top student at medical school

Chapter 185 is extremely insulting (5th installment, please subscribe)

Wang Liang'an is actually feeling a bit irritable right now.

Even more so than Wu Guonan and Xue Tao.

Wang Liang'an is an associate chief physician working under Li Junfeng, the director of the joint surgery department. However, although Director Li Junfeng is the director of the joint surgery department, he has always preferred to remain in his position and does not like to compete for any position.

But Wang Liang'an felt that if Director Li was capable, the position of head of orthopedics was not a private domain of trauma surgery. He should have fought for it. Why give it to Wu Guonan? He didn't even have that thought.

Li Junfeng exposed the brachial artery much faster than Wu Guonan. After tying up the brachial artery, Wang Liang'an, as the assistant, continued to speed up his work while thinking, "With your level of skill, Wu Guonan, do you still have the ambition to compete for the position of chief of orthopedics?"
Do you think you're Director Zhang Mingcan, and that the position of Director of Orthopedics was specially created for your trauma surgery department?
Even a simple amputation is being done with such a long and drawn-out process—

He's incredibly efficient at performing upper limb amputations!

He's already cleanly and efficiently severed two and a half muscles! He almost severed three. That's a whole more than Wu Guonan.

But now he was in an awkward situation. He quickly covered the incision with a saline pad, then looked up, subtly glancing around, and tiptoed to look in the direction of Fang Ziye's leg...

Amputation, simply put, is the process of severing a limb.

But it has its own absolute definition.

Amputation is a treatment measure that removes necrotic, damaged, severely diseased, painful, or life-threatening limbs, or limbs that are completely disused and impair function.

The purpose is treatment.

Amputation inevitably causes disability, so it should not be performed lightly.

As an orthopedic surgeon, the indications for amputation, a terminal surgery, must be ingrained in one's very being; it is the first lesson in formally entering the field of orthopedics.

Use sparingly and with caution.

Amputation is a treatment, and it has strict indications:
For example, if the main blood vessels of a limb are damaged and the opportunity for repair is missed, the limb may become ischemic and necrotic. If the necrotic toxins are not removed, they will be absorbed and endanger life. Other examples include vasculitis.

When amputating, an appropriate length should be chosen whenever possible:

For example, foot amputations should be performed at the metatarsal joint, not shorter than the talonavicular joint. Otherwise, due to insufficient dorsiflexor muscle attachment, it will be difficult to counteract the contraction force of the plantar flexor muscles, leading to foot drop and hindering weight-bearing...

The lower third of the lower leg has poor blood supply, and the amputation site cannot bear weight, so it is generally not chosen as an amputation site...

It is clear that this patient has thrombosis, which is an indication for amputation!
It is a persistent, long-distance arterial thrombosis.

The indications for amputation are very clear.

The formation and harm of blood clots are similar to a stone getting stuck in a water pipe, causing the distal end of the pipe to lose blood supply.

This is equivalent to cutting off the blood supply to distant cells and tissues.

Although there is only a one-word difference between limb salvage and amputation, both are extremely complex surgeries involving multiple disciplines.

Strictly speaking, it is not a surgery similar to internal fixation of a fracture.

Limb preservation also has its indications. Leaving aside other considerations, the most important thing to ensure is blood supply...

It's like our plumber going to check the water pipes, finding out where the blockage is, and then taking it out.

However, in the human body, because patients don't have time for preoperative examinations, you have no idea where the blockage is.

If you can't even find the location of the blood clot, then finding the location of the blood clot is undoubtedly just a matter of luck.

Therefore, even directors of general surgery like Peng Yuanming, who are also vascular surgeons, cannot guarantee that they can perform limb-sparing surgery to remove the blood clot. They might as well have the limb amputated first to save the patient's life...

Fang Ziye also does not know how to perform limb-saving surgery.

Fang Ziye's initial idea was simply to move the amputation area downwards. He originally planned to amputate in the middle of the thigh, but if it could be moved to the lower part of the thigh at the knee joint, that would be a good thing.

Fang Ziye thought that since he couldn't learn a major skill like limb preservation, he should learn some minor skills first.

Extend the blood supply plane downwards as much as possible.

