super anesthesiologist

Chapter 33 The helplessness of the rural hospital

As soon as Lin Xiaobei's words fell, Dean Li, his assistant, and Wang Xuguang seemed relieved. With the protection of a great god, they were immediately full of confidence.

"Prepare for surgery immediately." Dean Li immediately went to the locker room.

Lin Xiaobei took this time to check the patient's case carefully.

Patient, Liu Gensheng, male, 52 years old.

Features of a case:

1 Chief complaint: lower abdominal pain for one day.

2 History of present illness: blank
3 past history: blank
4 Physical examination: body temperature: 37.5 ℃, pulse: irregular, 82 beats/min, respiration, 16 beats/min, blood pressure: 135/76mmHg.Cardiac auscultation sinus rhythm...

5 Auxiliary inspection None
Two diagnoses: 1 Abdominal pain awaiting investigation; 2 Rectal tumor (sigmoid colon cancer?); 3 Coronary heart disease; 4……

[-]. Diagnosis basis: characteristics of the same case as above
Four Differential Diagnosis: Further examination is needed to differentiate.

Five diagnosis and treatment plans: 1 Consult the superior physician to complete relevant auxiliary examinations (three routines, liver and kidney function).

2 Adjust the treatment at any time according to the condition.

……

Relevant inspection data later:
Cardiac color Doppler ultrasound showed: left ventricular dysfunction, mild mitral valve regurgitation; mild restriction of left ventricular diastolic function, ... .

Chest radiograph (X film): bilateral pulmonary fibrosis.

ECG (electrocardiogram): sinus rhythm, HR 68 beats/min.

……

The medical records were completely incomplete. Lin Xiaobei frowned and asked Wang Xuguang, "Don't you prepare for such a special patient?"

This patient still lacks many vital tests.

He has a history of coronary heart disease, so he should also do cardiac CT and coronary angiography to determine which blood vessel in the heart has the disease.

The patient's ECG is normal, which is very deceptive. A 24-hour dynamic electrocardiogram should also be done to check whether he has symptomatic or asymptomatic myocardial ischemia and arrhythmia in various states within a day.

Moreover, the medical history is blank, and it is not known whether there are other important diseases combined.

Wang Xuguang explained helplessly: "Mr. Lin, let me tell you the truth, our hospital is not as formal as yours (hospital). Patients come to us to see a doctor, nothing more than trying to save money. You let him If all the inspection items are done, the cost will rise immediately. With the same money, who would not choose a better hospital? Who will stay here?"

"That can't be so hasty? At least stay in the hospital for a few days first, and adjust and adjust!"

Preoperative preparation is very important for such a major operation.The patient is in good physical condition, and the postoperative recovery will be much faster. The so-called "sharpening the knife does not miss the woodcutter".

"Mr. Lin, you also shop around when you buy things, right? It's not that we don't want to do that, it's that the patient doesn't give him time to deal with it. He comes for an operation, and you let him recuperate here for three to five days, and he will be transferred to another hospital immediately. "

Lin Xiaobei no longer blamed, what he said was the truth.At present, the current situation of medical development in our country is like this, and everyone wants to enjoy the best medical services.So even if you have a small cold or a small hernia operation, you have to go to a big hospital to find the most authoritative experts.

In fact, rural hospitals are capable of treating these minor illnesses.

"Then you should prepare first and give the patient an epidural anesthesia." The patient's blood coagulation function is close to normal, and compound anesthesia is the most suitable for him.Because it can save a lot of general anesthetics that affect the heart and lungs, it can also obtain good muscle relaxation and analgesic effects.

"The patient has already been anesthetized!" Wang Xuguang said in embarrassment. The patient did not respond and could not cooperate, which was a huge challenge for him.

"I'm afraid it will be difficult to wake up from general anesthesia." Lin Xiaobei encouraged him and said, "I'll do the positioning, and you can do the puncture."

This is a good opportunity, and Wang Xuguang immediately prepared for epidural outsourcing without hesitation.

Lin Xiaobei slowly laid the patient on his side and asked him to protect his head so that his neck would not twist.

After the body position was set, Wang Xuguang began to position, disinfect, spread the drape, and inject Pichu. This set of procedures is well learned.

Lin Xiaobei couldn't help laughing secretly, the patient was unconscious, and there was no need for local anesthetic at all.

But it didn't matter, so he didn't stop Wang Xuguang.

Wang Xuguang frowned during the puncture, holding the No. 5 syringe in his hand and hesitating.The other hand groped aimlessly on the patient's back, like a rock climber who can't find a point of strength.

"what happened?"

"Mr. Lin, this person's back is unclear, like a wall, there is no gap."

"Don't worry, take your time."

Wang Xuguang's right hand pierced several needle holes in the patient's back, as if piercing a stone.He himself was sweating profusely.

"You come to help the patient, I'll call you!" Lin Xiaobei changed places with him.

It is true that the patient's back is like the legendary "tortoise shell", and the bone calcification is obvious. It is estimated that he usually has the symptoms of low back pain.

But Lin Xiaobei's hand feeling is incomparable to Wang Xuguang's. No matter how the human spine is fused, there will be gaps. Otherwise, he can't do movements such as bending over, bowing and leaning back, and can only stand upright, like a piece of wood.

It took almost only 2 minutes, from puncture to catheterization to fixation.

"You can lie on your back, pay attention to protect the patient's neck."

