Nineteenth Century Medical Guide

Chapter 236.

Carvey admitted that he had made a mistake in his judgment.

There were many reasons for this, and besides increasing his options with the intrusive advice around him, the medical environment of the 19th century also created additional concerns for him.However, it is not his style to shirk responsibility. Taking this as a lesson, it is definitely more meaningful for everyone to learn a lesson than to maintain some unnecessary self-esteem.

In the absence of examination, there is nothing wrong with whether to directly open the chest to bear the risks of major surgery, or to perform pericardiotomy first and gamble on the success rate of conservative treatment.

The fault is that Carvey's cut choice is not good.

When heart 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 very important.

The pericardial fenestration incision chosen by Carvey is a longitudinal 5cm incision under the xiphoid process.Here, the bone structure on the outside of the thoracic cavity can be successfully avoided, and the incision path can also reach the posterior pericardial wall, and the suction is convenient and clean enough.

If an emergency thoracotomy is needed for cardiac surgery, the longitudinal incision under the xiphoid process can directly enlarge and cut the sternum upward.The incision usually extends from below the suprasternal notch to the xiphoid process, and is separated with a sternal saw.

This is the most widely used surgical incision outside the cardiothoracic, median sternotomy [1].

Cooperating 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 wounded is a combined thoracoabdominal trauma, this incision can also continue downward for laparotomy.

But unfortunately, it is now the 19th century, and how to split the sternum and how to pull the sternum to both sides to resist the huge rebound force after the split has become a difficult problem for Carvey.

He doesn't have a retractor that can fix the surgical field. Although it can be done by manpower, human muscles can't stabilize it for a long time like a machine.

Moreover, splitting the sternum is not as easy as imagined. It is difficult for ordinary bone saws to complete the correct median sternotomy.

It is only a trivial matter if the split is crooked, and it will affect the prognosis of sternal closure after operation.But once the force is too large, it will be a big trouble, because except for some shallow fibrous tissue below the sternum is the right ventricle.

This is a flaw in surgical tools, and the scarcity of cardiothoracic surgery does not give Kavey the experience of practicing existing tools, which cannot be made up for by his own skills.

In comparison, the left anterolateral thoracotomy with the fourth and fifth ribs as the entry point is much more modest. 【2】

This traditional approach will encounter many blood vessels and nerves, and surgical operations will inevitably produce intraoperative injuries.And because the wounded is lying flat on the operating table, when the blood and fluid in the pericardial cavity are sucked, there will definitely be residues, that is, the suction will not be clean.

In the face of major heart repair surgery, in order to expand the field of vision, it is also necessary to remove a considerable part of the bone structure.

The rib incision on the left side of the chest has a lot of shortcomings, and many trauma centers have already abandoned it.However, in today's surgical environment, it can handle both pericardial tamponade and cardiac repair without using a sternal retractor, achieving dual-purpose use in one bite.

This incision also reverses the transection of the sternum for increased exposure if the surgery requires increased central vision.
In fact, there are many advantages. It boils down to fast and convenient chest insertion, and faster recovery after surgery.Carvey's modern surgical thinking ignores this point, and although it will not produce much bad results, it makes Rogerini suffer another stab.

"There was a problem with the subxiphoid-process incision just now. I will make another incision now. Prepare the rongeur and bone scissors."

Carvey asked Lucius and Goram to handle the incision under the xiphoid process, while he quickly cut the skin on the fifth rib: "From this position, go directly to the left heart, and solve the pericardial tamponade and heart tear."

The people around have never seen such a large chest incision, and the operation has been developing in a direction that no one can imagine.

As surgeons, they have mixed feelings. On the 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 Kavey's inhuman technique collides with such serious trauma. Whether there will be new miracles in the future.

The distance between the skin and the ribs was very short, so Kavey separated the subcutaneous tissue and muscles, and quickly freed the ribs, then used scissors and rongeurs to remove about 4 cm of the costal cartilage between the sternum and the ribs, and entered the precordial area through the costal bed. 【3】

This time the field of vision is much better than before. I can see a large pericardium, and I can see more blood clots and loose connective tissue.

