According to modern trauma concepts, emergency treatment of trauma patients should follow the ABC principles [1].
In the 19th century, when everything was lacking, there was definitely not so much emphasis on things. Kawei could look at the current situation and adapt accordingly, without having to follow a strict sequence. But principles are principles, and the order can be changed. None of the three things ABC must be missed, and what needs to be checked must be checked.
The bullet did not have a long eye, and the position of entry into the body was also very ambiguous, in the middle of the upper abdomen. Kawei didn't know the angle of entry of the bullet, and he didn't have any radiographic examination at hand. He needed to rule out the possibility of the bullet traveling up into the chest immediately.
Gunshot wounds are very troublesome, especially since the bullets of the 19th century lacked kinetic energy and were lead bullets. After the bullets entered the human body, they would spin and turn, forming an irregular blind cavity.
If it really hits the lungs, it will cause hemothorax, and then Orji will be really hard to save.
After quickly finding two damaged parts of the liver and spleen, Kawe began to explore the diaphragm upward. Fortunately, the angle of entry of the bullet was not too tricky. It only made a hole in front of the left outer lobe of the liver and did not even penetrate the liver.
Now Orgi's breathing is fine, A and B in ABC are normal, only one C is troublesome.
The liver and spleen are solid organs in the abdominal cavity, containing a large amount of blood. Once trauma occurs and contusions and lacerations occur, they are often accompanied by large amounts of blood loss. No matter who it was, after seeing the non-coagulated blood in his stomach, he knew that Orgi wouldn't be able to hold on for long. 【2】
Although Kawei has never seen a bullet penetrate the liver, liver contusions and lacerations are a very common surgical emergency in his eyes. Stopping bleeding is the first priority, but at the same time, considering that the operation cannot be completed in a short time, he still needs to give Orr Kyrgyzstan expansion. 【3】
"If anyone has time, go get some water, clean water!"
Kawei first put gauze under the spleen with a tear, and used the organs to squeeze to help compress it. At the same time, he did not forget to ask someone to prepare other things: "Where do you have running water here?"
"It's available in the theater."
"Carry two kettles to get water." Kawei used another piece of gauze, pinched a corner, and filled the bullet holes in the liver that were constantly bleeding to stop the bleeding. "After you get the water, get some salt and baking soda. Just use the one from the kitchen..."
Lockard didn't know why Carvey did what he did, but Hills seemed to understand something.
In his eyes, Kawei's surgery was meticulous and clean, and water was indispensable before, during and after the operation. Especially for abdominal surgery, water can be used to wash the stomach, just like the appendix that Hills missed earlier.
Water is easy to understand, but what about salt? What about soda?
"Water can flush the abdominal cavity, so what is the salt used for? Isn't soda used to make bread?"
"The surgery hasn't been done yet, why are you flushing your stomach?" Kawei didn't bother to explain, so he randomly found a nurse and said, "If you're fine, go get something quickly."
The nurse was a little confused. The purpose of the previous order could still be seen, but the request she made now had no idea what Kawei wanted to do. She glanced at the two surgeons in this hospital, meaning she wanted to ask clearly whether she should do what Kawei said.
But the problem is that Lockard and Hills are also confused. The surgery requires Carvey, but the requirements are indeed weird. They don't understand why he always likes to use something else when an operation can be solved with a scalpel, pliers and some surgical instruments.
Before it was alcohol and bleaching powder, now it’s salt, soda and water...
They were not afraid that the operation would fail. Even if Orgi died in the office, it would not be unacceptable, because the injury was indeed too serious. But it would be too frustrating and tiring if he could survive but was killed by Kawei's itching operation.
Just like that, the three of them were stunned for a while, not knowing how to answer the conversation.
"If you want to save people, you have to be obedient. If things arrive late, don't blame me if someone dies." Kawei used gauze to compress the bleeding from the liver tear and touched the first liver port [4] with his fingers. Here, Lockard holds the gauze, and Hills gives me the crow's beak pliers."
If the liver was a stab wound, Kawei could still suture it, but now that there was a gaping defect, things would become very complicated.
Bullets not only create trajectories in the liver, but may also cause necrosis of the tissue surrounding the trajectories. Kawei was unable to use the naked eye to judge the subsequent evolution trend of the tissues around the ballistic path in the early stage. In order to solve the problem once and for all, he could only cut off the entire affected left outer lobe of the liver.
The abdominal cavity is a restricted area for surgery, and the liver is an even more restricted area within the restricted area. There are rich blood vessels here, as well as hepatic ducts, bile ducts, various ligaments, gallbladder, duodenum, etc. They don't even understand the lobes of the liver, let alone perform liver surgery.
