Chapter 274: Chapter 275: Practicing dicine, As If Treading on Thin Ice! (Extra Long Chapter of 5000 Words)
After that incident, Tan Zhonglin smoothly joined Chen Cang’s team, becoming Chen Cang’s second assistant, briefly known as “Second Room”!
The addition of the Second Room brought a bit more competition to Chen Cang’s team of assistants.
The chief assistant An Yanjun finally stepped out of his comfort zone as well and began competing for favor against Tan Zhonglin.
But such competition was clearly beneficial, as both sides relied on their abilities in the contest for affection, which greatly increased their enthusiasm for learning.
Ultimately, it was An Yanjun, as the chief assistant, who had the upper hand, thanks to the dedicated support of three young nurses.
After all, it was only by keeping Chen Cang that they could compete fairly.
If Tan Zhonglin were to win him over, the competition would lose its aning.
At that ti, Chen Cang suddenly realized that having the favor of two people wasn’t such a blessing after all, and he was getting annoyed… Chen Cang suddenly missed Qin Yue.
She never spoke unless necessary.
Occasionally praising with an appealing “You’re really sothing”.
Blinking her large eyes.
Always in good spirits during surgeries.
And most of all, she was pleasing to the eye.
Looking at these two old n vying for attention, Chen Cang was indeed very annoyed…
…
…
Finally, October 1st arrived, and Chen Cang was on the first shift,
Even though being on ergency duty was as busy as fighting a war, at least it wasn’t so irritating.
He finally understood why so many officials in ancient tis passed away at a young age—they were simply too exhausted!
By day, they had to deal with thousands of things, and at night, they had to deal with thousands of… well.
Sigh…
The hospital saw far fewer patients on National Day, with outpatient visits not even half of what they usually were.
However, the ergency departnt was not any less busy. On the surgery side, Chen Cang and Wang Yong were bustling about all morning.
While on the internal dicine side, Doctor Yao was as busy as a dog, especially since today he was on duty with Doctor Yan Ming.
Doctor Yan Ming was notorious in the ergency departnt for shirking his duties—as bad as Li Baoshan. He swaggered around every day with his thermos cup, calling for consultations whenever a patient arrived.
In short, his ergency departnt was like a retirent ho.
The hospital wasn’t really willing to quarrel with such people who just wanted to coast for a few years until retirent, figuring that no major issues would arise as long as he was around.
Although Yan Ming did not manage things much, he was very adept at ensuring his own safety, a skill of great value in today’s climate.
Nowadays, the first lesson taught to any doctor when they start their job is how to protect themselves.
Yao Zhiwen had entered the hospital with Chen Cang as part of the sa cohort—graduate students from Dongyang dical University’s Cardiology departnt, like Wang Qian and Qin Yue, with regular positions.
Yao Zhiwen was a little introverted and didn’t talk much, always smiling at people as if he was a bashful girl, and was quite simple and honest. He was quite unlucky to be paired with Yan Ming.
He had been so busy all morning that he hardly had ti to rest.
Around eleven o’clock, Yao Zhiwen hurriedly found Chen Cang, looking rather worried as he said, “Doctor Chen, could you help to examine a patient?”
Chen Cang nodded, following Yao Zhiwen to the ergency room.
As they walked, Yao Zhiwen explained, “The patient is a middle-aged man, 41 years old, who was brought in with chest pains by the 120 ergency services. He fell into a coma not long after arriving, and the situation is very serious.”
Upon hearing Yao Zhiwen’s words, Chen Cang quickly grasped several clues.
“Chest pain!”
“Coma!”
Could it be a myocardial infarction?
That was Chen Cang’s first thought.
Yao Zhiwen continued, “The patient started becoming ntally unclear shortly after arriving at the ergency departnt. According to the ambulance doctor accompanying him, the patient was still conscious during transport, just complaining of chest constriction and unbearable chest pain like being pricked by needles. They administered nitroglycerin, but it didn’t provide relief, and the initial ECG appeared normal.”
Chen Cang was taken aback and quickly asked, “Did you get another ECG in the ergency departnt?”
Yao Zhiwen nodded, “We did, and also urgently checked the troponin level.”
“There wasn’t any sign of acute myocardial infarction on the ECG, but the blood test showed elevated troponin levels.”