Preserving more of a limb can help retain more of the patient's functions.

Without preoperative examinations, he could only conduct basic medical examinations, and then improve his tactile sense based on the examination results and his anatomical knowledge.

By performing a blood vessel incision procedure, some of the blood clots can be removed.

……

After performing four arterial thrombectomies, Fang Ziye first moved to the lower part of the thigh. Then, he got a little greedy, thinking that if the patient could keep the amputation plane in the lower leg, the patient would be much more comfortable when getting a prosthesis after surgery.

So Fang Ziye removed the thrombus from the anterior tibial artery in his lower leg.

At this moment, Fang Ziye made an unexpected discovery!
The dorsalis pedis artery is open!

Fang Ziye's original intention was to have his leg amputated; he just wanted to keep it longer.

Men, you know, all like thick and long ones, but Fang Ziye's length is a bit too long...

Seeing this, even Wu Guonan, who was standing on the opposite side, had a momentary urge to strangle Fang Ziye.

Because Fang Ziye has now brought the surgery to a stage where its future is uncertain.

At least for Fang Ziye's side, amputation is not an option for the time being; he may have to switch from amputation to a more complex limb-sparing procedure.

"Let me check the situation first." Wu Guonan gently tossed the things in his hand into the curved plate.

Xue Tao quickly reached out to feel for the dorsalis pedis artery.

The most direct and gold standard test to determine whether blood vessels are unobstructed is angiography!

But the simplest and most direct method is palpation.

Patients cannot undergo the gold standard examination before surgery, so now we can only use the simplest palpation to verify.

The arteries in the human body are continuous, and therefore strictly follow a certain pattern!
That means that an arterial pulsation can be felt in the distal end, which absolutely proves that the blood vessels in the proximal part of the distal artery are at least locally patent.

Otherwise, the blood pumped by the heart won't reach the distant parts.

Even through the glove, Xue Tao could still feel the faint pulse of the artery on her fingertips.

The amplitude and force of the pulsation are not large, nor are they particularly strong.

The patient was on the verge of shock; how much could we expect from the dorsalis pedis artery pulse?
But that's enough.

Xue Tao immediately thought of another useful test on the operating table to prove that blood circulation was unobstructed.

It's also the test that men like the most.

It caused bleeding.

"Circulating nurse, please prepare a syringe needle and bring it up to the station." Xue Tao immediately asked the circulating nurse for the equipment.

"It's right there on the stage!" Two circulating surgeons were on standby at all times, not concerned with the progress of the surgery, but simply providing immediate responses, demonstrating great professionalism.

Here, a syringe needle.

As soon as Xue Tao called out, everyone in the orthopedics department stopped what they were doing. Wang Liang'an, still quite professionally, covered the severed muscle layer with a damp gauze to prevent the surface from drying out too much.

This is the kind of major that's a bit of a pain.

But she still looked towards Fang Ziye, her expression revealing a sense of helplessness.

If you had said earlier that you could save your limb, Director Li Junfeng and I would have just cut the artery and left the stage. Why bother with an amputation?

However, Wang Liang'an also knew that Fang Ziye's appearance was an accident. From Xue Tao's eyes and Fang Ziye's expression, it was clear that this was an accident.

Even Fang Ziye wasn't sure if he was capable of performing such surgery.

Wang Liang'an felt his gluteal muscles were numb, so he twisted his hips from side to side to relieve his embarrassment and confusion.

It's like having to forcefully push the poop back in halfway through taking a dump—it's incredibly uncomfortable...

Fortunately, Fang Ziye responded quickly.

Wang Liang'an's immediate thought was one of relief.

If Fang Ziye's surgery progresses very slowly, much slower than theirs.

Then, he and Li Junfeng had both upper limbs amputated, and Wu Guonan had his lower limbs amputated as well. In the end, Fang Ziye's leg was still intact! And the limb was successfully preserved.

Bingo!

Perfect four-protect-one strategy!

Didn't he live in Bengbu?

What should we do then?
Wang Liang'an didn't know what to do then, but fortunately, such a thing hadn't happened yet; before that, a good 'accident' had occurred.

