Friedrich-Wilhelm von Lieben, a German knight with a slightly weird name.
Based on Ignatz's experience in high-level affairs, aside from his rogue-like behavior, the name itself is problematic. He knew many German and Austrian nobles, but had never heard of such a noble surname, and none of them would embarrass a married civilian woman for their own selfish desires.
Because this will damage your status.
But doubts are doubts, and Ignatz has no motivation to take action to investigate further. Today, he came to the Riverside Surgical Theater not for him, but to see Kawei's amputation.
Amputation is the basis of surgical medicine and also a key point that must be mastered.
A qualified surgeon may not be able to perform any abdominal surgeries, and may not be familiar with or even understand facial plastic surgery. He may not speak Latin or French. It does not matter if he does not understand most of the detailed anatomy of the body. But amputation is absolutely not an option.
Even for those barbers who still work in rural barber shops, amputation is something they must learn.
Because too many people need amputations.
Austria was already mired in the quagmire of war, and it was not easy for soldiers to keep their bodies intact. Daily open fractures, wound infections, and even severe paronychia and erysipelas also need to be treated by amputation, otherwise the gradually worsening infection will slowly devour the patient's life until death. 【1】
In addition, diabetic foot caused by diabetes, terminal necrosis caused by long-term compression, congenital deformity of the limbs, and dislocation injuries caused by various machines also require amputation.
Before the advent of antibiotics, amputation was considered a major category of surgery, with every joint a cutting point and a point of knowledge for surgeons.
Amputation is not as easy as it sounds. It is also an amputation. There is no way that a barber's amputation can be compared with that of an orthodox surgeon. And those young doctors who have finally picked up a scalpel after a few years of graduation are several grades behind Kawei.
Considering Li Ben's special status, Cavett deliberately set the operation in the morning.
At 8 o'clock in the morning, Li Ben was reluctantly sent to the preparation room of the surgical theater.
Everyone could see his nervousness, helplessness, and dissatisfaction with his rough fate, but when things got to this point, he couldn't think of any better way besides accepting it. At least in the past few days in the postoperative ward, apart from listening to other people's ridicule and abuse, I was more convinced of Kawei's surgery.
It has a 0% mortality rate and a 20% postoperative incision ulcer rate, which is unique in the world. Another blessing among misfortunes. The last time he had the same thought was when his neck had just been sutured.
He smelled the faint scent of blood on the tip of his nose and wanted to struggle one last time: "Doctor Kawei, is it really true that I can't save my leg?"
"You've asked me a dozen times."
"I think it's better to try another debridement, just in case it can grow well."
Kawei also wanted to debridement and limb preservation. It can be said that any doctor who has received medical education does not want to perform amputation on the patient, especially this kind of amputation to prevent the worsening of infection. Standing on the amputation operating table and watching the limb being cut off from the patient's body, no doctor would think that the operation was beautiful.
Because this is just wiping the butt of previous failed treatments, and there is no sense of achievement at all. 【2】
But if you put aside the subjective psychology and look at it from the perspective of surgical operation, the technical content of amputation is not low. The main difficulty is not cutting the flesh and sawing the bones during the operation, but the damage judgment before the operation, the selection of the cutting path during the operation, and the suturing after the operation.
Typical types of surgery where the decision trumps the action.
"Don't think about this." Kawei drew several solid lines on his leg with a pen [3], "Even if you do debridement, it will only get worse. Now I can still save your butt. Don't talk about your butt then, I'm afraid you may not even be able to save your life. After all, the higher the amputation, the more dangerous it is, and the greater the chance of the incision becoming ulcerated. You don't want the wound to rot anymore."
Li Ben's heart was filled with despair.
He didn't sleep all night last night and couldn't understand why his legs were missing when he just came to Vienna to hunt for gold. Now that I have no money, I have to live with crutches for the rest of my life.
At this time, the host of the surgical theater knocked on the door and came in: "Dr. Kawei, are you ready? You can enter now."
"Get ready, let's get started." Kawei said with a smile, "It's quiet in the morning, even the entrance introduction is omitted."
"I see there are still people in the auditorium, as per the regulations."
"I know, they should all be acquaintances, there is no need to waste time making introductions." Kawei patted the host on the shoulder, "When you have time, you might as well help Berget and the others move the things, these cleaning and disinfecting equipment and medicines It’s pretty heavy.”
"okay, I get it."
In addition to Ignatz, there were several colleagues in the audience who needed to perform surgery today. After reading the surgery program, they all wanted to see Kawei's ability as the surgeon.
