Zheng Ren instructed in a deep voice, "Appendix retractor."
He used the retractor to pull the incision edge to Xie Yiren's side and adjusted its position before passing the tool to her. That way, she could help him expand the operative view to its maximum.
Then, he extended his hand again and a pair of dissecting forceps was gently placed on his palm.
The gastrosplenic ligament was clamped with the dissecting forceps before being ligated and incised. After that, he quickly ligated the short gastric arteries to avoid damage to the gastric wall.
[His movements are so f*cking fast…]
[The host surgeon's understanding of the anatomical structures has reached a very high level. Why do I have a feeling that they know where the short gastric arteries are without even searching for them?]
[You'll know after repeated executions. Young man, more surgeries and thinking are the keys to success.]
As the comments passed, the splenic artery was separated and exposed in the operative field. After ligating it using a 3# suture thread, Zheng Ren noticed a significant reduction in spleen size.
Subsequently, the spleen was removed from the splenic fossa. The splenophrenic ligament and splenocolic ligament were transected, and the vascular pedicle was treated using double ligation and transfixation with nonabsorbable suture ligatures.
These were accomplished in less than five minutes.
[That's very fast. I think I know why the host surgeon occluded the porta hepatis in the first place.]
[He is confident that occluding the hepatic hilum can minimize hemorrhaging as much as possible. If I'm not mistaken, the occlusion can go up to ten minutes, max.]
[Fifteen minutes, but we usually release it every ten minutes to prevent ischemic liver injury.]
The doctors in the live broadcast room understood the host surgeon's methods. Despite their astonishment at the removal of spleen in only five minutes, the surgery itself was not difficult. It only showed that the host surgeon had a deep understanding of local anatomy, no more.
Yes, that was basically it.
Apart from blind manipulation to occlude the porta hepatis, everything else was plain and simple, but how many surgeons in this world could finish it so quickly?
Everyone understood the principle behind it, which was why there were relatively few comments thus far. They were eagerly waiting to see what the host surgeon was going to do with the ruptured liver.
Liver surgery was ten times more difficult than a splenectomy.
After simple ligation of the vascular pedicle on the diaphragmatic surface using a 2# suture thread, Zheng Ren began extending the surgical incision to the right.
There was no bleeding from the subcutaneous tissue: a typical manifestation of hemorrhagic shock. This was due to peripheral vasoconstriction, which was a compensatory mechanism to maintain vital organ perfusion.
Despite the absence of bleeding, Zheng Ren remained vigilant and quickly performed blunt dissection, trying his best not to cause any further damage to the surrounding tissue.
A large sterile gauze was used to protect the peritoneum before he repositioned the appendix retractor and let Xie Yiren pull on it.
At this moment, Chu Yanzhi and the circulating nurse finally returned.
"Transfuse the blood!" Zheng Ren ordered while exploring the peritoneal cavity.
Resuscitation was of utmost importance and courtesy was absolutely unnecessary in this instant.
The circulating nurse and Chu Yanzhi each took a bag of fresh frozen red blood cells and hung them on the infusion stand.
Warm blood had to be used, so they had been trying to use their body temperature to thaw the bags on their way back to the operating theater.
After an identity check between the patient and his blood components, the circulating nurse placed a bag of fresh frozen red blood cells into the pressurized infusion device before putting another bag into her embrace.
"Give me a bag," said Chu Yanran, who was attentively watching the data on the ventilator and various monitors.
Without wasting any time, they divided up the blood bags and constantly changed positions to warm the frozen blood as much as they could.
The blood bag in the pressurized infusion device soon depleted and was quickly replaced with another.
Seeing the dark red fluid entering the patient's vein via the central venous line relieved everyone's anxiety to a certain extent.
Chapter 93 - Hectic
The operative view opened up, revealing a 5cm wound on the left side of the liver. Despite the rubber drainage tube controlling the bleed at the hepatic hilum, there was still a significant amount of blood flowing out.