Li Junfeng, Wang Liang'an, and Wu Guonan kept glancing at Xue Tao and Fang Ziye. Wu Guonan, somewhat skeptical that Fang Ziye had actually cleared the blood vessels, reached out and touched them himself.

Chi Chi.

Chi Chi.

The pulsation of blood vessels in the extremities is certainly not as intense as the pulsation of the heart and aorta; one can only feel a slight pulsation.

But the pulsation is real.

Xue Tao then removed the needle and cap from the syringe and inserted an injection into Fang Ziye's left big toe and three other toes, one in each foot, and then observed the situation.

Using a syringe to puncture the distal end of the body to draw blood is one of the most compelling pieces of evidence that blood circulation exists...

Moreover, it's the simplest, most economical, and effective method; however, it's not very suitable for clinical outpatient settings. It's easy to get attacked.

Therefore, it is only suitable for use on the operating table.

The orthopedic team was all staring at the toes.

It's as if those toes are incredibly alluring.

The blood didn't seep out as quickly as a normal person's. It took a full ten seconds before a tiny drop came out, like a shy bride half-covering her face, hesitant to emerge.

But even so!
Everyone breathed a heavy sigh of relief.

It's good that it's out, it's good that there's bleeding.

Nowadays, patients' blood pressure is already very low, so the body will prioritize supplying vital organs such as the brain and heart as a self-protective mechanism. It is already generous of the body's mechanism to only give a tiny bit of blood pressure to the distal extremities of the toes!

As long as it's still working!

If even a tiny bit of nutrition can be delivered to the distal limbs, preventing them from starving, then there are ways to replenish it after surgery.

There's no need to examine the veins. They're definitely thrombotic, but the vein network in the lower limbs is intricate, so they shouldn't be completely blocked.

Moreover, large venous return systems have two sets, so thrombi in the veins can be completely dissolved by postoperative heparinization of the blood vessels!
Managing arterial thrombosis is of paramount importance in limb-sparing surgery!
Wu Guonan took a deep breath, concealing and suppressing his embarrassment, and said to Fang Ziye, "Ziye, let's switch positions. You can go back to working on your right foot."

"For the left foot, Xue Tao and I will do the subsequent cleaning and suturing."

"You and Wang Zhongxing take a look at the blood clot in his right foot and see if it can be removed."

"Okay!" Fang Ziye didn't try to be accommodating; he nodded and even offered to change seats.

The reason he asked Xue Tao that question before was because he was afraid he lacked experience and might have made a mistake. Wouldn't directly making a suggestion then cause trouble for his superiors?
Moreover, Fang Ziye was unaware of Wu Guonan's conversation with the patient's family. He had only signed a standard amputation consent form and had not discussed limb preservation.

Now that the procedure needs to be temporarily changed to limb preservation, the surgical method is different. What kind of trouble will this cause? Wu Guonan has to make the decision and take responsibility.

The responsibility lies with Wu Guonan, so Fang Ziye has no right to swagger around; he can only offer suggestions.

However, thinking about it, it's probably because if a patient can get off the operating table without amputation, their family would be willing to accept such an unexpected outcome.

Moreover, it also perfectly aligns with the principle of non-harm in medical practice.

I knew about the amputation.

However, being able to preserve the limb without amputation is more in line with the principle of non-harm.

But just then, from somewhere in the operating room, someone poured cold water on the idea: "The dorsalis pedis artery is a continuation of the anterior tibial artery. The anterior tibial artery is just one of the continuations of the popliteal artery."

"If the posterior tibial artery is not examined carefully, it will eventually lead to a second hospitalization."

"And it could mean all our previous efforts were in vain."

The sound was coming from the direction of the anesthesia monitor.

It was Nie Mingxian from the Department of Anesthesiology. After he finished speaking, he was exchanging information with Huang Qiaoshan, the director of the Department of Anesthesiology.

Huang Qiaoshan said in a low voice, "Xiao Nie, don't make a fuss. Director Wu and the others will evaluate the surgical results themselves."