Carefully removing the clot with forceps and pushing away connective tissue, Carvey asked, "How's the tension on the sutures underneath you?"

"There is a problem with tension." Lucius sewed up the pericardium for the first time, not to mention experience, he had never even touched anatomy, "It may take time to suture."

"Can't sew?"

"There's a bit of bleeding, and"

"Forget it, don't suture for now, just leave it like this." Kavi quickly made a decision, "Gorham is responsible for sucking the bleeding, and the incision will be sterilized first, and then covered with wet gauze. Come up and help Me, I need people here."

The incision is left just in case, and multiple incisions can provide one more way to operate.Although this approach is unconventional, since it has been cut, it is simply a mistake.

What's more, the pericardium is something that can be sewn or not. Forced suturing is a constraint on the heart, and it may also cause other unpredictable injuries.Opening the pericardium can give a gap to the attractor, at least not to refill the pericardium.

Carvey reproduced the surgical method of treating the pericardium just now, but changed the traction wires used for suspension to two, located on the left and right sides of the incision, and gently incised the middle with a scalpel after lifting it.

Suddenly, the nurse at the side reported Rogerini's vital signs: "The heart rate suddenly increased, and it is now 145 beats per minute."

In fact, there is no need for a nurse to explain, just relying on the naked eye Kavi and the other surgeons at the operating table can see how crazy Rogerini's heart is beating: "Re-test the blood pressure, is the blood matching in place? I am going to have a blood transfusion now." !"

"It should be better soon."

"Increase the infusion." Carvey inserted a finger into the pericardial opening he had cut, and while scraping off the blood clots, the auxiliary suction device sucked them away. "What about blood pressure? Report your blood pressure, and your heart rate." .”

"Heart rate 147, blood pressure 87"

The nurse's measurement speed was already very fast, and being able to be on Lucius' operating table already showed her excellence.Before Carvey proposed to take a blood pressure measurement, she had already tightened the air bag of the sphygmomanometer, and gave the systolic blood pressure in less than half a minute.

Just wait for the mercury level to drop for the diastolic reading to come out.

But Rogerini's heart and Kavey's fingers didn't have time to wait for this value, only a soft "hiss" was heard, and a straight dark red strip of blood shot out from the center of the operating table.

[The height is estimated to be half a meter. It may be higher, or it may be a meter. I can't remember the distance, but it is too exaggerated!If it were me, I don’t even know what to do]
This was the impression left by the scene in the eyes of bystanders during the operation. Although the bleeding was quickly stopped, such an exaggerated amount of bleeding was still fresh in people's memory.

However, Carvey's next operation is even more difficult to let go.

He saw the location of the bleeding in an instant, and after successfully avoiding the gushing blood, he only used one left index finger to press down on the rupture at the apex of the left heart. 【4】

When other people's minds are troubled by questions such as "something is wrong", "why is the bleeding suddenly", "it's over", "what should I do", etc., he has easily solved this problem and is presenting The nurse on the side asked for sutures.

"Give me the needle and thread, quick!"

".Um, good."

"blood pressure?"

".Depress 35."

"Quicken the infusion."

Kavi's fingers lightly pressed on the surface of the heart breach, and the height fluctuated up and down with the fast beating heart. He looked back at the other doctors who were already excited, but called Sarson alone, "Sarsen goes to wash his hands , came to the stage to take over Goram's lower cut."

"it is good."

"Gorram came up to suck up 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 had worked in surgery for more than ten years, and it was the first time he took over such an exaggerated operation.Using his fingers to press the opening of the heart and maintain the original beating of the heart, he had never even thought about it before.

Excitement is already hard to describe his current mood, and there is only one word left: bewildered.

"Is it okay? If not, forget it."

Lucius swallowed and nodded repeatedly: "Okay, I'll try."

Although Carvey valued his previous puncture performance, but now he does not complete this handover with a teaching mentality, but because he needs to free up his hands to find the bullet that entered Rogerini's chest.

Judging from the ballistic position, the bullet should have passed through the left lung and entered the pericardium, and then created a gap a little above the apex of the left heart.