Zheng Ren immediately started to clean the wound. There were no signs of necrosis yet as the wound was still fresh.
An in-depth investigation revealed the tear to be on the inside of the liver, around 4cm deep. A few blood vessels were leaking dark red blood.
Zheng Ren extended his arm and a mosquito clamp was placed in his hand.
The ruptured blood vessels were clamped and ligated, followed by the damaged bile duct.
Once the bleed was controlled, Zheng Ren let out a breath of relief. The drainage tube indicated that the bleeding had stopped.
"Blood pressure?" Zheng Ren asked.
"80/60," Chu Yanran answered.
The ruptured spleen was removed and the bleed at the liver was controlled. In response, the patient's vital signs took a turn for the better.
The patient would be better after a transfusion of 16U of blood and 1000ml of plasma.
Zheng Ren assessed the area around the wound of the liver and said, "Call Su Yun. Ask if he is confident with handling a hemorrhagic shock patient post-surgery. If he is, get him to the ICU."
Chu Yanzhi hesitated slightly before dashing out of the operating room to wake the drunken man.
Zheng Ren cut out a part of the greater omentum and used it to plug the leak. Then, he used an interrupted mattress suture to close the wound. The distance between each stitch was precisely 1 centimeter.
[His stitchwork is perfect! You could use a caliper to measure the 1cm!]
[Amazing! The surgeon is very attentive. He left a piece of the greater omentum at the wound to prevent capillary bleeding after blood pressure is restored.]
[To reach his level of skill, one cannot be anything but attentive. Young ones, let me tell you, you need to develop yourself with each surgery.]
[How many minutes have passed? Fifteen?]
[From my calculations, the whole operation took around 13.5 minutes from spleen removal to stitching up of the liver. It's not a big operation but their speed is impressive.]
[In a life or death situation, speed is key. Notice the surgeon did not make a small incision and just went for a 25cm cut. This surgeon is efficient.]
Xie Yiren had warm saline water ready when the suture was complete.
The abdominal cavity was irrigated, and after that, the mixture of bodily fluids and saline water was aspirated.
Zheng Ren double-checked the abdominal cavity and area of the splenic hilum. He placed drainage tubes at both the splenic hilum and the liver wound and began closing the abdomen.
"Su Yun is awake. He'll be there soon," Chu Yanzhi reported when she got back.
"Is he completely awake?"
"Sounded like it." Chu Yanzhi's hands were icy from the frozen blood bags. She rubbed her hands to warm them and as she thought of last night's amazing feat, a smile graced her face.
"Good. The ICU is better-equipped and better-staffed." Zheng Ren had to agree.
He predicted that the patient would not have many post-surgery complications, but to be safe, he wanted the patient to stay in the ICU for one or two days of observation.
The number of patients who would require the same treatment was not on his mind.
He only focused on the emergency at hand.
"Inform the ICU to prepare a ventilator. Patient arriving in 20 minutes," Zheng Re
n ordered.
Suture, closure. The patient was intubated and sent to the ICU.
Chu Yanran sat atop the trolley bed with her legs tucked to minimize occupied space.
Her position was awkward as she clutched the ventilation bag to sustain respiration. She had to keep an eye on the patient's vitals during transport.
After transporting the patient, Zheng Ren rushed back to the emergency department.
Although the surgery was quick on his part, from end-to-end, it had taken nearly an hour.
In that time, other injured patients had been brought in.
At the emergency room, Old Chief Physician Pan was managing the crisis. The old chief was calm and collected as he assessed each patient's condition and triaged them to particular departments.
Zheng Ren's eyes swept across the room. There were many patients, but most of them had fractures or external head injuries that were minor. His shoulders sagged in relief.
He asked around and found two more patients that had come in with internal hemorrhaging. The more severe case was sent to the second general surgery department with Chief Sun heading that rescue. The other case was sent to the first general surgery department for the deputy chief to work on.