But at this moment, Nie Mingxian had already decided to stand up: "It's okay, Director Huang. I'm an anesthesiologist now. I can't go on stage, but it's not against the rules to say a few words on the side. This Dr. Fang has very good basic skills. It would be a pity if we didn't give him proper guidance and make good use of his abilities."

"The peroneal artery of the posterior tibial artery, and the middle and lower third of the posterior tibial artery, are the most prone to embolism." Nie Mingxian finally couldn't sit still any longer and walked over to the operating table.

After Nie Mingxian spoke, for a moment, the expressions of Peng Yuanming, Wu Guonan, and the others turned somewhat unpleasant.

The reason Nie Mingxian didn't speak earlier was that he was too lazy to talk back because his team's skills were lacking.

It would be a waste not to guide Fang Ziye's current skill level. If we were to give them pointers based on mere words, it would be a waste of our breath.

Nie Mingxian's words were not harmful at all, just a little insulting.

However, Nie Mingxian didn't seem to care about the expressions of the directors.

Xue Tao stood opposite Fang Ziye, looking intently at him, and suddenly felt that Fang Ziye had become a stranger once again.

It seems that it's not the Xiao Fang I've known for the past two weeks.

Seeing the strange expressions on the faces of the directors, Wang Liang'an immediately turned to the circulating nurse and said, "Bring me a few No. 3 cables."

While Li Junfeng and the others were still battling Nie Mingxian, he quietly performed his little trick—self-injured biceps and brachialis muscle suture.

Li Junfeng did not speak.

Wu Guonan quickly had Fang Ziye return to the leg, because Wu Guonan was not skilled in thrombotomy, and even if Nie Mingxian had told him, he couldn't follow Nie Mingxian's instructions to continue.

Wu Guonan himself was aware of this. Even though he thought that he would sometimes perform hand surgery, hand surgery vascular suturing and vascular surgery thrombectomy and removal are two completely different things, okay?

……

"You know limb-saving surgery?" After Fang Ziye regained his footing, Xue Tao, having processed some of his emotions, asked him.

This question made Wu Guonan immediately perk up his ears.

This question made Peng Yuanming, who was standing not far away, feel slightly embarrassed.

Thrombosis, no matter where you talk about it, is a problem for vascular surgery. Now, this department, which is labeled as vascular surgery, can't handle it, but the orthopedics department has done it, even though no one is making fun of him.

But he felt awkward about his existence!

Even when Peng Yuanming saw his subordinate, Associate Chief Physician Chen Liwei, casting strange glances at him, Peng Yuanming felt an indescribable sense of shame.

He glared back.

What's wrong?

If you can't perform this kind of thrombus removal surgery, are you not even worthy of living?
I am a surgeon specializing in hepatobiliary and pancreatic surgery.

Are you trying to embarrass me too?

Chen Liwei immediately lowered his head and quickly cooperated to begin the liver repair surgery.

Enshi Central Hospital does not have a dedicated vascular surgery department. If it had such expertise, it would have been separated long ago…

Fang Ziye first shook his head subconsciously, and then shook his head again.

Limb-sparing surgery has a relatively high threshold, no less than osteotomy or orthopedic surgery. It is a surgical procedure that is not yet routine and is currently only a theoretical surgical procedure.

He hasn't had any experience with it, so he can't just make things up.

"No." Fang Ziye's understanding of limb-saving surgery was that it required systematic learning and research.

"All I was thinking about was minimizing amputations and preserving as many limbs as possible."

Fang Ziye spoke with utmost sincerity and told the truth.

Wu Guonan could only smile wryly. So Fang Ziye had just stumbled upon a lucky break; in reality, he was still somewhat behind Wu Xuanqi.

He said, "Let's take another look and see if we can remove the blood clot at the back."

Fang Ziye's words and actions were absolutely correct.

Is vascular ligation a limb-sparing procedure? No.

Is arterial thrombectomy a limb-sparing procedure? Not entirely.

They were just performing minor surgeries at Fangziye!
However, these two surgeries are actually important components of limb-sparing surgery. Fang Ziye used these to turn amputation into limb preservation.

This is what limb-saving surgery is, okay?

Limb salvage surgery is not just a rigorous surgical procedure; it is a science. Any procedure that can achieve the goal of saving a limb can be called limb salvage surgery.

