Carvey admitted that he had made an error in judgment.
There were many reasons. In addition to the disturbing advice surrounding him that expanded his options, the medical environment of the 19th century also gave him additional concerns. However, it is not his style to shirk responsibility. Taking this as a lesson and letting everyone learn a lesson is definitely more meaningful than maintaining some unnecessary self-esteem.
In the absence of examination, there is nothing wrong with whether to directly open the chest and bear the risks of major surgery, or to perform pericardiotomy first and gamble on the success rate of conservative treatment.
The fault lies in Kawei's choice of incision.
When cardiac repair has been listed as a substitute option and repair needs to be included in the surgical procedure at any time, the choice of incision becomes important.
The pericardial window incision chosen by Kawei is a longitudinal 5cm incision under the xiphoid process. The bone structure on the outside of the chest can be successfully avoided here, and the incision path can also reach directly to the posterior wall of the pericardium, making suction easy and clean.
If an emergency thoracotomy is required for heart surgery, the longitudinal incision under the xiphoid process can be expanded directly upward to open the sternum. The incision usually extends from the inferior aspect of the suprasternal concavity to the xiphoid process, and is separated by a sternosaw saw.
This is the most widely used surgical incision outside cardiothoracic surgery, the median sternotomy [1].
Combined with the upper sternal retractor, the four chambers of the heart and the ascending aorta can be well exposed, and extracorporeal circulation can be established if necessary. If the injured person has a combined thoracoabdominal trauma, this incision can also be continued downward for laparotomy exploration.
But unfortunately, this is the 19th century. Splitting the sternum and how to pull the sternum to both sides to resist the huge rebound force after splitting have become difficult problems for Kawei.
He did not have a retractor sufficient to fix the surgical field. Although it could be done manually, human muscles could not achieve long-term stability like machines.
Moreover, splitting the sternum is not as easy as imagined. It is difficult to complete a correct median sternotomy with an ordinary bone saw.
A crooked split is just a trivial matter, and it affects the prognosis of the sternum closing after surgery. But once the force is too much, it will be a big trouble, because apart from some shallow fibrous tissue below the sternum is the right ventricle.
This is a shortcoming in surgical tools. The scarcity of cardiothoracic surgeries does not give Kavey the experience to practice existing tools. This cannot be made up for by his own skills.
In comparison, the left anterolateral thoracotomy incision made through the fourth and fifth ribs is much more modest. 【2】
This traditional approach will encounter many blood vessels and nerves, and surgical operations will inevitably cause intraoperative injuries. And because the injured person is lying flat on the operating table, when the blood and fluid accumulated in the pericardial cavity are aspirated, there will definitely be residue, which means the aspiration will not be clean.
When facing major heart repair surgery, a considerable part of the bony structure also needs to be removed in order to expand the field of vision.
The rib incision on the left side of the chest has a lot of shortcomings, and many trauma centers have long abandoned it. But in today's surgical environment, it can handle both cardiac tamponade and cardiac repair operations at the same time without using a sternal retractor, making it a dual-purpose device.
If surgery requires increasing the central field of view, this incision can also reversely transverse the sternum to increase exposure.
In fact, there are many advantages. It boils down to the fact that it is fast and convenient to insert into the chest, and the postoperative recovery is also faster. Carvey's modern surgical thinking ignored this point. Although it did not produce too bad results, it caused Rogelini to be stabbed again.
"There was a problem with the subxiphoid surgical incision just now. I will make a new incision now. Get the rongeurs and bone scissors ready."
Kawei asked Lucius and Golam to handle the incision under the xiphoid process, while he quickly cut open the skin on the fifth rib: "Go directly into the left heart from this position to resolve the cardiac tamponade and cardiac breach."
No one around him had ever seen such a large chest incision, and the surgery had gone in a direction that no one could have imagined.
As surgeons, they have mixed feelings. On one hand, they believe that such a dangerous structure of the heart cannot be repaired by surgery. On the other hand, they also want to see how Kawei's inhuman skills collide with such serious trauma. Will there be any new miracles in the future?
The distance between the skin and the ribs was very short. Kawei separated the subcutaneous tissue and muscles, quickly freed the ribs, and then used scissors and rongeurs to remove about 4cm of the costal cartilage between the sternum and the ribs, and then entered the precordial area through the costal bed. 【3】
The field of view this time was much better than before. A large area of the pericardium could be seen, and more blood clots and loose connective tissue could be seen.