The real enlightenment of liver surgery was in 1888, when the left and right lobes of the liver were distinguished by the portal vein shunt. In the same year, a doctor performed a tumor resection of the left lateral lobe of the liver.
If Kawei's surgery is successful, it will be able to advance the time by 22 years.
He and Lockard exchanged positions, and using the crow's beak forceps and scalpel given by Hills, he slowly began to separate the connective tissue near the liver portal: "There is too much bleeding from the liver rupture, and we cannot allow Orgi to lose any more blood. , I now need to block the hepatic portal vein."
What followed was something they had never seen before. Lockard and Hills couldn't help but put their heads together and open their eyes to see what happened.
"So who is going to get the water?" Kawei used pliers to fiddle with the surrounding tissue, and took the time to check his pulse: "The heart rate is 120, and the blood loss is estimated to be more than 1000ml..." [5]
At this point, Hills and Lockard didn't need to say anything more. A nurse immediately stood up and said, "I'll go."
Kawei immersed himself in the separation and said: "Take as much as you can, go and come back quickly."
"I see."
The nurse thought of a big kettle in the ward. Just as she was about to go out, she was suddenly stopped by him: "By the way, are the salt and soda ash in your kitchen clean? The salt I bought from the vendor last time didn't seem to be pure salt, soda ash." The powder is also mixed with some other messy things."
"Ours is a formal channel, but..." Hills wasn't sure, and looked at Lockard beside him, "It should be fine."
"Forget it, I can't worry about that much, I have to get the things here first."
"good."
Kawei looked at the remaining three nurses and began to assign tasks one by one:
"(Nurse A) She's gone. Don't just stand there. You (Nurse B), go find a kerosene stove. I want to boil water [6]; you (Nurse C), listen to his heart rate. Watch your breathing; and you (nurse D), help pass the equipment, we won’t be able to free our hands later.”
Soon the nurses went about their duties, and the office finally had the feel of an operating room.
Orgi was seriously injured. Although the stab wound on the left side of his abdomen was not deep, it also damaged his intestines and spleen, and there might be damage to other places as well. The bullet in the middle of the abdomen deflected to the left, hit the liver, and created a gap about 2cm in diameter.
Considering the excessive blood loss, Kawei did not have time to explore other places. Fortunately, the spleen was temporarily safe and he could stabilize the bleeding in the liver first.
"The bullet destroyed the left lateral lobe of the liver, and repairing it was unrealistic. I decided to perform resection of the left lateral lobe of the liver."
Kawei finally isolated the anatomical structure of the first porta hepatis[7], found the hepatic portal vein, used a gauze strip to make a portal blocking band, and then asked Lockard to hang crow's beak forceps on the cloth strip. Lockard was like an intern who had never been on the operating table. He held the gauze in one hand and the forceps in the other, standing there blankly not knowing what to do next.
Kawei gently patted the forceps in his hand with the back of his scalpel: "This is placed outside to prevent the gauze strips from being missed. Why are you holding it with your hands?"
Lockard let go: "..."
The back of Kawei's knife changed direction and hit his other hand again: "The liver hilus is blocked, why are you still stuffing the gauze inside? Does it look good?"
"Forehead......"
Lockard has been practicing medicine for eight or nine years and has done a lot of major and minor surgeries. He has never felt so stupid. It was the same as when he first entered medical school and had no idea about anatomy: "Dr. Carvey, what you just said Where is this in the liver?”
"Left outer lobe of the liver."
Kawei put more force on the retractor, trying to open up the field of vision as much as possible, and then used a scalpel to make partitions on the surface of the liver: "The liver can be divided into five lobes and eight segments, the upper and lower segments of the left outer lobe, the left inner lobe, and the right front lobe. The upper and lower parts, the upper and lower parts of the right posterior lobe, and the caudate lobe." [8]
Lockard had never heard of this anatomical term before, and the familiar liver in front of him suddenly seemed unfamiliar: "This..."
"I am certain that this method of lobulation is not found in anatomy books, and can the liver really be divided into lobes?" Hills was still direct enough and asked, "Where did you learn it?"
"Self-taught."
Kawei said casually and continued the preparations for removing the liver lobes.
If you want to cut off an organ, you can't just pinch the blood vessel and cut it off with one knife. Because the organs are surrounded by supporting ligaments and many connective tissues, all the cut parts must be freed before cutting.
