tissues -"

When Fang Xian said this, he made a trapezoidal gesture with both hands, which represented a gradually increasing trend.

The two continued to nod.

Fang Xiancai added: "Then, on this MRI image, we cannot see similar content on the pancreas because there is extensive edema and swelling."

"But based on this theory, let's push the blood vessels out of shape——"

Fang Xian suddenly changed another organ, jumping from the pancreas to the blood vessel.

"This is the abdominal aorta, this is the aortic wall. Its shape is uniform from top to bottom, right?"

"This means that it is either extensive edema, or it is normal, otherwise it will not be so uniform. During the operation, we found that the blood vessel wall must be good, otherwise, the rupture of the abdominal aorta, such bleeding, half The patient may be gone in minutes.”

"However, when we look for such trapezoidal changes, we will find that several branch vessels of the abdominal aorta that supply the pancreas have what we call transitional changes -"

"here."

Fang Xian pointed with the mouse——

"Celiac artery: The celiac artery is an important branch of the abdominal aorta. It mainly supplies blood supply to the head of the pancreas. This branch is also called the gastrointestinal mesangial trunk. When it passes from here, its blood vessel wall is still uniform. "

"It is divided into many small branches. One of the branches is the pancreatic artery, which is responsible for supplying blood to the head of the pancreas. Here." Fang Xian turned up and down, trying to let the two of them see the cross section of the artery.

After that, Fang Xian asked again: "Have you found such a trapezoidal structure?"

"Damn it, it turns out to be here. Edema?"

"It's just that there was no rupture or bleeding at that time." He Donglai suddenly realized and patted his head.

"Yes, the blood vessel wall will become brittle after edema. If stress contraction occurs, it will rupture during the operation." "However, it is not necessarily just this blood vessel that is ruptured. Whether it is ruptured or not, You only know it during the surgery.”

"Let's look at the second artery that branches from the abdominal aorta trunk, the superior mesenteric artery. It's here. This patient's superior mesenteric artery has a relatively classic branching structure, without errors or variations."

"Most of it moves toward the intestines and mainly supplies blood to the intestines, but it also sends branches to the pancreas to ensure blood supply to the body and tail of the pancreas."

"Moreover, when we read, we will find that where is this ladder-shaped structure? It is not on the blood vessels of the pancreatic branches, but at this location-"

"It's a trapezoidal or transitional structure, so the vessel wall is uniform proximally and distally, but if it thickens locally, often in ischemic conditions, when the artery constricts, it's also prone to rupture there."

"Thus, I was caught off guard. If I speculate, the ruptured blood vessel is more likely to be this one."

"After all, if it is difficult to find the bleeding point during the operation, it is easy to find the rupture of blood vessels close to or supplying the pancreas. On the contrary, rupture of other blood vessels far away from the pancreas is difficult to locate!"

"After we see bleeding, we will subconsciously find blood spots nearby. If we don't find them, they must be relatively hidden, right..."

When Fang Xian asked if it was right.

The corners of the mouths of He Donglai and Huang Qian moved, but they did not make a sound, as if they were paralyzing you. Are you a movie watcher or a fortune teller?
Of course, they couldn't refute what Fang Xian said.

They secretly sighed in their hearts, they didn't know how big the gap between TM's level 3 skills and level 4 skills was, but the gap between TM's level 5 skills and level [-] skills was like a despairing chasm.

"After we find the edema, we look at the bleeding: Internal bleeding may occur when the pancreas is bruised, and MRI can show signal changes in the bleeding area, which are usually hypointense on T1-weighted images and hyperintense on T2-weighted images."

"This can be easily understood. The theory of nuclear magnetic imaging is about the relaxation of H ions. In other words, as long as there is a high content of H ions, such as fat and water, those with a high proportion of H ions will be weighted in T2 There’s a high signal on it.”

"In the blood, the concentration of water is actually the highest substance."

"Based on this, let's look at it again. There is extensive contusion on the pancreas. The contusion will ooze blood, and the peritoneal effusion underneath is not a mass, but linear. This means that the pancreas does not have extensive bleeding or a large amount of it. Bleeding.”

"But behind the spleen, there are clumps of blood here, which means there may be a rupture in the cortex here, causing a large amount of blood to spurt out, and the hole will not be particularly large..."

"Of course, in fact, if we look back at the celiac artery and superior mesenteric artery based on this injury symptom, we can find that in the transitional segment of the superior mesenteric artery, there has already been a breach in the vascular intima, but only in the blood vessel wall. and the outer membrane structure, which is temporarily damaged.”

"There is a white triangular structure here, and it is not a neat triangle. This should be caused by the blood flushing after the intima of the blood vessel is broken..."

"Then there's inflammation...the inflammation caused by the contusion may affect the tissue surrounding the pancreas, and MRI can show the imaging characteristics of this inflammation, such as swelling and enhancement."

