godfather of surgery

Chapter 1386 I'm Just the Tenth Bread
That afternoon, Zaxi went to find his two roommates and told them what Yang Ping had said.

"Missing a link?" Bilige, my roommate from Inner Mongolia, frowned. "Which link?"

Aili, who came from Xinjiang, thought for a moment and said, "A stool sample? But the patient isn't defecating right now, what should we do?"

Zaxi said, "We can't just wait for him to poop, can we? What if he doesn't poop for ten days or half a month and the aneurysm ruptures?"

The three of them remained silent for a while.

Bilig suddenly said, "How about we ask if we can use an anal swab?"

“Anal swab?” Ali asked.

Zaxi said, "It involves taking a sample from the anus with a cotton swab, without having to wait for a bowel movement. Some hospitals use this method to test for Clostridium difficile."

Bilig's eyes lit up: "That's a good idea."

Ali said, "But I have to talk to Professor Yang first; I can't just do it on my own."

Tashi nodded, having made up his mind.

On Friday morning, Zaxi arrived at the hospital at six o'clock.

At seven o'clock sharp, Yang Ping arrived. Seeing Zaxi, he raised an eyebrow: "So early?"

Zaxi took a deep breath and explained his idea of ​​using anal swabs.

After listening, Yang Ping smiled and said nothing more. He pushed open the office door and said, "Let's go to the Overseas Chinese Building."

That morning, with Yang Ping's intervention, the family agreed to the anal swab test. The sample was sent for testing, and the results would take two days.

As Zaxi walked out of the Overseas Chinese Building, his heart was pounding with anxiety. What if the result was negative? What if his guess was wrong?

Yang Ping seemed to see through his thoughts and said, "Don't overthink it. There are ways to test for negative results and ways to treat positive results. That's how clinical work is; we move forward step by step."

Tashi nodded, but he was still nervous.

Two days later, the results came back positive for Clostridium difficile toxin.

When Zaxi saw the report, his hands were shaking.

Holding the report, Yang Ping said to Director Tian and Dr. Meng, "Treatment plan: oral vancomycin for two weeks, while monitoring electrolytes and continuing potassium and sodium supplementation. Ignore the aneurysm for now, and have a follow-up angiography in two weeks."

Dr. Meng looked shocked, but didn't ask any questions. He nodded and went to write the prescription.

Zaxi stood behind Yang Ping, and after holding back for a long time, he finally asked the question that had been on his mind for two days: "Professor Yang, when did you start to suspect that it was Clostridium difficile?"

Yang Ping turned around, looked at him and said, "The first time I came for a consultation."

Zaxi was stunned: "First consultation? Then why didn't you just start the examination?"

Yang Ping said, "Because there's no evidence, suspicion is suspicion, and a diagnosis is a diagnosis. I can't just order tests for the patient based on suspicion alone. I need more clues, I need the family's cooperation, and I need to rule out other possibilities." He paused, looked at Zaxi, and said, "Do you know what the hardest part is?"

Zaxi shook his head.

Yang Ping said, "The hardest part is to stay calm when you have doubts, find evidence step by step, not rush to conclusions, and not let go of any doubts."

After he finished speaking, he patted Zaxi on the shoulder: "You did well this time, keep it up."

A feeling that was hard to describe welled up in Zaxi's heart.

He knew this was just the beginning; the chain of evidence had only just closed, and the real treatment had not yet begun.

The aneurysm is still inside the patient's brain, like a time bomb waiting to be defused, ready to explode at any moment before it is removed.

Two weeks later, the patient underwent a follow-up cerebral angiography.

Zaxi stood at the door of the reading room, clutching the medical record in his hand, his heart beating twice as fast as usual. He didn't know why he was so nervous. It wasn't like he was performing surgery or that the patient was his, but having followed the case from beginning to end, it felt like the case was ingrained in his mind, something he would review every night.

In the reading room, Yang Ping was already standing in front of the lightbox. Dr. Meng clipped the film onto the screen, her hands trembling slightly. What if the aneurysm was still there? What if it had grown larger? What if the antibiotics she had taken these past two weeks had been wasted?
The films were clipped in one by one.

Distal branch of the right middle cerebral artery.

Zaxi took a step closer.

The aneurysm that was once 8mm has disappeared.

In its original location, the blood vessel wall was smooth, blood flowed freely, and there was no bulging or narrowing, as if nothing had ever grown there.

The viewing room was quiet for a while.

Dr. Meng took off his glasses, rubbed his eyes, put them back on, and leaned close to the lightbox, his nose almost touching it. "Disappeared...disappeared?" His voice trembled.