Among them is Hills, who is about to preside over the laparotomy.
He found Ignatz and hesitated for a long time before leaving his two assistants and sitting next to him. Hills knew that Ignatz was in a bad mood. His departure had weakened the surgical strength of the Municipal General Hospital to a certain extent, and he needed to apologize.
"Teacher, I'm really sorry for leaving the hospital suddenly. I learned a lot by your side, but I feel that I need a broader space for development."
These cliches seemed to have been prepared early in the morning, and a lot of them were spouted.
It's a pity that Ignatz has long lost interest in this student, and his face is full of perfunctory: "I understand, let's watch the operation."
Li Ben was admitted to the hospital late, and Hills didn't know much about his physical condition. After listening to Kawei's simple description of his condition, he realized that Li Ben was the lucky one under the complex trauma suture machine.
"it's him?"
"Yes, what's wrong?"
"Among the five incisions, only this one was damaged?"
"seems like it."
Hills replaced his surprise with silence, his eyes fixed on the operating table: "He is going through these boring disinfection procedures again."
"I remember you should have seen it during cesarean section."
"I've seen it before, but I still can't figure out why you do it. Why do you need to wash your hands repeatedly? Isn't washing once enough? Why do you have to wipe the same surgical area repeatedly, isn't once enough? And why do you have to spread the wiping from the inside out? ?Why is the scope of the second wipe smaller than the first?”
Hills had too many reasons in his mind, and Ignatz couldn't figure it out, but he chose to believe: "The postoperative recovery ward of the Municipal General Hospital is the evidence. As for the principle, he will write a paper and publish it."
".Wait, what is that?"
I saw Berget moving a machine and pointing it at the air around the auditorium and operating table: "This is the miasma purification device invented by Mr. Lister. It has been demonstrated before during the regular surgical meeting discussion, and I deliberately copied it. One unit. The principle is very simple, it is to break the disinfectant into small water droplets and spray them in the air."
Hills looked at the water bottle, which looked like a modern watering can, and always felt ridiculous: "Why does he always think Liszt is right?"
"Since we admit that there is miasma in the air, there is no logical problem in using the corresponding disinfectant to deal with the miasma."
“But can disinfectant really extinguish the miasma?”
Ignatz sighed: "I'll have to let you know the results after the operation. I can't answer that either."
Bergert was the first assistant during the operation, Mellen was the second assistant, and Sarson stayed in the preparation area. The specific division of labor seemed to have been decided by a deck of playing cards this morning.
Kawei still used high-concentration alcohol and bleaching powder as the main methods of disinfection this time. After Li Ben fell asleep, he applied a hemostasis compressor [4] to the root, and then the scalpel quickly cut into the skin.
"The day before yesterday, I attended a regular discussion meeting of the College of Surgery. Someone mentioned the 'Pelvic Common Iliac Artery Compression Hemostasis Method'. Although it saves time and effort, it can easily cause double ulcers. Today I will separate the skin, muscles and blood vessels layer by layer. Expose the incision to the front of the amputated femur, then cut the femur again and continue to expose it posteriorly.”
In just two sentences, Kawei had already sutured two blood vessels: "Everyone should have encountered the problem of incision ulceration after amputation. This is actually the product of a combination of multiple factors, the most important of which is It was just an error in judgment.”
At this point, the scalpel has come to the femoral artery and vein.
Compression cannot completely block the blood flow, but with Kawei's meticulous anatomy and separation, the ligation and disconnection of blood vessels are done very beautifully. In the eyes of everyone, Kawei's operation did not have an exaggerated range of operations. He just buried his head and the blood vessels were processed in a short time.
"The femoral artery and vein are very thick, and a single suture is not enough to block the blood flow. In order to prevent avulsion and collapse of the suture, I chose double suture ligation."
Kawei cut off the severed blood vessels, along with the sciatic nerve, and then quickly cut through the skin and flesh on the back as he had done before. His hand speed is not that fast, and he is not even ranked among the top three in the audience, but there is one thing that no one can match.
That's blood loss.
The tedious repeated soft-tissue separations gave Kavey an advantage only modern surgery can provide: minimal blood loss. After he cut through all the flesh, there was not much blood left around the operating table, and the leather skirt in front of him was as clean as new.
This quiet surgical feature indeed brought a different experience to several colleagues on the stage, but his choice of amputation plane attracted criticism.
"Begert, give me the bone saw."