However, this cannot be said now; it must be said after stepping down.

……

Fang Ziye no longer held back. He listened as Nie Mingxian approached and gave relatively detailed instructions on which blood vessels to check. Then, Fang Ziye quickly used basic physical examination techniques to examine the pulsation of the blood vessels in the corresponding locations.

Moreover, with the help of Director Wu Guonan and Associate Chief Physician Xue Tao, Fang Ziye can roughly feel where the arterial pulse is not good once they loosen the proximal ligation of the femoral artery.

"The posterior tibial artery pulsation is difficult to feel on the body surface, requiring an absolute talent for physical sensation or a rich sense of physical examination. Only a very small number of people can feel it on the body surface."

“I’ve never seen anyone like this before. Let’s proceed with the examination.” Nie Mingxian, who was standing nearby, stopped Fang Ziye from conducting the examination by checking the anterior tibial artery.

His tone carried a hint of mockery, or perhaps a sense of unease that Fang Ziye was somewhat arrogant and presumptuous.

In short, they weren't as kind and approachable as their teachers and senior classmates, nor did they speak as pleasantly.

But Fang Ziye knew that without a master-disciple relationship or fellow disciples, teaching you was a favor, and not teaching you was his duty. In reality, no one could be like Long Aotian, whose body would tremble and everyone would flock to him.

"Okay!" Fang Ziye didn't suspect anything and didn't even turn around. He made an incision from the side and quickly performed the exposure technique.

The posterior tibial artery is the most crucial anatomical structure in the lower leg in orthopedics, so I have long been familiar with it.

After exposing the skin.

Fang Ziye immediately repeated the same mud loach catching technique he had used before.

The round knife breaks the skin, the blunt forceps pierces the intermuscular space, reaching the course of the blood vessel. Once the thrombus is seen, the knife is immediately used to cut it open!

After removing the blood clot, suture it back up, and then continue to loosen the proximal ligation of the blood vessel.

So back and forth.

The process is naturally quite complex, and the steps are extremely tedious.

Nie Mingxian's experience was correct. Fang Ziye made four incisions in a row before he was able to clear the four long blood clots in the posterior tibial artery and peroneal artery.

Xue Tao continued to examine blood circulation using palpation and a syringe needle.

suitable!
In this way, Fang Ziye and the others finally completed the limb-saving surgery on their left lower limbs!
Fang Ziye then looked at Nie Mingxian.

"Unobstructed blood flow is the primary guarantee. The rest depends on fate. Even if there is no function in the future, it is better than amputation. As long as there is blood flow, other functions can be ignored for the time being."

"Go to the other side. Some minor issues can be addressed by postoperative heparinization," Nie Mingxian instructed.

Then I said to Dr. Huang Qiaoshan, the director of the anesthesiology department, "Dr. Huang, please draw another electrolyte. After the blood circulation in the lower limbs is unobstructed, it is possible to bring back a lot of residual substances in the body. We need to pay attention to electrolyte imbalance."

"This is a variant of reperfusion injury."

Nie Mingxian has a profound understanding of theory.

Huang Qiaoshan did as instructed, and ordered another associate chief physician to personally draw blood for testing. After adjusting the ventilation rate and anesthesia concentration, he reported to everyone: "The vital signs are now close to stabilizing, and the blood pressure has returned to normal a little."

Wu Guonan and Xue Tao then began to sew the stitches together.

Seeing this, Li Junfeng felt particularly distressed.

He had just finished stitching up the muscle. Across from him, Wang Liang'an, who also wanted to show Wu Guonan his arrogant back, was stunned after stitching up the muscle, unsure of how to conduct himself.

After all, he actually came to help Wu Guonan, but instead of helping, he almost got into trouble.

Just now?

It seems that both Wang Liang'an and I are in a rather unpopular situation.

However, the two had already completed the exploration and hemostasis of the brachial artery...

Li Junfeng cleared his throat and said with a smile, "Director Wu, I've finished treating this. The bleeding has stopped effectively. I don't know how to do anything else, so I'll be going now."

Li Junfeng started playing with a yo-yo.

(End of this chapter)