Chen Cang frowned upon hearing this. After entering the room, Yao Zhiwen hurriedly brought over the electrocardiogram and handed it to Chen Cang, “Take a look.”
Chen Cang took the electrocardiogram and saw that it didn’t show typical signs of myocardial infarction; the S-T segnt was essentially normal…
This was puzzling!
Yao Zhiwen said, “I’m still worried about a cardiac issue. I just called for an ergency consult with the cardiology departnt, but they haven’t arrived yet. Dr. Yan… went up to ask for help!”
Chen Cang couldn’t help but let out a snort of derision…
Both of them knew that even if the electrocardiogram didn’t show typical patterns, the patient’s condition could still not rule out the possibility of acute myocardial infarction.
When faced with a typical example of myocardial infarction, the electrocardiogram would indeed display those characteristic S-T segnt patterns. That’s easy to understand, as normal myocardial cells show electrical activity, while dead myocardial cells do not. The principle behind the electrocardiogram is to detect these abnormalities and represent them as waveforms.
However, during the early stages of a myocardial infarction, the myocardium might not be completely necrotic, and electrical activity could still be present. In other words, the electrocardiogram might not show typical signs.
In addition, cardiac troponin, which is mainly located within myocardial cells, elevates when there is damage to the myocardial cells.
Chen Cang asked, “Is there any dical history?”
Yao Zhiwen replied, “The dical history provided by the family is largely reliable. The patient has a past history of hypertension, hyperlipidemia, and fatty liver disease. So… the possibility of acute myocardial infarction is even less likely to be excluded.”
Chen Cang acknowledged with a hmm, “Do you suspect cardiogenic shock?”
Yao Zhiwen nodded!
While talking, the two had already arrived in the resuscitation room where the patient was now on cardiac monitoring.
At first glance, Chen Cang didn’t see any particular expression on the patient’s face, and he was already unconscious, lying on the hospital bed without any movent.
On the cardiac monitor: Heart rate 120 beats/min, a bit fast, blood pressure was 80/50mmHg, too low… Normal blood pressure should be 90-140/60-90mmHg,
A blood pressure of 80/50 is undeniably low; low blood pressure ans the patient is in shock.
All the clues were still unclear.
Odds are bad!
The patient previously had a history of hypertension, and now the blood pressure was only 80/50. Under these circumstances, the pressure is simply not enough to satisfy the brain’s need for blood — simply put, the heart is like a pump that must push blood throughout the body, and now the pump is not providing enough pressure to get the blood to the brain.
And the brain is very sensitive to ischemia and hypoxia. Once the blood and oxygen supply diminishes, unconsciousness follows!
To quickly rule out myocardial infarction, Chen Cang perford another electrocardiogram on the patient.
Chen Cang hesitated, “I’ll go ask the family about the situation.”
The patient’s family mber present was his wife, with an accent from another region.
Chen Cang asked, “When did the chest pain start?”
His wife, clearly terrified, spoke sowhat illogically, “He’s generally been in good health, just likes to drink alcohol, but… I… I can’t rember when he started feeling unwell, probably yesterday. I didn’t pay much attention to it, but today it got so severe he couldn’t walk and I imdiately called the ambulance. Not long after arriving at the ergency room, he fell unconscious.”
As she spoke, she began to cry, overwheld with fear.
Chen Cang sighed; he understood. After all, seeing a perfectly healthy person suddenly fall unconscious would make anyone anxious.
Chen Cang empathized with her, but now was not the ti for consolation.
That’s because myocardial infarction can be fatal,
If confird, every second counts and the patient must be sent for interventional treatnt imdiately.
What is myocardial infarction?
It occurs when the blood vessels of the heart are blocked by a clot, stopping the blood flow. The heart is essentially a muscle, and all its activity depends on the blood supply from the coronary arteries.
If the heart is deprived of blood for too long, the myocardial cells will gradually die. Should enough myocardial cells die, the heart will lose power, leading to heart failure and eventually shock and death.
This process could take as little ti as a few minutes!
Therefore, once myocardial infarction is confird, the most effective treatnt is to promptly and decisively restore blood flow as soon as possible, whether through dication to dissolve clots or through interventional stenting. The goal is to clear the blocked vessels and resu cardiac blood flow.
Hence, there’s no ti to waste!
Chen Cang habitually placed his hand on the patient, checking pupils and reflexes.
