Chapter 478 Closed chest drainage, like to teach others
Pneumothorax can be divided into two categories based on its cause: primary and secondary.
This patient had his first pneumothorax after yelling, which is a primary pneumothorax. This disease is more likely to occur in men than in women, with a ratio of about 6 to 1.
The main cause of pneumothorax in men is rupture of subpleural bullae.
Especially some tall and thin people are more likely to suffer from spontaneous pneumothorax.
Through diagnosis, Zhou Can has determined that the patient suffers from left-sided spontaneous tension pneumothorax.
He had just used an 18-gauge thick needle to puncture the second intercostal space on the left side of the patient's clavicle to vent the air. Currently, the patient's pneumothorax symptoms are still severe after treatment.
I originally thought it was a case that could be easily cured, but unexpectedly something went wrong.
He took the patient's chest X-ray and looked at it again, thinking quickly about a solution.
"Performing closed chest drainage on the patient to expel the gas may be a good treatment method."
After careful consideration, he decided to use this technique to treat the patient.
There are two important indications for closed chest drainage: first, the lungs are compressed by more than 30%. Second, there is tension pneumothorax. This patient met both indications, and there was no problem with the procedure.
There are two methods of drainage intubation for closed chest drainage, one is the cannula method and the other is the incision method.
The incision is not a major operation, and only an incision of about 1.5 cm is required.
The two methods are basically the same in principle, and each has its own advantages and disadvantages.
Zhou Can prefers the incision method.
This method is more direct and more likely to produce results quickly.
After communicating with the patient's family, they trusted him very much and agreed to receive further treatment.
This trust is very rare.
Because the first puncture treatment was ineffective, most family members will begin to question the doctor's ability.
Zhou Can is so young that his family members may easily think that he is incompetent and unreliable.
It has to be said that mutual trust between doctors and patients is indeed very important. It can greatly enhance the enthusiasm and autonomy of doctors in treatment plans and dare to give full play to rescue.
If the family members are difficult to deal with and question the doctor at every turn, this will cause the doctor to instinctively protect himself.
In terms of treatment plan, conservative treatment is definitely the main focus.
Director Xue fully cooperated and quickly allocated a temporary surgery room for Zhou Can to use during the operation.
After infiltration anesthesia was administered to the patient's pleura, the operation began.
This does not require entering the operating room and can be performed directly in the ward.
With the assistance of the instrument nurse, he held the traditional willow-leaf scalpel and made an incision of about 1.5 cm directly on the patient's chest skin. After cutting the subcutaneous tissue, he used a long curved vascular forceps to bluntly separate the muscle layer until the pleura.
The entire operation was completed in one go, quickly and efficiently.
After separating the pleura, he carefully inserted the drainage tube into the chest cavity along the separated hole.
It seems easy, and the entire operation is performed with superb surgical skills.
One minute on stage, ten years of hard work off stage.
After all, this minor operation requires the placement of a drainage tube into the chest cavity, so the danger is self-evident.
Blunt separation of the chest muscle layer to the pleura, needless to say.
If the tearing is not done well, it can directly tear a big gap in the patient's chest.
After the drainage tube was successfully inserted, he fixed the drainage tube firmly and then connected the drainage tube to the connecting tube.
"Can you hear me?"
Zhou Can looked at the patient.
"able!"
The patient's voice is still a little weak, and it is easy to cause chest pain when speaking.
After a pneumothorax occurs, breathing becomes painful.
Many people describe the feeling of being heartbroken after a breakup as being unable to breathe. The symptoms are actually quite similar to pneumothorax.
"Try to take a deep breath!"
Zhou Can asked the patient to take a deep breath.
There are two purposes for doing this. The first is to observe the fluctuation of the water column in the water seal bottle. The second is that the patient's deep breathing is conducive to the early expansion of the compressed lungs.
The patient's left lung was compressed by more than 90%, which is very serious.
Reinflating the patient's left lung as soon as possible will be beneficial to recovery.
“It hurts, it hurts so much!”
The patient tried to take a deep breath, but halfway through, he cried out in pain and gave up.
"Procaine is still having an anesthetic effect! Even though it's only a local anesthetic, it can at least relieve some of your pain. You can't stand such a little pain. Keep taking deep breaths. You are a man. Don't worry, I'm here to watch over you. Nothing will happen to you."
Zhou Can encouraged the patient to try deep breathing again.
For many patients, pain is one of the difficulties they have to endure.
The patient took a deep breath again and still cried out in pain, but it was much better than the first time.
"Okay, stop and take a deep breath first!"
Zhou Can called a halt, while observing the water seal bottle with a frown on his face. The cannula had been successfully placed and connected to the connecting tube, so why was there no fluctuation in the water column in the bottle?
Fortunately, there is negative pressure.
If the water column does not fluctuate and there is no negative pressure, it means that the drainage tube is leaking or has fallen out of the chest cavity, and it must be dealt with promptly.