Old Chief Physician Pan was seated calmly amidst the chaos, his presence a source of comfort for many.
As the families of these patients had yet to arrive, medical administrative personnel were extremely busy. They were taking down patients' details, conditions, justifications for surgery—all information required by-law.
As medical lawsuits were on the rise, the hospital made sure to be extra cautious with legal procedures. The paperwork had to be perfect even in emergencies like this.
This was after receiving hundreds of lawsuit threats in a year.
Zheng Ren once heard an old physician say that back in the eighties and nineties, even though public safety was lacking, doctors were very much respected by society. People with injuries could come in and be treated as an anonymous patient. The lack of procedure meant quicker emergency response.
Now, if a doctor dared to do as such… Zheng Ren was sure one encounter with an unscrupulous family member would end their whole medical career.
Old Chief Physician Pan saw Zheng Ren and asked, "How did the surgery go?"
"Laceration at the liver, ruptured spleen. Surgery went well. The patient's in the ICU now," Zheng Ren summarized.
"Good." Old Chief Physician Pan nodded and said, "There's a lot of patients today but only a few had internal lacerations and all were from the Pentium Overpass incident. Fractures and external head injuries were the main conditions observed in the other patients. We'll have to monitor them."
Zheng Ren uttered a grunt of acknowledgment.
"We need to keep an eye out for delayed traumatic intracranial hemorrhage. Stay on guard," Old Chief Physician Pan instructed.
Zheng Ren nodded in assent.
As time passed, more patients with minor injuries were admitted. All 120 ambulances were overloaded but even so, a few victims could not catch one and had to walk to the hospital in the cold weather.
These patients mostly exhibited minor external injuries. It was likely that the sudden snow and frozen road made them lose control of their cars, resulting in a frontal collision.
Some of the patients were elderly people who had been on walks. The frozen pavement had caused them to slip and fall, leading to multiple cases of Colles' and intertrochanteric fractures.
Zheng Ren guessed that the orthopedic department would be bustling. Sea City General Hospital had four orthopedic departments and each received around ten patients.
This was excluding patients with Colles' fracture being treated in the emergency department.
Colles' fractures were largely caused by indirect trauma. It was a condition commonly observed when people tried to break their fall with their hands. The frozen ground played a role in today's incidents.
With the forearm extended and the hand outstretched, the force of a fall would cause the distal end of the radius to fracture.
The treatment was simple—resetting, immobilization with a splint and medication that improved blood flow.
Under normal circ.u.mstances, if the patient wanted to stay for further observation, they would allow it. However, with the emergency today, the doctors advised them to recuperate at home.
The whole emergency department was filled with patients. There were no available beds for observation.
Zheng Ren was not from orthopedics. He had only performed resetting once or twice during his housemanship and therefore was of not much use.
For the whole afternoon, he stuck to observing, diagnosing, and distributing the patients.
At 2:25 in the afternoon, a call came from the ICU. The hemorrhagic patient's condition required input from all departments.
The ground outside was frozen over like a layer of glass. People avoided the outdoors and the number of new patients gradually decreased. Old Chief Physician Pan noted the situation in the emergency room had stabilized and told the doctors on duty to call him if there were any problems. Then, he brought Zheng Ren with him to the ICU.
Chapter 94 - Retroperitoneal Hematoma
Zheng Ren entered the ICU and felt hateful gazes directed at him.
'What did I do?' Zheng Ren thought.
He had never had any misunderstandings with ICU staff. The nurses...
"Chief Physician Pan, you're here." An ICU doctor walked toward them and started to explain the patient's condition.
"The patient was involved in a traffic accident and sent to the fifth orthopedic department at 9:18 am. He was diagnosed with a pelvic fracture. Blood pressure was at 100/60 mmHg but an hour later, it was at 85/45 mmHg. We suspected severe hemorrhage from the fracture and did a CT scan. The scan revealed a retroperitoneal hematoma."