This was a ritual familiar to any surgeon.
And when Chen Cang’s other hand touched the patient’s abdon, he was taken aback!
Realizing this, Chen Cang quickly said to Yao Zhiwen, “Have you perford a physical examination?”
Yao Zhiwen shook his head, “I didn’t get the chance!”
Chen Cang shook his head and hurriedly lifted the patient’s clothes.
Pressed with his hand!
“My abdon’s a bit tense…”
This isn’t normal, right? Normally when soone lies flat, their abdominal muscles should be relaxed, no matter how many abs they have or how strong they are, their stomach should feel soft.
And yet, this patient has already lost consciousness, so why is their abdon hard and taut?
This man is sowhat overweight, clearly not muscle-bound…
Yao Zhiwen also suddenly realized this situation and urgently palpated it, montarily stunned!
“Muscle tension?”
Abdominal tension often indicates inflammation within the abdominal cavity, which irritates the peritoneum, causing the abdominal muscles to contract, hence the tension when touched.
Could it be that the patient’s myocardial infarction caused the abdominal tension?
At that mont, the ECG results ca out, and the nurse handed them over. Chen Cang took them and started to read them earnestly but still didn’t see the typical signs of a myocardial infarction.
Chen Cang couldn’t resist asking the family, “How long has it been since the onset?”
His wife, groggily, “Several hours already? Three, four…”
Chen Cang looked at Yao Zhiwen, “Doesn’t look like a heart attack! It’s been three or four hours. If it really were an acute myocardial infarction, there should be significant electrocardiographic changes by now.”
Chen Cang couldn’t resist asking, “Did you get a chest X-ray, CT scan?”
Could there be another cause for the chest pain?
Yao Zhiwen brought over the images, and upon inspection, Chen Cang found them to be largely normal!
How bizarre is this?
What in the world is going on!
Chen Cang’s brain raced, considering all the possibilities.
Though deep in thought, Chen Cang’s hands never stopped. He continued to examine the patient’s abdon, trying to discover more clues.
Just as he routinely tested for liver-area tenderness, he noticed that when he tapped on the liver, the patient suddenly furrowed his brow, displaying a look of agony.
This shook Chen Cang to his core!
A patient in coma showing a painful expression, what does that indicate?
There is only one possibility!
That is, Chen Cang had indeed caused him pain!
Well, it’s not nonsense, it’s true! Even if a person is unconscious, they can still feel intense pain.
In healthy individuals, tapping on the liver shouldn’t cause any reaction, unless they have a hepatobiliary system disorder!
And it would likely be one of those acute inflammatory diseases, such as liver abscess, cholecystitis, biliary colic, etc.
Seeing her husband grimace in pain, his wife thought he had woken up. She quickly slapped and patted his ear, calling his na loudly, but there was no response whatsoever.
To further confirm his suspicion, Chen Cang placed his left palm flat under the patient’s right rib cage and pressed the thumb of the sa hand into the gallbladder area. If the patient had an inflad gallbladder, then this deep pressing would surely cause severe pain, because the gallbladder was right beneath Chen Cang’s thumb.
As expected!
When his left thumb pressed deeply, the patient’s brows tightened even more, twisting in pain!
Chen Cang took a long breath.
The patient was indeed in shock, but it wasn’t cardiogenic shock; it might be septic shock.
Cardiogenic shock refers to shock caused by cardiac disorders. If it were myocardial infarction, then imdiate interventional or thrombolytic therapy would be warranted.
But if it’s a severe gallbladder infection, leading to septic shock, the treatnt would be completely different.
Moreover, inflammation of the gallbladder or bile duct could cause chest pain, uncommon though it may be. Conversely, myocardial infarction could lead to abdominal pain, not chest pain.
The human body is complex; pain does not necessarily indicate that the affected area is the problem.
At this ti, the patient very likely had a gallbladder system disease!
Chen Cang, “Get the lab results.”
If one confuses the two, missing the opportunity for the right treatnt, the patient could die.
After carefully reviewing the patient’s lab report, the complete blood count indicated a slightly elevated white blood cell count, not too high.
However, myocardial infarction itself can lead to an elevated white blood cell count, as can infection; hence the complete blood count itself cannot be the sole basis for diagnosis.
Chen Cang said to Yao Zhiwen, “Start fluid resuscitation! Administer a large amount of fluids!”