Zhou Can just made sure that the drainage tube was fixed.
There is negative pressure, which means there is no leakage.
There are only two situations: either the patient's lungs are already expanded or the drainage tube is blocked.
It is estimated that it is unlikely that the patient's lungs have expanded.
He speculated that the drainage tube might have been blocked during placement.
Try adjusting the drainage tube and have the patient take another deep breath. This time the water column fluctuates.
Finally got it done.
It seems that the drainage tube was inserted too deep and was blocked by the tissue in the chest cavity.
"Come on, keep taking deep breaths, things are going well!"
Zhou Can guided the patient to continue taking deep breaths, and everything was normal.
Checked and found nothing wrong.
The patient was sent back to the inpatient ward, and then the attending physician and nurse were instructed to monitor the patient's vital signs in a timely manner and actively provide the patient with oxygen inhalation, anti-infection, bronchial spasmolytic and expectorant treatments.
Director Xueyan couldn't wait any longer when she saw that Zhou Can had finally successfully treated the patient.
A nurse was sent over to urge him to help in the operating ward.
When performing some difficult surgeries, having Zhou Can by her side is like having an extra talisman. In many difficult surgeries, or when time is of the essence, Zhou Can can replace her as the lead surgeon.
Whenever unexpected situations occur during surgery, such as cardiac arrest, ventricular fibrillation, or a sudden drop in blood oxygen, Zhou Can is there to provide timely rescue.
When it comes to rescuing patients, Zhou Can is very good.
After studying with Director Feng of the Anesthesiology Department for the past two years, my skills in this area have become more and more outstanding.
On two occasions, patients suffered accidents during operations, and even Chief Physician Dongfang Xueluo had to ask Zhou Can for help.
…
The next day, Zhou Can was worried about the patient with pneumothorax, so after making rounds in the emergency department early in the morning, he went to the cardiothoracic surgery ward to check on the patient's condition.
After examination and questioning, the patient's left chest pain was relieved and his dyspnea symptoms were greatly improved, with significant improvement.
The family members were very grateful to Zhou Can. Seeing that the patient's condition had improved significantly after treatment, the patient's mother and sister were very happy and looked much more relaxed.
The nurse told Zhou Can that the patient's current body temperature was a low fever.
A low-grade fever is normal .
Zhou Can asked the nurse for the stethoscope and listened carefully to the patient's chest sounds.
"His left chest breath sounds are still a little weak, but fortunately there are no dry or wet rales, so he can take more deep breaths. Also, do not touch the drainage tube. If it becomes loose, you must find a nurse or the attending physician in time ."
In general, pneumothorax treatment still has certain risks.
When Zhou Can was doing his residency in cardiothoracic surgery, he saw a patient die after undergoing pneumothorax drainage.
The lesson that time was very painful. It was due to the nurse's carelessness and the attending physician's negligence, but also because the family members and the patient did not follow the doctor's orders and tampered with the water seal bottle.
There are many dangers that family members and patients cannot see because they are not professionals.
Even some medical staff who are not professional enough or have low vigilance cannot detect the hidden dangers in time.
Even after several years, Zhou Can still be extremely careful when treating patients with this type of pneumothorax.
He also repeatedly reminded the medical staff in charge of the patient not to be careless.
After more than ten hours of drainage, a moderate amount of gas could still be seen leaking out of the water seal bottle, and the amount of bloody fluid drained was as high as more than 900 ml, which was bright red in color.
This indicates bleeding.
The attending physician did not call him, but effective treatment measures had already been taken.
Including blood transfusion, blood volume replenishment, and intravenous cefradine to prevent infection.
At the same time, intravenous aminobenzoic acid was given to the patient to stop bleeding.
These measures were used promptly and reasonably, and also made Zhou Can look upon the level of the attending physician with new eyes.
After more than 20 senior medical staff were poached from the Department of Cardiothoracic Surgery, the department gained a large number of opportunities to attract young talents and gradually began to regain new vitality.
After all, it is an important department, and Tuya Hospital has a strong foundation.
There are many postgraduate students who have completed their regular training and have four complete certificates, and they are lining up and trying their best to get into this provincial tertiary hospital.
Many of these physicians are general practitioners.
In fact, current clinical medical students tend to choose general medicine when choosing their field of study. Don't be fooled by many instructors who say that you can't chew too much.
Only someone who stands at the level of a mentor is qualified to say this.
For ordinary medical students, the most important thing is how to find a job more easily and how to get into the important departments of large hospitals.
General practitioners are more competitive and have more opportunities to enter large hospitals.
In addition, even if a medical student is a doctoral student like Du Leng, or graduated from a prestigious overseas university, he still has to learn from the most basic practices after working in a hospital.
If you keep holding your head high, you will appear to be overambitious and ultimately end up in an embarrassing situation where you are crushed and beaten by an undergraduate like Zhou Can.