Wang Xuguang's eyes were full of envy, he was so awesome, he put all the catheters in before he could see clearly.No wonder Zhang Xiang said that Lin Xiaobei's puncture technique is absolutely top-notch in the anesthesiology department of S University, nothing else.

After pushing the test dose of lidocaine, the measured blood pressure did not change much, indicating that the impact on the circulatory system is small, and the block level of local anesthetics will not be higher than T8.

Dean Li and the others have washed their hands and came over.

"Shall we start?" he asked.

Wang Xuguang looked at Lin Xiaobei and listened to his opinion.

"can."

Dean Li was relieved, and greeted the little nurse, "He Ping, prepare the equipment."

Lin Xiaobei pushed the anesthetic dose of local anesthetic, and then turned the inhaled anesthetic flow rate to "1", mixed with oxygen.

"President Li, what are you going to do?"

"Anally."

Simple three words, but contains the most important knowledge points.Transanorectal cancer radical resection is currently the most commonly used surgical method for the longest clinical treatment. It has the advantages of simple operation, small trauma, and quick recovery of patients after surgery.

Of course, this surgical approach is limited to early-stage patients, and it is of little significance if the tumor metastasizes.

What Lin Xiaobei was worried about was that Dean Li and the others would take abdominoperineal radical surgery, which would cause too much trauma and would be unbearable for the patient on the bed, and might induce an acute attack of coronary heart disease.

The Affiliated Hospital of S University no longer advocates surgery for radical resection of rectal cancer. It is all laparoscopic minimally invasive surgery.This operation method is to make several holes in the patient's stomach, fill the abdominal cavity with CO2 gas, and display the situation in the abdominal cavity on the TV screen through the light guide, and then the doctor looks at the video screen and operates outside the patient's body through instruments.

The trauma of this kind of operation is very small, and the only requirement for the patient is whether he can tolerate the intra-abdominal high pressure. The patient can walk on the ground in a few days after the operation, while the traditional operation takes at least ten days and a half months or even longer.

However, this surgical method mainly relies on high-end instruments and equipment, which cannot be afforded by rural hospitals, and a random set costs several million.

The annual income of Wang Xuguang's hospital is only about 200 million.

"Doctor Lin, the anesthesia effect is good." Dean Li praised when cutting the skin.

"Well, let's maintain it like this." The effect of spinal anesthesia was very good, and Lin Xiaobei hardly added muscle relaxants.

What he is now focusing on is not the poor effect of anesthesia, but whether the patient's coronary heart disease will be induced.

This patient had already endured the violent fluctuations in blood pressure caused by Wang Xuguang's strong airway stimulation, and the probability of coronary heart disease attacks increased exponentially when he was hit by a wave of surgical trauma.

Lin Xiaobei didn't know what Dean Li's technique was like. Although the transanal approach he mentioned was less traumatic, it was only relatively speaking, and it depended on the individual's micromanipulation ability.

"President Li, try not to stretch the intestinal wall when you separate the tumor," he reminded.

Although this operation method does not require anus incision, separating the tumor in the intestinal cavity is also a very traumatic operation, which is a key step in the operation.

Due to the adhesion of the pelvic fascia, attention should also be paid to protecting the blood vessel damage, otherwise there will be no viewing angle to operate if there is massive bleeding inside, so many doctors like to use tearing violence to forcibly peel off the tumor, which can easily stimulate the vagus nerve in the perineum and cause the patient’s heart rate to drop sharply To 40 times / min or less.

Such a heart rate is a fatal predisposing factor for patients with a history of coronary heart disease.

"Well, we know." Although Dean Li said so, Lin Xiaobei clearly saw the movement of his hand retracting forcefully.

"Director Chen Xiangdong of our hospital usually uses No. 4 wire to fix the patient's skin." Chen Xiangdong is the best doctor in S major anorectal surgery and a well-known expert in this field.What Lin Xiaobei said was undoubtedly secretly instructing Dean Li and the others.

The purpose of fixing the skin with sutures is to better expose the surgical field of view in the intestinal cavity and increase the surgical space relatively.In this way, it will be much more convenient for the doctor to operate inside.

Dean Li understood what Lin Xiaobei meant, and said to the stage: "He Ping, come to Line 4."

He no longer has a noticeable pulling motion.

"President Li, you just need to ligate the inferior rectal artery first." The superior rectal artery is deep, and if it is forcibly separated, it is easy to damage other small blood vessels and cause bleeding.This is also one of Director Chen Xiangdong's experience, which is generally not passed on to the outside world.

"Dean Li, do you need to shake the patient's position?"

"Principal Li, use a piece of gauze to press it first."

"Dean Li,..."

"Dean Li,..."

At the critical point, Lin Xiaobei borrowed the name of director Chen Xiangdong to secretly give pointers, and the operation went relatively smoothly.

About an hour passed.

The calm voice of the monitor suddenly became sharp. Lin Xiaobei quickly checked and found that the patient's heart rate was 120 beats/min, and the electrocardiogram showed a significant downward shift of the ST segment, accompanied by bigeminy.

Myocardial ischemia!

　It is very tiring to work the night shift 24 hours a day, but for the sake of everyone, I will keep chasing one chapter and strive to ensure that there are two updates every day.

　　Not much to say, I implore everyone to spread the recommendation tickets in your hands, thank you! ! !
　　


(End of this chapter)