He first cut off the round ligament of the liver, then used crow's beak forceps to clamp the round ligament of the liver and gently pull it down to free the falciform ligament, left coronary ligament, part of the right coronary ligament, left triangular ligament and hepatogastric ligament, and fully free the left side of the liver. Outer leaves. 【repair】
"Self-taught?"
Seeing Kawei's skillful operation skills, Hills definitely didn't believe it, but he really couldn't find anyone who had this ability: "Don't be ridiculous, I have never seen anyone who can be self-taught."
"You can't be self-taught. Was anatomy invented by God?" Kawei didn't want to waste time on this matter. "Nurse C, please check the heart rate."
The nurse was stunned for a moment, then realized that C was referring to herself: "Um...it's always been around 120."
"It's still stable." Kawei looked up at the door and continued to immerse himself in the separation. "My father often has corpses left over from autopsies. I found the liver quite interesting, so I tried to dissect it."
"But the liver is one piece, why do we need to divide it into lobes?"
"It looks like one piece to the naked eye, but if you look at it according to the distribution of blood vessel supply, it can be divided into leaves and segments." Now that the rescue is urgent, Kawei can't elaborate, "Do as I say first, and wait until the operation is completed. Let’s discuss it again, okay?”
Isolation of the hepatic hilus and left lateral lobe of the liver is very troublesome, time-consuming and labor-intensive.
Until the two pots of water, a large bowl of salt, half a bowl of baking soda, and a kerosene stove that Kawei asked for were all in place, Kawei was unable to free the entire left outer lobe: "Boil the water first. How much does this kettle have?" ?”
"About 1L."
"First boil half a pot." Kawei started to change the angle, separated the left hepatic vein, and ordered at the same time, "Then put salt and baking soda in another pot of cold water."
"How much do you want to put in?"
Kawei put down the scalpel, wiped off the blood on his hands, turned around and picked up the small spoon given by the nurse, and put the salt and sodium bicarbonate into the water as if adding condiments to a dish: "That's it for now, wait. After the water boils, mix the water on both sides back and forth." [9]
"What are you going to do?" Hills couldn't understand his operation more and more.
"To create a water temperature that is closer to the human body, it should be possible if the hot and cold ratio is 1:2." Kawei did not explain any more. He needed to separate the left hepatic vein as soon as possible and then cut off the entire left outer lobe. "Heart rate, heart rate, Quick heart rate report.”
"127."
The nurse did not dare to neglect, and the number reported made the whole office very nervous. Obviously, the large abdominal incision aggravated the loss of body fluids, making it increasingly difficult to maintain blood pressure, and Orji's heart rate began to rise.
"Speed up, hurry up, hurry up!!!" Kawei encouraged them, and also gave himself a hand speed boost, "Come on, Nurse B, don't worry about the stove, go find an iron rod."
"Iron rod???"
"Yes, be thinner, preferably something like wire, without sharp cuts in the front." Kawei wiped the sweat from his forehead with his sleeves and said, "Go quickly, I will use it later."
Hills stopped asking questions and just stood aside with Lockard, pulling the hook and doing what he was told, while watching Kawei separate the tissue around the blood vessels. As for what the water, salt, baking soda and the iron wire we want now are used for, it's pointless to ask anyway.
"Nurse D, please get off the stage. There is no need to hand over the instruments." Kawei looked sideways at the instrument nurse and ordered, "Go get the syringe."
"oh."
"Take two more,"
"I know." The nurse put down her things, left her desk, and took out several syringes from the storage box on the side, "What next?"
"Bring it over first, wait until the water is mixed, and fill it up for later use." Just after Kawei finished speaking, he couldn't help but glance at Orji, whose face became increasingly pale, and asked again: "Nurse C, heart rate! Heart rate! Don’t let me remind you, this thing is life-saving and you have to report it every two minutes!!!”
"It's now, it's 131 now..."
"It seems we have reached our limit." Kawei put down the pliers and scalpel, turned back to the two nurses and said, "Don't worry about the temperature of the water, just mix the water together, and then use a syringe to inject it into Orji's blood vessel. .”
"Just punch in like this?"
"Yes, punch in."
"Is this okay?"
"Of course it can work. Even if it really doesn't work, there is no other way." Kawei explained, "The lack of so much blood must be supplemented."
"But the syringe is only 1ml."
"An extra ml is better than nothing." Kawei glanced at Lockard and Hills, "You two, stop pulling the hook and get more syringes. Don't take out the needles. Pump the water out of the syringes. Relay. Get half the pot in first, and as long as you cooperate quickly enough, you can finish it in a while."
－－－－－－Digression－－－－－
It’s so tiring to code on duty. . .