Director Tian stood to the side, equally incredulous; an aneurysm had simply vanished.

Yang Ping stood behind, his face expressionless, only nodding slightly.

Tashi stared at the lightbox, his mind blank. He had been a doctor in Changdu for five years, witnessing aneurysm surgeries and interventional embolization, but he had never seen an aneurysm disappear on its own. On the operating table, surgical clipping or interventional embolization was like defusing a bomb. But now? The bomb was gone? The blood vessel had healed itself?

“Professor Yang!” Dr. Meng turned around, her voice filled with awe. “How were you so sure? Two weeks ago, when you prescribed vancomycin, I didn’t say anything, but I was actually very worried. What if it wasn’t an infection? What if the aneurysm ruptured? What if…”

Yang Ping interrupted him: "Are you still playing the drums?"

Dr. Meng paused for a moment, then shook his head: "No more injections."

Yang Ping said, "That's good!" He turned around and looked at Zaxi, "You understand too?"

Zaxi nodded, then shook his head: "I understand, but I don't understand how antibiotics can make an aneurysm disappear?"

Yang Ping walked to the lightbox and pointed to the angiography film, saying, "This isn't an ordinary aneurysm. An ordinary aneurysm is caused by the blood vessel wall being constantly impacted by blood flow, gradually thinning and bulging, like an inflating balloon. Antibiotics don't work for that kind of aneurysm; surgery is the only option, otherwise the thinned part will eventually rupture." He paused, then clipped on a film from two weeks prior, placing the two side-by-side for a stark contrast. "But this is different. This is an infectious aneurysm. Bacteria adhere to the blood vessel wall, causing local inflammation. The inflammation damages the vessel wall, causing it to bulge. It's not an inflating balloon; it's a ruptured vascular malformation."

Zaxi stared at the two photos, and images slowly formed in his mind.

Yang Ping continued, "Once you kill the bacteria with antibiotics, the inflammation subsides, the blood vessel wall repairs itself, and the aneurysm disappears naturally. It's like if you get a cut on your hand, it will heal on its own without infection."

Zaxi was stunned; he had never imagined that an aneurysm could "heal" like this.

Dr. Meng sighed from the side, "Professor Yang, when you came for the first consultation, you asked me if I had checked the infection indicators. At the time, I thought you were overthinking it, but now I realize that I was just too inexperienced."

Yang Ping shook his head, his tone calm: "It's not that you lack experience, it's that you trust the test results too much. A negative blood culture doesn't mean there's no infection. Infections can hide in the intestines, teeth, sinuses, or even in places you can't see. The job of a clinician is to find these hidden things."

"Professor Yang is truly amazing! We've learned something real from him today. Aren't you going to take notes?" Director Tian urged Dr. Meng to take notes as well, seeing that Zaxi was taking notes.

He glanced at his watch and said, "Let's go see the patient."

Zaxi followed Yang Ping towards the ward. His mind was still churning. Back in Changdu, how many "idiopathic" diagnoses had he seen? Unexplained headaches were called idiopathic headaches; unexplained cerebral hemorrhages were called idiopathic cerebral hemorrhages; unexplained aneurysms were called idiopathic aneurysms. The word "idiopathic" covered up all the problems, as if the diagnosis was complete.

But now he understands that "idiopathic" is not the end of diagnosis, but the starting point of reflection.

In the ward, the patient looked much better than he had two weeks ago. His face had regained color, his eyes were no longer so sunken, and he was leaning against the headboard, talking to his wife. When he saw Yang Ping enter, he immediately sat up straight.

"Professor Yang!" His voice was much stronger than it had been two weeks ago. "Dr. Meng just came by and said my aneurysm is gone. Is that true?"

Yang Ping walked over, picked up the film from the bedside table, and held it up for him to see: "Look for yourself."

The patient stared at the scans for a long time but couldn't make heads or tails of them. However, he believed what Yang Ping said. His lips trembled a few times, but he couldn't utter a word.

His wife was already crying beside him. She took out a tissue from her bag, wiped her eyes, and said in a choked voice, "Professor Yang, thank you, thank you so much. For the past two weeks, I've been on tenterhooks every day, afraid that thing would suddenly explode. I couldn't sleep at night, so I sat by his bedside watching him, afraid that something would happen to him. Now it's all right, I can finally get a good night's sleep."

