Modern hospitals are places where diseases are treated and patients are saved. The first impression they give people should be that they are neat and clean, but these inherent impressions are completely divorced from reality.
In fact, it is impossible to be clean wherever there are people.
Modern cities are clean only because of their complete garbage disposal and sewer systems. European cities in the 19th century were not modern, so they were not as beautiful as people thought. They were synonymous with chaos and filth.
As hospitals are highly populated places, this situation will only become more serious.
It is still the transition between winter and spring, and the fat mice have already swaggered out of their burrows and foraged for food under the beds and corners of various houses. If the time goes back a month, when the weather gets warmer, those little ones hiding in the gaps will crawl out in groups to bask in the sun. (1)
The hospital is such a place.
Although the wards in the old days were noisy, dirty, and crowded, this familiar scene immediately reminded Kawei of his own job as a doctor.
In the past, he would have been considered too modest to call himself this. Even if he left out those titles, he would still have to add the prefix of "director" to himself to be justified. But now Kawei is just an assistant, not even as good as the assistant physician back then.
After all, the latter still has a certain degree of professionalism and requires several years of professional study and professional examinations.
The contrast in identity was so sharp that Kawei couldn't adapt to it for a while. When introducing himself, the word "doctor" just blurted out.
The 19th century was an era when all doctors wore formal attire when entering and exiting wards and operating rooms. The coat he wore looked so dirty that it was impossible for a normal person to equate him with a doctor.
"Sorry, I was a little excited just now."
Kavi re-introduced himself: "My name is Kavi, Kavi Hines. I am the assistant recommended here by Teacher Ignatz. I work in the surgical ward."
The young nurse was wearing a pale golden dress with a white apron on top. She was probably in her 20s. Seeing Kawei's behavior, she didn't pay much attention. She just nodded and pointed to a hospital bed in the distance and said, "Since you are an assistant, hurry up and follow him. They are doing rounds."
Ward rounds...
The original meaning of the little nurse's words when translated was indeed ward rounds, but Kawei looked closely and didn't see a trace of what a ward round should look like.
The three young men were all dressed in black formal suits, tall and tall, and their manners were gentlemanly and elegant. If they were walking on the street, Kawei believed that their posture would not be bad and would definitely attract the attention of all the girls.
But this is not a runway show, but a ward round!
They did not perform a physical examination, did not communicate verbally with the patient, did not carry a stethoscope, and did not carry the patient's medical records. At most, I just asked a few words to the family members beside me, and then hurriedly walked to the next bed.
"It's more casual than going through the motions at night..."
Kawei muttered something in a low voice, and suddenly reached out towards the little nurse just now: "Where are the medical records?"
"Medical records?"
"It's my first time here. Of course I have to read the medical records before the ward rounds."
"Um...the medical records are on the doctor's examination table."
In fact, it's not that the young nurse remembered the rules wrongly, after all, it was what the head nurse emphasized repeatedly. In fact, Kawei's actions and tone could not be rejected, which made her feel like she was being questioned by a superior doctor, so she reacted naturally.
"Bring it to me and see."
"Okay, wait a moment."
After she handed everything into Kavi's hands and relaxed, she realized that the patient's medical history information should not be handed over to an assistant casually.
However, it was already too late. Just when the little nurse knew that she had made a mistake and wanted to actively seek ways to correct it, Kawei had already remembered all the conditions of the 13 patients in this ward: "Thank you, I see. It’s over.”
"so fast?"
“The admission record is written on it, and there is nothing difficult to remember.” (2)
The little nurse only regarded it as a joke because of her pride. There were 13 beds of patients with different types of diseases and different priorities. It was so easy to remember. What's more, the medical records were all written by Ignatz, filled with all kinds of professional terms, and used complex and difficult Latin.
Even those young doctors have to look at it for a while to understand what it means. How can an assistant understand it?
The little nurse wanted to scold him because she had come to the hospital a week earlier, but she didn't expect that Kawei didn't give her the chance and ran to a bed not far away in the blink of an eye.
Lying on the bed was a 10-year-old boy, with his mother standing beside him, looking anxious.
It was probably the first time for the mother and son to meet these doctors who were born into celebrities. It could be seen from the way they acted during the "ward rounds" just now that their words were a bit reserved. Now that people have gone to the lower hospital beds, my mother has been hesitating whether to discuss it with those people again.
Kawei has worked in the hospital for more than thirty years, and it was obvious at a glance that the ward rounds just now failed to solve their problems. In addition, Ignatz’s first operation today was on bed 11, so he walked over immediately and asked, “Can I help you?”
The mother finally found someone who could speak and explained: "My son's leg was seriously injured. They said it would be amputated..."
"Yeah, I know, so how can I help you?"
The mother looked back at her son who was enduring severe pain on the bed, and felt very uncomfortable: "But my son doesn't want to have his leg amputated, and neither do I. He is only 10 years old. If it is amputated, he will definitely lose his job, and the family will not have much money anymore." ..."
Kawei had just seen the medical record, which clearly stated the diagnosis of "tibia compound fracture", in Ignatz's own handwriting. (3)
He didn't understand what a "compound" fracture meant, but he knew very well that when dealing with such trauma patients, without the help of an X-ray machine, a rigorous physical examination must be used to determine the fracture injury.
The mother lifted the quilt off her son, revealing the severely injured left leg.
The shape of the left leg is indeed not right. There is a deep depression in the middle bone area, and the surrounding skin is swollen to varying degrees. The most critical thing is that there is a skin defect in the deep concave area, and there is an obvious avulsion and separation between the subcutaneous tissue and muscle fascia.