Carefully using forceps to remove the blood clot and pushing away the connective tissue, Kawe asked, "How's the suture tension down there?"
"There's something wrong with the tension." It was Lucius's first time to suture the pericardium. Not to mention his experience, he had never even done anatomy. "It may take time to suture."
"Can't sew?"
"There was a bit of bleeding, and"
"Forget it, we don't need to suture it yet, just leave it like this." Kawei quickly made a decision, "Goram is responsible for absorbing the bleeding. The incision will be briefly disinfected first, and then covered with wet gauze. Come up and help. I, I need help here."
The incisions are left just in case, and multiple incisions provide an additional way to operate. Although this approach is unconventional, since it has been cut open, it is easy to make mistakes.
Moreover, the pericardium is something that can be sutured or not. Forced suturing is a constraint on the heart and may also cause other unpredictable injuries. Opening the pericardium will actually create a gap for the suction device, at least it will not refill the pericardium.
Kawei reproduced the surgical method used to treat the pericardium just now, but changed the traction wires used for suspension to two, located on the left and right sides of the incision. After lifting, the middle was gently cut with a scalpel.
Suddenly, the nurse on the side reported Rogelini's vital signs: "The heart rate suddenly increased, and it is now 145 beats/min."
In fact, without the nurse's explanation, Kawei and the other surgeons at the operating table could see how crazy Rogelini's heart was beating with the naked eye: "Take the blood pressure again. Is the blood matching in place? I need a blood transfusion now." !”
"It should be fine soon."
"Increase the infusion." Kawei inserted a finger into the pericardial gap he had made. While scraping off the blood clots, the auxiliary suction device sucked them away. "Where's the blood pressure? Please report the blood pressure and heart rate. .”
"Heart rate 147, blood pressure 87"
The nurse's measurement speed was already very fast, and being able to get on Lucius's operating table already showed her excellence. Before Kawei asked to take a blood pressure measurement, she had already tightened the balloon of the blood pressure monitor, and the systolic blood pressure was given in less than half a minute.
Just wait for the mercury level to drop and the diastolic blood pressure reading will come out.
But Rogelini's heart and Kawei's fingers didn't have time to wait for this value. They only heard a gentle "hiss" and a straight dark red blood curtain shot out from the center of the operating table.
[The height is estimated to be half a meter. Maybe higher, maybe one meter. I can’t remember the distance, but it’s too exaggerated! If it were me, I wouldn’t know what to do]
This was the impression left by that scene in the eyes of onlookers during the operation. Although the bleeding was quickly stopped, such an exaggerated amount of bleeding was still fresh in people's memories.
But Kawei's next operation is even more difficult to let go.
He immediately saw the location of the bleeding, successfully avoided the gushing blood, and pressed the rupture at the apex of his left heart with just one left index finger. 【4】
When other people's heads were troubled by questions such as "something bad happened", "why did he bleed suddenly", "it's over now", "what should I do", etc., he had already solved the problem easily and was asking questions. The nurse on the side asked for sutures and needles.
"Give me needle and thread, quickly!"
".Um, okay."
"blood pressure?"
".Press down 35."
"Speed up the infusion."
Kawei's fingers gently pressed on the surface of the heart tear, and the height rose and fell with the rapidly beating heart. He looked back at the other doctors who were already excited around him, but called Sarson alone, "Saerson, go wash your hands." , stepped up to take over Gorham’s lower cut.”
"good."
"Goram came up and sucked out all the blood clots and blood around the breach, exposing the situation around the heart."
"yes."
"Lucius, do you want to try to close the gap?"
"I?"
Lucius has worked in surgery for more than ten years, and this is the first time he has undertaken such an exaggerated operation. He had never even thought about using his fingers to press the break in the heart and maintain the original beating of the heart.
The word excitement can no longer describe his current mood. There is only one word left: confusion.
"Is it okay? If not, forget it."
Lucius swallowed and nodded repeatedly: "Okay, I'll try."
Although Kawei valued his previous puncture performance, he did not complete this gag handover with a teaching mentality, but because he needed to free his hands to find the bullet that entered Rogelini's chest.