"Give."
Even after working here for more than half a month, Kawei's surgical style still follows modern concepts, and even if an amputation is performed, the residual limb will be preserved as much as possible. This will leave room for prosthetics in the future, and the dressing and sitting posture will be more beautiful.
If the incision becomes infected according to a method similar to that of Ignatz, the entire femur will have to be removed. 【5】
But Kawei left a section for Li Ben, as a way to give him a thought, and at the same time to show off his amputation skills.
"I followed Mr. Li Ben's wish to preserve the limb as much as possible and made some changes to the thigh amputation. I preserved the femoral neck and joints, and left some skin as much as possible to leave some space for him to make prosthetic limbs in the future. "
This approach has clearly been questioned.
"Dr. Carvey, you lack experience in amputation and the amputation site was too low."
"Yes, you should not be soft-hearted when performing amputation. Once you are soft-hearted, the incision will be easily ulcerated if it is too close to the injury. If ulceration occurs, the patient will have to undergo a second amputation. In fact, not many people can tolerate a second amputation."
Hills also held the same view: "Mr. Ignatz, don't you think his approach is too radical? The upper edge of the ulcer is very close to the incision position he chose, and secondary ulceration is inevitable. He said The selection of the resection plane was so hasty, and in the end it was the patient who suffered."
Ignatz had the same idea, but he was willing to say a few words of help: "Don't worry, he has his reasons for his decision."
"It's nothing more than a prosthetic leg. In my opinion, there is no need for a prosthetic leg at all."
Ignatz stopped talking, and the right to speak was still in Kavi's hands: "Please be patient, of course I know that the amputation needs to be done as high as possible, so as not to cause secondary ulceration. But this is just a surgeon. The helpless behavior after being unable to clearly understand the damaged platform is to escape.”
"What did you say?"
"What do you mean?"
Kawei smiled and picked up the bone saw: "If according to your statement, all lower leg injuries will be treated with patellar plateau resection, and all thigh injuries will be removed by removing the femoral head, what technical content does such an operation have? Don't you think that the saw Doesn’t it take some skills to make a bone?”
There was silence in the audience, and the only sound in the venue was the strange sound made by the teeth of the bone saw as it repeatedly touched the femur.
Of course Kawei understands what they mean. In fact, when modern orthopedics perform amputation, they often encounter situations where one operation fails and a second or even third amputation is required.
Many orthopedic surgeons have made the simple mistake of being soft-hearted and taking chances when making decisions. However, those who can truly complete the amputation of large limbs in one go without having to do it twice are all amputee masters.
What this requires is not superb surgical skills, but a strong judgment on the injury level of the end of the limb.
Each stump has its own ideal amputation plane. Which tissues are necrotic and which ones are still usable need to be known at a glance. If the judgment is wrong, what will be sutured will be necrotic tissue that is no longer alive. Even if the disinfection and anti-infection are in place, it will still not be able to prevent the incision from necrosis.
Carvey has this experience because the trauma center handles so many amputations.
Cutting machines, threshing machines, tree cutters, car crushers, fan cutting, steel pipe punctures, glass cutting, meat processing and dividing machines, high falls, etc.
He was unable to judge the vitality of the muscles in the limb stump at first, and he also underwent amputation surgery that disappointed him. At that time, his teacher told him that the operation should not be done too hastily. He could open the amputation site first, perform multiple wound debridements, and then do the final suturing after it was found that the muscles were indeed not necrotic.
This kind of practice has become experience over time, and now Kawei can judge the activity of muscles as much as possible from the cause of injury and the appearance of the wound.
But Li Ben's situation is a simple infection, so it is easier to judge.
"I have already done the disinfection work before the operation. The miasma in the air will not affect Mr. Liben's wound." Kawei explained, "And after the operation, this disinfection work will still continue. I can tell you now Everyone, the chance of ulceration of this amputation wound is approximately 0."
This is not his boast, but the real data compiled by Dr. List.
The bone saw given by Ignatz was not very useful, and Kawei wasted some time on the femur. After he cut off the bones and removed Li Ben's entire left leg, he did not directly suture the muscle flaps on both sides of the fish's mouth like other doctors did.
"Beget, pull the skin on both sides." Kawei looked at the preparation area, "Sarson, file for me."
"A file? Where's the file?"
"On the bottom layer of the box, I wrapped it with clean cotton cloth." Kawei explained, "I need to smooth all the sharp ends of the femur."
(End of chapter)