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Yao Zhiwen now also understood the situation, “Are you saying… you’re worried about septic shock?”
Chen Cang nodded!
In fact, whether it’s cardiogenic shock or septic shock, replenishing fluids at this ti was correct.
Only by increasing the patient’s blood volu and raising the blood pressure can one ensure blood and oxygen supply to all organs; otherwise, those ischemic organs would starve one by one!
“Notify the ultrasound departnt for an urgent consultation!” Chen Cang gave the dical order decisively.
The young nurse quickly picked up the phone to make contact.
To be completely sure, Chen Cang conducted another detailed examination on the patient. Auscultation of the heart and lungs revealed no significant abnormalities, reading the chest X-ray again showed no signs of heart failure or pulmonary edema, and a new ECG was taken, which still did not display typical signs of a myocardial infarction—the patient truly wasn’t suffering from a myocardial infarction!!!
Chen Cang was almost certain now!
To diagnose myocardial infarction early, the most objective thod was to continuously perform ECGs.
ECGs are not only cheap and convenient, but also radiation-free, and can provide imnse value—they really are an excellent test.
The ultrasound departnt was nearby, and it wasn’t long before they wheeled their equipnt over.
Soon enough!
The examination results ca out.
The results startled both Chen Cang and Yao Zhiwen!
The ultrasound showed a significant enlargent of the gallbladder with thickening of the gallbladder and bile duct walls. There were also many stones inside the gallbladder, and clear dilation of the bile duct!
All these signs indicated that the patient’s gallbladder and bile duct were inflad, and it was very likely acute obstructive suppurative cholangitis.
Once a stone blocked the common bile duct and bile could not drain smoothly into the digestive tract, bile would inevitably accumulate more and more, ultimately leading to increased pressure within the bile duct, bile reflux into the bloodstream, accompanied by the entrance of bacteria into the blood, thus producing distinct signs of sepsis, and in severe cases, shock.
Chen Cang imdiately took out his phone to call Zhang Youfu, and Zhang Zhixin happened to be on duty, running down with leaps and bounds!
They discussed together with Teacher Bai from the ultrasound departnt.
Having assessed the patient comprehensively, they clearly considered acute obstructive suppurative cholangitis, septic shock, and recomnded imdiate transfer to general surgery for tily operation for bile duct decompression and drainage. Just by cutting open the bile duct to let the surging bile flow out, the condition would significantly improve.
As for the gallstones… that can be discussed later, and they could be removed slowly if necessary.
After sending the patient off, Yao Zhiwen was scared into a profuse sweat.
Chen Cang patted his back only to find it soaked with sweat.
Tears clouded in Yao Zhiwen’s eyes, “Chen Cang… you tell … if I hadn’t called you here… would he have died?”
That one question left Chen Cang speechless.
Chen Cang sighed, not knowing what to say.
Disease diagnosis is too complicated; who can guarantee they can always make an accurate diagnosis?
Chen Cang had an extra edge, but he could not see through everything at a glance, and if he hadn’t gently touched, even Chen Cang wouldn’t dare to assure…
Chen Cang looked at Yao Zhiwen, this couldn’t be blad on him…
Diseases can be incredibly varied, and the symptoms and diagnostic tests of different diseases often overlap. If one does not differentiate ticulously, it’s very easy to make errors.
So it is said.
Those who practice dicine must do so with extre caution as if treading on thin ice!
At that mont, Dr. Yan returned… accompanied by a cardiologist.
Chen Cang sighed and looked at Yao Zhiwen, “You’ve done very well; at least you didn’t run…”
Yao Zhiwen laughed through his tears, truly laughing until the tears stread down.
“I really want to be a good doctor!”
Chen Cang smiled, “You already are…”
What else could he say to comfort him at this mont?
Yan Ming ca running over in a hurry, “Little Yao, where is the person? Where has the patient gone?”
Seeing Yao Zhiwen’s tears, Yan Ming shuddered in fright, “Has the person left?”
Chen Cang sighed, shook his head, and went back to ergency surgery.
ps: Thanks to Xiaoya for the generous reward, thank you!
Being a clinical doctor indeed requires caution as if treading on thin ice. Before any young doctor grows into a truly senior doctor, they must undergo constant training. I myself faced this in my clinical practice, and when confronted with such situations, I really was at a loss.
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