This is a crushing injury caused by the strong traction force generated by the rotation of the wheel. Modern doctors also call it "avulsion injury" or "degloving injury".
Kawei looked at a ring-shaped avulsion wound on his leg and made a simple measurement: "Is it crushed by a carriage?" (4)
"Yes." My mother couldn't help but shed tears again. "Last night when I was returning home from work, I was accidentally knocked over by a carriage and my leg was crushed."
Kawei nodded, avoiding the wound and doing a simple check on his leg. The main focus was not on the fracture itself, but on the soft tissue, blood vessels and nerves around the bone.
The soft tissue test examines the tension of the soft tissue of the calf, as well as the temperature and color of the calf skin. If the soft tissue is swollen, the skin temperature is elevated, the skin is red and dark, and there is severe pain, it is likely to be compartment syndrome. (5)
With the current medical level, there is nothing to hesitate about. The limb must be amputated, otherwise death is certain.
The tibial blood supply test is the pulse of the dorsalis pedis artery, and the nerve test is to check whether there is restriction and pain in the toe movement, whether there is foot drop, etc. If the blood vessels and nerves are damaged, the function of the distal limb will inevitably be impaired, so leaving the leg alone and letting it get infected is not the solution. It might as well be amputated.
The child was lucky and there were no problems with the soft tissue, blood vessels and nerves.
Kawei then began to focus on the fracture. He needed to carefully examine the shape, length and circumference of his left leg to determine the fracture displacement.
Because there are no steel plates and nails for internal fixation, the scope of application of simple manual reduction and fixation is very limited. If the displacement is severe, it will be difficult for the bone to heal even if it is reset, and the final result is likely to be a burden for the rest of your life.
Now the shape of the left leg has changed. The displacement is there, but the amplitude is not large from the appearance, and the length has not changed. It just happens to be the surgical indication for amputation.
At this time, the doctor needs to make a judgment whether to save or cut off.
If it is safe, reduction and fixation are required. These are no problem. Fracture treatment has been practiced since ancient times. Manual reduction is not difficult, and the technique of splinting is already quite proficient. But the key problem lies in the avulsion wound. In such a hospital environment, with such a large area of open wound, infection and ulceration are inevitable.
Amputation does not have this problem.
As long as the severed stump is well buried, the chance of infection at the suture line will definitely be much smaller. Even if an infection occurs, it develops at a much slower rate.
Although in Kawei's eyes, they are all similar and fighting for their lives, but in Ignatz's hands, the mortality rate of conservative treatment is definitely higher, and there is no problem in choosing amputation: "Personally, I think Teacher Ignatz's choice That’s right, amputation is the safest option and can minimize the mortality rate.”
This is not Kawei's cold-blooded approach, it is the optimal solution within the constraints of the times, and Ignatz has reduced the mortality rate during and after amputation to about 20%, so you can definitely give it a try.
However, medical treatment is never unilateral treatment by doctors. It also needs to listen to the demands of patients and their families.
"I don't want an amputation."
This time it was the child who was lying on the bed who spoke: "I'm afraid of pain, and I'm also afraid of losing my job. I still have two younger sisters to take care of at home. I can help my mother earn an extra 400 helles a month. Without this salary, They will starve to death.”
"Then you need to be prepared for wound necrosis." Kawei said, "If necrosis occurs..."
"I understand this. Aulat who lives next door died because of a rotten wound." The boy glanced at his mother, and then said calmly, "If I die, I will have one less mouth. It is better than lying on the bed with my limbs amputated. Be strong.”
Kawei nodded: "Okay, I will talk to Teacher Ignatz and then make an evaluation of this leg..."
...
While he was discussing the treatment plan with the patient, the ward rounds of the three young men had also ended.
The boy's leg was seriously injured and he was admitted to the hospital as soon as he arrived last night. Preventing wound infection from worsening was more important than other surgeries, so Ignatz put his amputation at the top of the list today, and set the time at ten in the morning.
After the failed cesarean section the day before yesterday, the three of them were much more cautious. Not only did they get up early to check the ward, but they also focused all their attention on him after the ward check.
"He should be the first surgery today, and Mr. Ignaz will be the surgeon."
"His medical history...here, bed 11, a little boy named Eston, 10 years old."
"Compound tibial fracture...a tibial knee amputation was done."
"Teacher Ignatz's amputation technique is well-known at home and abroad. The operation is stable and fast. I must learn more today."
"I remember making an incision under the patella, cutting off the tibial plateau and the ligaments and muscles around the knee joint, and then using the remaining skin flap for final embedding."
"Indeed it is."
After reading the medical records, the three of them suddenly found a stranger beside the bed of bed 11. He was wearing a black coat and chatting with his family members: "Who is that person?"
"I haven't seen him before. He must have been away just now."
"Probably family members."
"I think it's almost time. Push people to the theater as soon as possible. We still have a lot of preparation work to do. Teacher Ignatz hates people being late. Don't be scolded by him again."
The three of them were from well-off families and had never worked as a cart pusher. Besides, the person sitting in the cart was still a poor man. But working under Ignatz, it was unrealistic not to do it. For the sake of fairness, they chose to solve this problem by guessing coins.
Just as one of them took out a krona coin from his pocket, the nurse working nearby suddenly said: "How about asking an assistant to push him over?"
"assistant?"
"Don't physicians only have assistants? We also have assistants in our ward?"
"Yes, isn't that the one standing there talking to bed 11?"
