Nineteenth Century Medical Guide

Chapter 496, Section 492: Pray that God will give you good luck.
The operating room was a complete mess.

Anders' hospital gown sleeve was torn, the bed sheet under him was crumpled and twisted, and the instrument table next to the bed was kicked over and the things were scattered everywhere.

Bergette's mask was ripped off, revealing a faint bloodstain beside her face. Antonio had also been kicked twice; two large footprints were clearly visible on his apron. He was now calling for the nurses to redo the disinfection, and the entire theater was in chaos.
But in any case, Anders finally fell asleep.

Looking back on the whole process, Kavi did not handle it well. Firstly, he hadn't encountered this kind of patient in a long time, and secondly, Anders' fear was too intense, but the most important reason was that he misjudged the efficacy of "chloral hydrate".

After reflecting on his actions, Kavi walked to the control panel, picked up the medicine bottle, and glanced at the unfamiliar label: "Where did this medicine come from?"

Antonio, oblivious to the problem, only felt that the medicine could bring him and Cavie closer, so he was very excited: "I've read your experimental report published in the journal and learned that it's very effective for postoperative analgesia and sedation, so I suggested a few months ago that the hospital keep some on hand."

That wasn't what Kavi wanted to know. He turned to Bergert and asked, "Isn't this our chloral hydrate?"

Bergette hesitated for a moment: "I saw some medicine in the cupboard, so I didn't use my own."

“The label is wrong, the bottle size is incorrect, and it wasn’t produced in our factory.” Kavi looked at Antonio. “Where did the medicine come from?”

"I don't know, I just made a suggestion to the dean, and the medicine arrived a week later." Antonio realized something was wrong. "The medicine did arrive very quickly, but I didn't think much of it at the time. Now that I think about it..."

"Although the synthesis of chloral hydrate is not difficult, in principle the patent for the drug is still in my hands. From ordering, contracting, making payment to delivery to Spain, it will take at least two weeks."

Kavi withdrew his gaze from Bergett and returned to Anders' side. After examining his pupils, he pressed down on his eye sockets to confirm the depth of the anesthesia: "Judging from the effect, the effective ingredient is limited; it's probably a counterfeit, low-quality drug."

"Or perhaps."

Bergert interjected at the opportune moment: "Or perhaps someone tampered with the medicine. Chloral hydrate is not difficult to synthesize; surgical departments in various European countries purchase it, and it's available here as well. Counterfeit drugs of such poor quality shouldn't be made for profit; there might be other motives."

Kavi was well aware that his Swiss pharmaceutical factory's processes were far inferior to modern methods in terms of purification, resulting in a slight difference in efficacy. Even considering individual differences, it was unlikely that a large dose would have no effect whatsoever.

There must be something wrong with the medicine; the first thing that came to his mind was Laszlo.

It's not fair to blame Kavi for being sensitive; he and Laszlo had always had friction over pharmaceuticals, and their separation wasn't exactly amicable. Had Kavi not voluntarily given up the old factory in Austria, it would have been difficult for him to break free from Laszlo's control.

Of course, what outsiders see as a drastic decision was merely a necessary process of self-reflection for him.

Originally, each drug patent was only valid for one year, and most of the key figures in the pharmaceutical industry had gone to Switzerland with Cavie, including the dye factory that Linette inherited from her father, which was also moved there.

With preferential policies from Mayor Rost, financial support from Victor and Gustave, and management from Savarin, Mattick, and Linette, the pharmaceutical company quickly dominated the European pharmaceutical market from the moment it opened, under the name "Kavi Hines".

The Vienna location quickly became an empty shell.

Even with László's intelligence, he knew that it would be unwise to fight to the death with this genius when he knew he couldn't keep him. The punitive pressure to relinquish the old factory was merely a test of Kavi's resolve; if one was willing to give up, the other would be willing to let go.

With Kavey gone, it's almost impossible for the old factory to stay afloat.

In his view, with several drug patents expiring and no new drugs being added to the production line, the old factory would go bankrupt within six months. But in reality, under Laszlo's management, the old factory persevered.

Kavi didn't understand business management, so when the medicine had a problem, his first thought was Laszlo. That's why he couldn't help but glance at Bergett, afraid that his good assistant would find out the inside story.

But he soon realized that large capitalists like László controlled countless industries, large and small, in Austria, and there was no need for him to do such a thankless task. Considering that the previous fake drug incidents were unrelated to László, he quickly abandoned the idea.