There is the gap under Kavey's finger, and the feeling from the pulp of the finger is that the gap is a tangent line rather than a bullet hole.This shows that the bullet just passed close to the apex of the heart, causing a tangential injury, but the angle of entry was obliquely downward, and the bullet was likely to go further down.

Residual warheads are a more troublesome thing, which may cause sequelae to soldiers, but it may not.

If what is being done now is conservative treatment like those common thoracic gunshot wounds, there is no need to remove the bullet.However, Carvey had already opened Rogerini's chest cavity. At this point in the operation, removing the warhead should also be included in the surgical procedure.

"Whether you tried to find and get it" and "whether you found it or not" and "whether you can get it" are completely different things.

"Put your fingertips against mine, yes, just use that force!" Carvey and Lucius pressed their fingers together, "Slowly move down, yes, slow no no no, stop!"

The handover was stopped temporarily, and Kavey quickly removed his fingers, and continued to cover the rupture with his left index finger: "Your fingers are too stiff, I asked you to use force, it is the wrist, not the knuckles. ,understand?"

After hearing this, Lucius looked at the beating heart again, and nodded: "Understood, the knuckles need to fit the beating of the heart, and it shouldn't be too heavy."

"Try again, if it doesn't work, forget it."

Kavi didn't dare to make fun of the heart. The exaggerated ejection ability of the left ventricle can make Rogerini go to God in a short time.Some teaching needs to be done, and some teaching is too dangerous to be done until the trainee has enough experience.

The fingers of the two continued to do the action just now, and this time Kawei also used his right hand.

The thumb and index finger of the right hand are placed on both sides of the rupture, and follow the beating of the heart like the index finger of the left hand, and try to align the two sides of the rupture: "Yes, that's it, use your wrist hard, otherwise your fingers will be bounced away by the blood The metacarpophalangeal joints must be rhythmic and relaxed, but the pulp of the fingers must fit on the surface of the heart without leaving any gaps, right, right."

A breach of only 1.5cm, but it took a full 2 ​​minutes to hand over the fingers.

There is Kawei's caution in it, and it is also full of giving Lucius the time to fully familiarize himself with the beating of the heart.After all, surgery has never been a genius, and it is difficult for a doctor who has not experienced heart surgery to seal the heart breach with his fingers.

Relatively speaking, Kavey was just an accident, and there was not much talent behind it, and some were just the experience and skills gained from more than 30 years of tireless practice.

Now the situation has gradually stabilized from the chaos at the beginning. Although the vital signs are a little dangerous, the infusion is increasing, and the blood transfusion is on the way. Everything is developing in a good direction.

But the better the situation is, the more we cannot take it lightly.

Carvey now successfully freed his hands and began to re-explain the operation: "Rogerini's luck is really good, the bullet did not enter the heart chamber, but shot from the left front, rubbing the myocardium above the apex of the heart. into the back of the heart.

Now I need to find the bullet head, that stuff stays in the body no one knows what's going to happen next. "

At this time, Sarsen had already stepped onto the stage and picked up the attractor left by Goram.What he has to do is to clean up the blood clot in the incision here, and then ensure that the outflow of blood will not accumulate in the incision.

Gorham replaced Lucius's position, doing the work of protecting the hook of the incision.Lucius blocked the opening in the heart, and Kavi used his fingers to gently dig into the back of the heart to search.

"If his luck is really good enough, the bullet should stay in the pericardial cavity. If his luck is too bad, then I will only have to" Kavey's fingers repeatedly stirred the back wall of the heart, feeling the beating, and suddenly touched A hard solid, "It looks like the warhead is really here, quick, give me the tweezers."

The nurse delivered the surgical forceps.

"Lucius, you lift your heart a little with the other hand. Yes, gently, not too hard."

Carvey inserted the tweezers into the opening of the pericardium, followed the direction and path that his fingers entered just now, and searched for it behind the heart.Relying on his amazing fingertip feeling, he finally touched the bullet with the tweezers in a corner.

"Come on, come on, come on, give me a bend, this criminal bullet that seriously injured the Austrian soldier has finally come out!!!"

(End of this chapter)