"Excuse me, excuse me. The patient in bed 55 just had arrhythmia and I rushed over to treat him. Doctor Zhou, I'll write down what instructions you have given me!"
The attending physician was not the intern who had brought the patient from the emergency room yesterday.
It was a young male doctor named Pu.
He is in his early thirties, with a shaved head, wearing a pair of frameless glasses, a round face, a broad and round forehead, and a square chin. The first impression he gives is that he is a down-to-earth, honest and kind person.
"Did Dr. Pu perform the blood transfusion, hemostasis, and anti-infection for the patient last night?"
Zhou Can admired this doctor very much.
"Yes... I did it all. I considered that it was already one in the morning and you didn't start the surgery until nearly twelve, so I didn't disturb you. Is there something wrong?"
Dr. Pu is also a resident doctor, although he is several years older than Zhou Can.
At this moment, he was talking to Zhou Can as a junior doctor.
It's a gesture.
No one taught him, it was purely a decision made by his personal ability to survive in the workplace.
"You did a great job. This is how you should treat patients with hemothorax. For patients like this, as long as the drainage is effective and the bleeding area is compressed after the lungs are re-expanded, they can basically heal on their own. If bleeding continues, you must consider performing a thoracotomy in a timely manner to stop the bleeding. When you take over, you must explain clearly to the doctor who takes over and observe closely."
Zhou Can really isn't someone who puts on airs.
Normally, even when the attending physician talks to him, he basically uses this attitude of asking for advice.
He used to try to talk to them politely, but then he found that he made the other party feel flattered and it was very difficult to have a conversation.
Zhou Can really doesn't have the time to waste on long-winded and polite conversation.
Besides, he is a very down-to-earth and straightforward person, and he doesn't like false politeness. Later, he just let things take their own course.
"Okay, I'll make it clear."
Doctor Pu wrote it down carefully in his notebook.
"Doctor Zhou, can you tell me the reason for bleeding in these patients? There is a big discrepancy between practice and what is in the book. I would like to learn more about practical experience in this area."
He explained with a smile.
"The main cause of hemothorax is the tearing of the adhesion between the visceral and parietal layers of the pleura. Most of the bleeding is caused by the rupture and breakage of small arteries at the broken end of the adhesion. So after the lungs are expanded, compressing the bleeding area can stop the bleeding. Most hemothorax bleeding can be cured without surgery. If you give blood transfusions and intravenous hemostatic drugs in time, it is a very good treatment."
While Zhou Can imparted some clinical practical experience, he also praised Dr. Pu generously.
"In clinical practice, hemothorax is more common in young male patients, and more often in the left chest than the right. The disease is often very hidden, difficult to detect, and diagnosis is easily delayed. So when I give medical advice, I specifically ask you to observe the patient's bleeding more."
After completing closed chest drainage for the patient yesterday, Zhou Can gave some verbal medical instructions.
However, it did not explain how to deal with patients who develop hemothorax.
Because he believed that the attending physician and the nurse would definitely report to the superior doctor in a timely manner.
If Zhou Can had not been in a hurry to rush to the operating room for two other major operations, he would probably have discovered that the patient had hemothorax by just observing for a while longer.
Judging from the patient's drainage last night, the bleeding was quite severe.
I hope I don't have to open my chest to stop the bleeding.
But sometimes, the disease will not go along with the doctor's wishes. Nor will the doctor be lenient just because the patient's family is pitiful.
The disease is merciless and often extremely cruel to its patients.
Therefore, this patient needs to be closely observed to prevent any accidents.
"May I ask again, how long after closed chest drainage is performed on such patients can we determine whether further surgical treatment is needed?"
Doctor Pu carefully wrote down the key points Zhou Can said in his notebook.
A good memory is not as good as a bad pen.
Doctors have a lot to learn, and taking more notes is definitely a good thing.
"Basically, if the leakage does not stop after more than 24 hours of drainage, further measures should be considered. However, for most patients, gas continues to be discharged from the water seal bottle, and it may take three or four days for the gas to gradually weaken and disappear. Only in a very small number of patients, gas is still discharged for up to a week. In this case, it should be considered that the rupture is too large and closed chest drainage is difficult to heal. Open chest surgery is required to repair it."
For both newcomers and old comrades, Zhou Can basically tells them everything he knows and teaches them patiently.
This excellent quality of being a good teacher was also passed on to him by Director Hu Kan, Dr. Xu, Director Shen and others.
All the teachers Zhou Can met, even if they were introverted and aloof, would basically take the time to teach him patiently as long as the questions he asked hit the point and they thought he was really studying hard.
At least so far, Zhou Can has never encountered a situation where a senior doctor did not teach him.
Including Director Feng of the Anesthesiology Department, such a cool doctor, he even took the initiative to ask Zhou Can to learn from him.