Yang Ping waved his hand and said calmly, "No need to thank me. This kind of case is actually very deceptive. I was almost fooled by it too. Fortunately, Director Tian and Dr. Meng were very careful and gave me a lot of clues, which helped me solve it. If it weren't for their meticulous and solid preliminary work, I wouldn't have been able to find out. So I want to thank them. You've eaten ten loaves of bread and are full. I'm just the last tenth one."

The woman wiped away her tears, laughing and crying at the same time: "Thank you, Director Tian, ​​thank you, Dr. Meng."

Director Tian and Dr. Meng felt a little embarrassed by the undeserved reward and simply nodded slightly.

Yang Ping added, "However, I want to make it clear to you that although the aneurysm has disappeared, the intestinal problem is not completely resolved. Clostridium difficile infection is prone to recurrence. After discharge, you need to continue taking medication and have regular check-ups. You also need to pay attention to your diet, eating less oily food and more easily digestible food. If diarrhea occurs again, come to the hospital immediately."

The patient nodded repeatedly: "I've got it, I've got it!"

Yang Ping asked a few more questions, checked the nervous system, and only after confirming that everything was normal did he turn around to leave.

Suddenly, Zaxi mustered up his courage and asked, "Professor Yang, may I ask the patient a few questions?"

Yang Ping glanced at him and nodded.

Zaxi walked to the bedside and asked, "You mentioned before that you started having diarrhea about six months ago. I'd like to ask if you've been to the hospital and what medication you've taken?"

The patient thought for a moment and said, "I've been to several hospitals, and they all said it was irritable bowel syndrome. They prescribed probiotics and montmorillonite powder... but it didn't work. Later, a doctor prescribed cephalosporin, but after taking it for a few days, my diarrhea got even worse."

Zaxi's heart skipped a beat: "Is it pulling even harder?"

"Yes!" the patient said. "I used to have diarrhea once or twice a day, but after taking cephalosporin, I had diarrhea four or five times a day. I thought it was a problem with the medication, so I stopped taking it."

Tashi nodded and then asked, "When you had a fever, did you have a blood test?"

The patient said, "I had my blood count checked, and they said it was high and I had inflammation, which is why they prescribed antibiotics."

Zaxi wrote all of this down in his notebook, and then asked, "Have you eaten any special foods or traveled far in the past six months?"

The patient shook his head: "No! I've just been eating normally, and I haven't traveled far."

Tashi asked a few more questions, and when he felt it was about time, he thanked him.

The patient was very cooperative with Zaxi, answering all his questions patiently and in detail, as if afraid of missing anything.

As they left the ward, Yang Ping asked Zaxi, "What are you trying to prove by asking these questions?"

Zaxi said, "I want to figure out how he got infected with Clostridium difficile. Was it because the antibiotics destroyed his gut microbiota that Clostridium difficile grew?"

Yang Ping nodded: "That's the right approach. So what's next?"

Zaxi thought for a moment and said, "Then, I can write a case report about this kind of cerebral aneurysm caused by Clostridium difficile infection. I have checked the literature, and it seems that there have been no reports of it in China."

Yang Ping glanced at him, a hint of surprise mixed with approval in his eyes. "You checked the literature?"

Tashi nodded, a little embarrassed: "Last time you said the chain of evidence was missing a link, so I went back and checked. I read through all the literature on Clostridium difficile-infected aneurysms. I found more than a dozen articles, most of which were from abroad, and there was only one review article from China."

Yang Ping was silent for two seconds, then said, "Then write it down, and I'll help you revise it when you're done. So remember, you need to weave your knowledge and experience into a net, and this net can be woven slowly, not in a day or two."

Zaxi was surprised that Yang Ping would offer to help him revise his thesis. He had written several case reports in Changdu, but they were all rejected, so he hadn't written any since.

"Thank you, Professor Yang." His voice was a little strained.

Yang Ping waved his hand and walked towards the elevator. After taking two steps, he stopped, turned around and said, "By the way, that case report must be written carefully. Do more research and try to use one case to thoroughly understand this disease."

Tashi nodded vigorously: "I will definitely write it well."

That afternoon, Tashi sat in his dormitory, staring blankly at his notebook. He had so much to write: medical history, physical examination, test results, imaging data, treatment process, literature review—every part had to be written clearly, and every detail had to be accurate.

He opened his computer, created a new Word document, and typed the title: "A Case of Infectious Intracranial Aneurysm Secondary to Clostridium difficile Infection".

Then he got stuck.

How should he begin? How should he describe the chief complaint? How should he organize the medical history? The case reports he wrote in Changdu were all just copied from templates. But this time was different. Yang Ping said he would help him revise them, so he couldn't be careless and wrote them carefully.

He thought for a long time, but couldn't type out a single word.