Judging from the trajectory, the bullet should have passed through the left lung, entered the pericardium, and then created a gap just above the apex of the left heart.
There was the gap under Kawei's finger. From the feeling coming from his fingertips, the gap was a tangent line rather than a bullet hole. This shows that the bullet just grazed the apex of the heart, causing a tangential injury, but the angle of entry was diagonally downward, and the bullet was likely to go further down.
Residual warheads are a troublesome thing. They may cause sequelae to soldiers, but they may not.
If the current treatment was conservative like those for ordinary chest firearm injuries, there would be no need to remove the bullet. However, Carvey had already opened Rogelini's chest. At this stage of the operation, removing the warhead should also be scheduled for surgery.
"Have you tried to find or get it" and "have you found it" or "can you get it" are two completely different things.
"Put your fingertips against my fingertips, yes, just use force like this!" Kavi and Lucius pressed their fingers together, "Move down slowly, yes, be slow, no, no, no, stop!"
The handover was temporarily stopped. Kawei quickly removed his fingers and continued to cover the crack with his left index finger: "Your fingers are too stiff. I asked you to use force on your wrist, not on your knuckles." ,understand?"
After hearing this, Lucius looked at the beating heart again and nodded: "I understand, the knuckles need to fit the beating heart and not press too hard."
"Try again, if it doesn't work, forget it."
Kawei didn't dare to joke about his heart. The exaggerated ejection ability of the left ventricle could allow Rogerini to see God in a short time. Some teaching needs to be done, and some teaching is so dangerous that it must be left until the trainee has enough experience.
The fingers of the two continued to do the same movements just now, and this time Kawei also used his right hand.
The thumb and index finger of the right hand were placed on both sides of the rupture, and they followed the beating of the heart like the index finger of the left hand. Try to align the two sides of the rupture: "Yes, that's it. You have to use force on your wrist, otherwise your fingers will be bounced away by the blood. . The metacarpophalangeal joints must be rhythmic and relaxed, but the fingertips must be close to the surface of the heart without leaving any gaps, yes, yes, yes.”
There was only a 1.5cm rupture, but it took a full 2 minutes to hand over the fingers.
There was Kavi's caution in this, and it also included giving Lucius time to fully become familiar with the beating of his heart. After all, there is no genius in surgery. It is difficult for a doctor who has not experienced heart surgery to seal the heart breach with his fingers.
Relatively speaking, Kawei was just an accident, and there was not much talent behind him. All he had was the experience and skills gained from more than thirty years of tireless training.
Now the situation has gradually stabilized from the chaos at the beginning. Although the vital signs are a bit dangerous, the amount of infusion is being increased, blood transfusion is on the way, and everything is developing in a good direction.
But the better the situation gets, the less we can take it lightly.
Carvey now successfully freed his hands and began to explain the operation again: "Rogerini was really lucky. The bullet did not enter the heart chamber, but entered from the front left side, grazing the myocardium above the apex of the heart. Enters the back of the heart.
Now I need to look for bullet slugs, those things that stay in the body and no one knows what will happen next. "
At this time, Sarson had already come to the stage and picked up the attractor left by Goram. What he has to do is to clean up the blood clots in the incision, and then ensure that the blood flowing out does not accumulate in the incision.
Goram took Lucius's place and did the work of retracting the hook to protect the incision. Lucius blocked the gap in the heart, while Kavi gently dug his fingers into the back of the heart and started searching.
"If he's really lucky, the bullet should stay in the pericardial cavity. If he's really unlucky, then all I can do is" Kawei's fingers repeatedly stirred the back wall of the heart, and while feeling the beating, he suddenly touched A hard solid, "The warhead seems to be really here. Quick, give me the tweezers."
The nurse brought surgical forceps.
"Lucius, use your other hand to lift your heart a little. Yes, do it gently, don't use too much force."
Kawei inserted the forceps into the open pericardial gap, followed the direction and path of his finger just now, and found it behind the heart. Relying on his amazing fingertip sensitivity, he finally touched the warhead with his tweezers in a corner.
"It's coming, it's coming, hurry up, give me the bend, the evil bullet that seriously injured the Austrian soldiers is finally out!!!"
(End of chapter)
