American Medicine: I survived the death knell thanks to the devil.

This young master is currently wearing a blue emergency room uniform, and the department on his name tag has been changed to "Emergency Room".

He was standing next to the second trauma bed, holding a CT scan request form in his hand.

He saw Lynn come in.

Julian was initially surprised.

Then came a fleeting moment of awkwardness.

In the end, he became a poker face.

"The orthopedic surgeon arrived quite quickly."

Julian slammed the CT request form onto the control panel.

What are you doing in the emergency room?

Lynn asked very directly.

Julian's jaw muscles tensed.

"Rotation".

He didn't seem to want to say a single word.

Lynn didn't press the matter.

Reassigning an attending physician from a specialist department back to the emergency room is no different from transferring a major general to stand guard.

The reason behind this is obvious even to a fool: old Cabot was angry.

But Julian's pride wouldn't allow him to show any resentment.

At least not in front of Lynn.

"Where is the patient?" Lynn asked, turning his gaze toward the trauma bed.

Julian opened the medical record folder.

When reporting on the patient's condition, he was concise, precise, and without a single superfluous word.

No matter how conflicted he felt, when it came to professional matters, he was still Julian. Apart from his medical skills, he was the most talented doctor in the metropolis.

"Male, 47 years old, Latino, construction worker. Accidentally wounded by a pneumatic nail gun at a construction site in the Bronx forty minutes ago."

He pointed to the patient on the trauma bed.

"An eight-centimeter frame nail was driven into the left palm, passing through the carpal tunnel area. The nail head was lodged under the skin on the palm side, and the nail tip was embedded in the trapezium."

Lynn walked to the bedside.

The patient was a Latino man of medium build, with skin tanned dark brown by the sun and hands covered in calluses and small scars.

His left hand was immobilized with a temporary splint, palm facing up, and the edge of the metal nail head could be seen bulging slightly from under the skin, with the surrounding skin bruised and swollen.

He was gritting his teeth, his forehead covered in sweat.

Standing next to him was a young man wearing a fluorescent green reflective vest, probably a fellow worker on the construction site.

The coworker's English was poor, with a heavy accent, and he kept telling the nurse, "Please help him" and "He has three children."

Lynn looked down at the X-ray.

Julian has already filmed.

On the anteroposterior radiograph, the frame nail is clearly visible, diagonally penetrating the carpal tunnel, entering from the palmar side, with the tip of the nail resting on the palmar cortex of the trapezium.

The key is the barbs on the nail.

Unlike ordinary nails, frame nails have spiral barbs on their bodies, specially designed to grip the wood and prevent it from coming loose.

This means you can't just pull it out directly.

The barbs will tear through all the soft tissue along the way as they are withdrawn.

The area through which the nail passed is precisely one of the most complex areas of the human hand structure: the carpal tunnel.

The median nerve, flexor tendons, and the superficial palmar branch of the radial artery are all squeezed into this channel, which is less than two centimeters wide.

"Lateral position," Lynn said.

Julian handed over the second film.

The lateral radiograph shows that the distance between the screw and the median nerve is less than three millimeters.

What's more troublesome is that there's a barb on the nail that gets stuck in the fibers of the flexor retinaculum, anchoring it like a fishhook.

Any violent pulling could tear the median nerve.

The median nerve controls the sensation of the thumb, index finger, and middle finger, as well as the opposition movement of the thumb.

A construction worker who loses the opposition function of his thumb loses the ability to grasp.

This is equivalent to losing the ability to work.

I've lost everything.

"Vascular condition?" Lynn asked.

"That's the problem," Julian said, his tone turning somber.

"Capillary return in the thumb and index finger is delayed, with a return time exceeding four seconds. The radial artery pulsation is significantly weakened distal to the wrist."

"I suspect that the nail compressed the superficial palmar branch of the radial artery, causing incomplete vascular occlusion."

He looked up at Lynn.

"The temperature at the fingertips is continuously dropping. It was 31 degrees Celsius when it was brought in forty minutes ago, and it's 28 degrees Celsius now."

Normal finger temperature is between 30 and 35 degrees Celsius.

Temperatures below 28 degrees Celsius indicate that tissues are beginning to experience ischemia.

The safe window for warm ischemia is six hours.

Beyond this time, irreversible damage will occur to the muscles and nerves, rendering the hand useless.

However, if the temperature continues to drop below 25 degrees Celsius, this window will shorten dramatically to two to three hours.

It took some time to get from the construction site to the hospital.

Every minute is being wasted.

"What about anesthesia?" Lynn asked the nurse.

"It has already been called."

The nurse glanced at the digital clock.

"The anesthesiology department said it would take at least another twenty minutes for an anesthesiologist to be available. There are two laparoscopic procedures being performed upstairs."

Twenty minutes to wait for the anesthesiologist to arrive.

The onset time for brachial plexus block is fifteen to twenty minutes.

The fastest it can take is forty minutes in total.

How low will the temperature of your fingers drop after forty minutes?

Lynn didn't want to gamble.

"Local anesthesia?" the nurse asked.

"Local infiltration anesthesia in the carpal tunnel area can cause tissue swelling and increase pressure within the carpal tunnel."

Julian answered for Lynn, "She already had vascular compression; injecting local anesthesia would only make things worse."

He paused for a moment after he finished speaking.

"I considered finger root block anesthesia, but the pin is located in the carpal tunnel, not in the finger. Finger root block is ineffective in the wrist."

Julian had already considered every possible solution.

All excluded.

"I'll come get it."

Lynn was already putting on gloves when he said this.

Julian looked at him.

"Without anesthesia?"

"We can't wait."

"So how do you plan to deal with the barb? Pulling it out directly is like tearing half of the carpal tunnel apart."

"Don't pull it out." Lynn braced himself against the glove a couple of times. "Go in, loosen the barbs from the fibers one by one, and then pull it out completely."

Julian paused for a moment.

"Without anesthesia? The patient will experience spasms of pain, and their hand will twitch involuntarily. A single twitch could sever the median nerve by a barb."

Any normal orthopedic surgeon would choose to wait.

Wait for the anesthesiologist to arrive, and then proceed with the procedure under completely painless conditions.

The price was forty minutes.

The price might be a hand.

"So I need someone to hold down his forearm."

Lynn looked up at Julian.

"Do you have the strength?"

Julian looked at him for three seconds, then put on his gloves.

"As long as you know what you're doing, that's enough."

Lynn walked to the patient's bedside.

"Sir, I am an orthopedic surgeon."

He spoke in Spanish, thanking the original owner for their efforts.

The patient's eyes lit up.

"Your hand is badly injured. A barbed nail is stuck inside, pressing on a blood vessel. If it's not removed quickly, you might lose your finger."

The patient's lips trembled slightly.

"I need to remove the nail without anesthesia. It will hurt a lot."

Lynn did not evade the question.

"But I'll do it as quickly as possible. What you need to do is: no matter how much it hurts, don't move your left hand. Can you do that? Otherwise, this hand will be useless."

The patient swallowed.

"Doctor." His voice was hoarse.

"I walk around on scaffolding 30 meters high every day, without any safety nets."

"My son says his dad is the bravest man in the world."

He looked into Lynn's eyes.

"I can do it."

When Lynn and Julian first met.

Lynn was promoted to second assistant in the emergency room, while Julian was the high-ranking attending physician.

Lynn is now the lead surgeon, and Julian is his assistant.