The patient's records detailed the condition with a simple, clear-cut diagnosis. The hematoma was to be expected due to pelvic fracture.
Minor pelvic fractures rarely required surgery and were manageable with just rest.
The design of the pelvis naturally made it so. Fractures typically led to bleeding that would cause a small to medium internal acc.u.mulation. Usually, treatment with hemostatics and antibiotics was sufficient.
However, if the pelvic fracture ruptured any blood vessels, it would be the internal and external iliac veins, along with the common iliac vein.
These blood vessels were located at the retroperitoneal space and the bleed would be enveloped by the peritoneum. In most cases, the ruptured vessel was either a small artery or vein and the bleeding would stop due to higher retroperitoneal pressure.
However…
This patient seemed to be a special case. The odds of a case like this was less than one in a hundred.
It was likely that there had been severe laceration to one of the bigger arteries in the retroperitoneal space and the pressure could not staunch the bleed. The patient's blood pressure was at a level that indicated hemorrhagic shock.
The higher retroperitoneal pressure was tricky as it did not allow for standard general surgery methods to stop the bleed.
If they cut open the retroperitoneum, the trapped blood would burst out due to pressure.
Zheng Ren looked to the side and saw Su Yun move a chair to the patient's bedside. He sat by the patient and scrawled something on a piece of paper as if making calculations.
Su Yun could be hungover but did not look drunk, just mildly dispirited.
The gloomy expression on a handsome face like his gave off a completely different vibe.
"Let's have a look at the patient first," Old Chief Physician Pan said steadily. He approached the patient and read his vital signs, then proceeded to view the CT scan.
"Pelvic fracture with ruptured arteries. Hematoma in the retroperitoneum." Su Yun heard Old Chief Physician Pan's voice and looked up. He did not rise from his seat or look at Chief Physician Pan, but only stared at Zheng Ren.
Zh
eng Ren knew what he meant.
The patient's condition was not suitable for open surgery, leaving only interventional surgery the only option for stopping the bleed. That was their priority now.
Su Yun's diagnosis and rescue plan were accurate. He was sharp.
"Little Zheng, are you confident?" Old Chief Physician Pan was not familiar with this manner of interventional surgery, but after the placenta abruption case, he had bought a book to study it further.
He was not capable of performing the surgery but wanted to make sure Zheng Ren was confident before rushing into it.
Sometimes, hot-headed youngsters need the steady hand of an older fellow to guide them.
A pelvic fracture with retroperitoneal hematoma and developing hemorrhagic shock was the perfect case for an interventional radiology-assisted surgery.
Nevertheless, Old Chief Physician Pan had never performed such surgeries before and wanted Zheng Ren's opinion.
"No problem," Zheng Ren replied confidently. "Get the paperwork. Prepare the blood and transfer the patient to the interventional radiology operating room."
Su Yun's black hair swayed as he bobbed excitedly. The tiredness in his eyes slowly disappeared.
The change in Su Yun made Zheng Ren cautious. 'What is this nancy boy up to?'
"I'll go in with you," Su Yun said, "These are calculations for contrast agent administration. Don't mess it up."
He handed the piece of paper to the nurse.
"Another calculation of contrast agent administration based on urine specific gravity?" the nurse said after glancing at the paper. She had a look of regret on her face. "Brother Yun, it's a shame you left for the emergency department."
"Haha." Su Yun gave a neutral response: a chuckle that accentuated his tousled hair.
Zheng Ren had no patience for Su Yun and his antics but the concept was correct. Using urine specific gravity for calculation, the contrast medium would provide a better chances for a hemorrhagic shock patient.
This was a high-level technique, something akin to a secret move from a Wuxia novel.
With the boom of the internet, this method of calculation was available online for reference. The problem was the complicated mathematics required, something beyond most medical students' grasps.
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