Bergett's subsequent explanation further corroborated this point.

“It seems I’ll need to speak with your hospital director after the surgery to find out more about the situation.” Kavi told Berget to put the medicine bottle into the briefcase. “Send it back and have them analyze the ingredients.”

"Should we look for Duke Aosta?"

"No need, this isn't Paris. You can see the situation here, there's no need to go through all this trouble, and he doesn't have time for such trivial matters."

Without blaming or wanting to take it out on anyone, Kavi's thoughts returned to the surgery itself. He waved to the nurse who wanted to spray the wine vinegar again and sent her away: "Let's do the surgery first, and we can talk about other things after Mr. Anders's stomach has healed."

Three years have passed since the promotion of laparoscopic surgery. After the Paris Medical Congress and the Vienna International Surgical Congress, laparoscopic surgery is far from being popularized and is not a basic surgical procedure that any surgical director would dare to try easily. However, thanks to Kavi's detailed hand-drawn atlas, it has been successfully included in the textbooks of various medical schools.

It also includes items such as surgical indications, diagnostic methods, anatomical details, intraoperative precautions, and postoperative care, which is like feeding food to every surgeon.

With surgical techniques constantly being updated and iterated, many surgeons want to break free from the constraints of a lifetime of dealing with amputations and stone removal, but very few actually make a living from it.

The main reason is that there are too many and too complicated anatomical details. A single surgery can involve several or even a dozen new knowledge points that have never appeared in anatomy textbooks. Not to mention surgeons who have entered clinical practice, even anatomy professors who spend all their time in the anatomy teaching and research department find it difficult to keep up with Kavi's pace.

After giving up, one can only rely on past achievements.

Doctors like Antonio, who spend exorbitant sums to acquire cadavers, practice repeatedly, and dare to explore new avenues of expertise, are destined to be a tiny minority. He needs more than just money; he also needs the courage to face setbacks and a touch of anatomical talent.

Even so, it was only after a year of study that he had the idea of ​​applying the surgery to clinical practice.

Kavi was willing to give him a chance, or rather, he was willing to give every brave surgeon or even medical student a chance.

For Antonio, the mere presence of Cavie was already a stroke of good fortune; to be able to watch him perform surgery from the stands was an even greater dream. To actually be able to operate alongside him as his second assistant today was truly an extraordinary experience.

His dream, which he had been having for a whole year, was slowly becoming a reality.

After disinfection and draping, a classic midline incision is made, the skin is cut open, and the abdominal cavity is dissected layer by layer, with retractors on both sides for fixation. These fixation steps are largely the same, but the following steps are somewhat different.

In the absence of imaging examinations and the inability to aspirate non-clotting blood, saline flushing is the preferred method. A large amount of saline can flush out blood accumulating in the nooks and crannies of the abdominal cavity, thus confirming the diagnosis of intra-abdominal bleeding. Once the diagnosis is clear, the surgical direction is defined, saving considerable time.

There was a lack of robust logistical support; preparing and storing saline solution was difficult. Antonio was prepared, but the amount was only suitable for an appendectomy, far from sufficient for intra-abdominal bleeding.

"No blood clots found." Bergett glanced at it briefly. "Should we wash it first?"

"There's not much water, so we need to use it sparingly. His heart rate is also unstable, so we need to find the bleeding site first and hurry."

Kavi didn't take the lead surgical position; instead, he delegated the entire process, from the abdominal incision to the organ examination, to Bergert, while he himself became the supervising nurse administering IV fluids. His attention constantly shifted, from Anders' vital signs to Bergert's abdominal procedures, and finally back to Antonio:
"Dr. Antonio, have you ever treated intra-abdominal bleeding before?"

This is a familiar yet unfamiliar medical term.

Antonio had naturally studied abdominal trauma, which was an important differential diagnosis for appendicitis. But when it came to the actual treatment, he faltered. When Cavie asked him this, he could only shake his head awkwardly: "No, the diagnosis isn't the problem. The main issue is the location; it's too complicated, and I don't have the ability to handle such a large incision."

"Afraid the incision won't heal properly?" Bergert reached into the abdominal cavity and touched the liver. "As long as disinfection and postoperative care are done well, the chance of incision infection is not too high."

“Well, disinfection is an important factor.” Antonio hesitated for a moment before telling the truth, “It probably also has something to do with the suturing technique.”

As if struck by a sudden thought, Bergette laughed: "Then the stitching up after this is all yours."