After Fang Xian went deeper and deeper, the two of them began to listen as if they were listening to heavenly scriptures.

Therefore, after talking for a while, Fang Xian sighed and stopped continuing.

"Dr. Fang, thank you. You are really awesome at being able to read so many things from this. It seems that there are too many points in the MRI that we have overlooked."

"This contains much more information than X-rays and CTs." Huang Qian sighed when Fang Xian stopped and gave up.

Extremely respectful attitude.

Fang Xian shook his head: "That's not necessarily true. Looking at the overall structure, NMR is too detailed, and the control of the macro structure is not as good as the previous two. It's just that the details are better."

"And if you want to read the images from a wide range of macroscopic angles of the damage location from the beginning, CT can omit a lot of steps, and you can scan a lot of things at a glance. Although it is blurry, it can also help us doctors reduce a lot of unnecessary unnecessary work. workload.”

Although X-ray and CT are classic examinations, their usefulness is irreplaceable today.

For example, in terms of reading liver cancer, intracranial hemorrhage, etc., it is more comfortable than MRI. Moreover, MRI is not particularly suitable for some diseases that require observing the general shape of the lesion.

For example, lungs, heart, etc., each has its own pros and cons, and there are many things that can be read on CT...

Lesions, nature of disease, anatomy, overall level, theory, etc.

While talking, Fang Yun returned to the office.

He Donglai quickly asked Fang Yun: "Director Fang, in the abdominal surgery done before, the point of sudden bleeding during the operation was the non-pancreatic supply segment of the superior mesenteric artery. This is relatively hidden and cannot be detected first during the operation." Time to discover?”

Fang Yun was carrying someone behind him at the moment, probably in his 40s.

Hearing this, he immediately blinked.

Fang Yun glanced at the showoff He Donglai, then looked at Fang Xian: "Did you help them read the film?"

Fang Xian blinked when he heard this.

He Donglai's eyelids drooped slightly.

Facing Fang Yun, he didn't even have the courage or guts to lie.

"It's okay. This kind of disease is actually unusual and not common. You should summarize it carefully. Now that you can see the anatomical structure, if you want to make progress, you must clarify the layers and even bring out the theoretical parts. Come to MRI reading."

"Theory is not something to be memorized, but something to be used and applied flexibly. It can help you solve a lot of troubles at critical times." Fang Yun did not continue to criticize.

"Do your work first. Take a good look at all the cases that have been encountered in the department. Don't swallow them all. These cases contain a lot of technical things. If you can all understand them, your skills will be natural. It can be improved.”

"Of course, given the known circumstances, it is actually impossible for you to deduce from scratch, but by inferring backwards and putting aside some things to deduce, you can gain something."

"Director Gong, I have caused you trouble again. This time, our trauma center's diagnosis was not thorough enough." After Fang Yun finished speaking, he apologized to Director Gong behind him.

But Director Gong immediately shook his head: "No, no, Director Fang, I was not careful enough in the preoperative assessment, and I caused you trouble..."

"Fang Xian, you go back to eat first. Just come back tomorrow morning."

"I also have something to do with Director Gong." Fang Yun casually explained to him.

Fang Xian nodded and said in a polite manner: "Okay, Director Fang..."

Naturally, after Fang Yun brought Director Gong into his office, Fang Xian did not leave directly.Instead, he asked Huang Qian and He Donglai about the personnel structure of the Trauma Center of Changshi No. 1 Civil Hospital before nodding.

There are not many people in the ward. The chief surgeons in the operating room are mainly a small number of professors and most of the deputy chief physicians. Then, for consultation and surgery, they are also replaced by the deputy chief physicians of the hospital.

As for this deputy chief physician, they are actually based on the grade certification of the Medical Association. Their true identity is actually the chief physician of a prefecture-level city hospital.

There is no way, if we want to strictly benchmark the level in the medical association, then many people really will not be able to get promoted, and their salary will not keep up.Therefore, when evaluating professional titles, this part of the actual situation will be taken into consideration in prefecture-level city hospitals and county hospitals.

When Fang Xian left, he looked back at Changshi No. 1 Civil Hospital.

I couldn't help feeling a little and murmured in a low voice: "Perhaps I am not as experienced as other doctors in terms of diagnosis and treatment experience, and my understanding of the mentality of patients and their families is not as mature."

"But my basic skills have already reached the advanced level."

"I moved too fast, so today's development is slightly unbalanced. But this imbalance is a good thing."

"With high skills, but not much experience in treating patients, I can still treat myself well."

"Diagnosis and treatment should be made first, and then the appropriate treatment method is selected. What should be left to specialists should be left to specialists. If it can be solved with basic skills of specialists, use basic skills of specialists. If specialist skills are needed, leave it to doctors with specialist skills. deal with……"

"This medicine is really a huge system..." Fang Xian's anticipation became even stronger.

(End of this chapter)