"what?"

“Dr. Kavi is here, what are you afraid of? Even if things get really bad, I'm here.” Bergett slowly leaned down, his hand already touching her side. “Everyone goes through this, don't be nervous.”

Kavi's mind raced, trying to formulate a diagnosis, but he wasn't in a good mood: "How is it? Is there an opening?"

“The liver is clean, no problem.” Bergett withdrew his hand, checked the gloves back and forth and found no blood, and began to examine the other side. “It should be a ruptured spleen, the location of the blow is quite close to the spleen.”

“If it were the spleen, the bleeding wouldn’t be so little,” Antonio suddenly interjected, then quickly explained, realizing his abruptness, “I had a spleen removal done once before, and the bleeding was so severe that it didn’t go well.”

"You've had a splenectomy, so how can you say you haven't dealt with internal bleeding?" Bergert joked while explaining another possibility, "Splenic bleeding can be massive, or it can be encapsulated, with only a small amount of blood flowing into the abdominal cavity, but the subcapsular hematoma can actually be very large."

At this point, he slowly frowned and had to look up at Kavi: "His spleen seems to be fine, its shape and size are normal."

Is there blood?

“A little, but not much.” Bergett pulled his gloves back. “Shall we move aside to examine it more closely?”

Compared to the more resilient liver and the better-hidden and protected porta hepatis, examining the spleen is more complicated. It requires examining the splenic porta hepatis, locating the accessory spleen, and, due to its anatomical location, also examining the pancreatic tail region of the retroperitoneum.

[After opening the spleen, the tail of the pancreas and the left lobe of the liver are exposed, and below that are the kidneys.]
Even a surgeon like Kavi cannot determine whether there is active bleeding in the spleen simply by touching it with his fingers. To determine this, one must rely on visual inspection, which requires dissecting the spleen to expose the area.

Is there any blood pooling around it?

“Emmm,” Bergett’s hand reached down again, this time following the splenic flexure of the colon into the lateral groove of the left colon and down. “There are some, but not many.”

This is the area most prone to blood accumulation when the spleen ruptures. Anders already had early symptoms of shock. If the spleen ruptured, a large amount of non-clotting blood would definitely accumulate here.

“It seems his liver and spleen are fine, but this is a bit troublesome.” Kavi’s judgment was swift, and he showed no intention of taking over the case: “Now we can only check his intestines. His condition is alright, so you guys hurry up.”

“People are annoying, and so are bleeding wounds!” Bergett disliked this step the most, but before Kavi could give the order, he had already reached into the lower abdomen, while simultaneously devising the next course of action in response to Kavi’s request. “Director Antonio, how about we split the work? I’ll check from top to bottom, and you check from bottom to top, okay?”

"Do we need to examine the entire intestine?"

"Of course. But it's mainly the small intestine that's affected; the colon usually doesn't rupture."

Bergert withdrew his hand, and finally, blood streaks and uncoagulated blood clots could be seen on the glove: "You should be able to find the ileocecal region, which is where the appendix is. If you can't find it, you can switch to another one."

Antonio could barely keep up with his train of thought. While his mind was still trying to figure out how to find the blind spot, Kave's voice arrived: "You should check the rupture by yourself. Antonio, get the blood out and be prepared to give yourself a blood transfusion in case of an accident."

"what?"

Kavi looked at the blood pressure monitor and felt a little relieved. "Your blood pressure is stable, but your heart rate is still a bit fast. I'll give you fifteen minutes, is that enough?"

"Your expectations are too high."

"Pray to God, and hope that He will give you, and Mr. Anders, good luck."

Bergett quickly located the ileocecal junction along the colon, instantly focusing his attention without uttering a single unnecessary word. Kavi also removed his gloves, preparing the equipment for autologous blood transfusion, sodium citrate, adrenaline, and saline solution for dilution: "Director, don't just stand there, hurry up and collect the blood."

"Fishing?"

“Your suction device here is too weak. It can only suction liquids like saline. How can it suction if there’s no blood clotting?” Kavi handed over the kidney dish and made a scooping motion with his hand. “Just do as I say and hurry up.”

Just as they confirmed Anders' diagnosis and the entire surgery was getting on track, the nurse knocked on the door of the operating room.

She hurriedly pushed open the door and saw a crowd of people wearing masks and hats. Not knowing who Kavi was, she simply asked them a completely new question in her Northern-accented Spanish: "That Spurs player, he, he can't breathe."