Chapter 493: The gap between the director and the deputy director, solved by interventional angiography
"Doctor Zhou is not only skilled, but also so sweet! Let's hurry up and discuss the patient's condition. If we delay for too long, something bad might happen!"
Director Shang is a very impatient person.
After the pleasantries, he urged Zhou Can to join the consultation.
It seems that even with the participation of Director Shang and his two graduate students, the cause of the patient's illness still cannot be clearly diagnosed.
He used to call Zhou Can "Xiao Zhou", but now that he hasn't seen him for a while, the way he addresses him has become much more unfamiliar.
"Director Shang is right. The patient's temperature dropped a little after taking the medicine, but he is still running a fever. What is more worrying is that there is probably a large source of bleeding in his body. The most urgent task is to find out the source of the bleeding."
Deputy Director Han is also a practical man.
These older doctors' serious attitude towards patients and diseases is definitely worth learning.
A doctor is like a loving parent, and these three words can often be reflected in some details.
"After the discussion between the two directors, did you come to any conclusion?"
Zhou Can asked humbly.
"It is not yet clear what disease the patient has. But I think the patient's symptoms are just similar to upper gastrointestinal bleeding. It is a good idea for you to ask Dr. Ai to draw gastric juice from the patient for monitoring. It has been implemented. In addition, I heard that you found dark red blood on the patient's gloves when you performed a rectal examination. I think if it is really upper gastrointestinal bleeding, it is difficult to find dark red blood during a rectal examination."
Director Shang should have been aware of the patient’s previous diagnosis and treatment plan.
"There is a method abroad specifically for identifying whether it is upper gastrointestinal bleeding or lower gastrointestinal bleeding. After clinical comparison, it was found that high plasma urea concentration is a characteristic of gastrointestinal bleeding, and the degree of increase is related to the amount of bleeding. The ratio of plasma urea ammonia concentration to plasma creatinine concentration can be used to infer whether it is upper gastrointestinal bleeding or lower gastrointestinal bleeding."
The chief physician's level is indeed not exaggerated.
Zhou Can had also seen the identification plan proposed by Director Shang in a medical journal.
However, he does not know how to apply it in clinical practice.
The main thing is that I can't remember those values at all.
And the accuracy of this method is not 100%, but about 95%.
"If the ratio of the two is greater than 100, the probability of upper gastrointestinal bleeding is high. If the ratio is less than 100, the probability of lower gastrointestinal bleeding is high."
The method proposed by Director Shang is worth a try.
Simply by comparing two simple biochemical indicators and calculating the ratio, it is possible to distinguish between upper and lower gastrointestinal bleeding.
Simple, practical and low cost.
"Through calculations, the probability of lower gastrointestinal bleeding is high."
Director Shang is indeed amazing, worthy of being the director of the Department of Gastroenterology. He personally came to the consultation this time, which also gave the emergency department a great face.
"For patients with lower gastrointestinal bleeding accompanied by fever, we should consider the possibility of inflammation and tumors. The patient had an acute onset, and the possibility of intestinal bleeding caused by intestinal tuberculosis was very small. Therefore, the main consideration was inflammatory lesions."
The two graduate students had already taken out their small notebooks and were taking quick notes.
Thinking back to the days when Zhou Can was studying with Director Shang, he would often take notes.
"Dr. Zhou has been away from the Department of Gastroenterology for a long time. Do you still remember the knowledge points about intestinal inflammatory lesions?"
For some unknown reason, Director Shang suddenly wanted to test Zhou Can.
"It's actually quite affectionate for you to call me Xiao Zhou like you used to."
Zhou Can also understood that Director Shang never treated him as a student.
When I was working in the Department of Gastroenterology, I received a lot of care and training from Director Shang.
For example, Zhou Can was asked to go to Xinxiang Women's and Children's Hospital with Deputy Director Shi. It was also that opportunity that allowed Zhou Can to be successfully selected into Tuya's famous doctor reserve team.
"Haha, no problem. This is because I'm considering that your status is no longer what it used to be. I'm worried that calling you Xiao Zhou will bring you adverse effects!" Director Shang explained with a smile.
"In front of you, I will always be that Xiao Zhou."
Zhou Can's words made Director Shang very happy.
No doctor dislikes a kind and righteous person. Director Shang had put in a lot of effort in training Zhou Can and had taken great care of him.
Three years have passed, and Zhou Can is still full of gratitude and respect for him, which naturally makes Director Shang feel very happy.
"I still remember a lot of the knowledge you taught me. Inflammatory lesions can be divided into specific and nonspecific. Inflammatory bowel disease generally refers to inflammatory bowel disease , which is a nonspecific chronic intestinal inflammatory disease, mainly including ulcerative colitis, Crohn's disease, etc., and is often manifested by abdominal pain, diarrhea, weight loss, etc."
Zhou Can had already mastered these knowledge points.
“Very good!”
Director Shang nodded happily.
"Based on the patient's medical history, symptoms, and biochemical results, bacillary dysentery and amoebic dysentery can be basically ruled out. I suggest checking the patient's Widal reaction. It is now almost the fifth week of the patient's illness, so it is the right time to check the Widal reaction."
"Does Director Shang suspect that the patient has typhoid fever?"
Zhou Can's eyes lit up slightly.
The director-level diagnostic thinking is amazing.
Compared with Director Shang, he could clearly feel the gap.
His current pathological diagnosis is at the level of associate chief physician, and it will take some time for him to be promoted to director level.
Especially in recent times, in order to prepare for the postgraduate entrance examination, the consultation hours have been shortened, the number of patients diagnosed has decreased, and the growth of pathological diagnosis experience has also slowed down.
Fortunately, the business of cardiothoracic surgery has been growing recently, and the number of difficult cases has increased, giving him the opportunity to earn a large amount of experience points in pathology diagnosis.
Zhou Can suspected that the patient might have intestinal malignant histiocytosis, which was a glimmer of hope.
He even thought of doing a bone marrow examination on the patient.
If it is typhoid fever, it can most likely be detected by doing a bone marrow culture.
As for blood culture tests, since the disease has progressed to four weeks and the peak of bacteremia has passed, the test results are likely to be negative.
"It is only initially suspected to be typhoid fever. For digestive tract diseases with obscure causes and long course of disease, after excluding malignant tumors, there are only a dozen rare and difficult-to-treat diseases. For example, Crohn's disease, ulcerative colitis, etc. However, most of these diseases have a slow onset and are often accompanied by intestinal obstruction and abdominal masses. This patient obviously does not meet many of the criteria."
"Some patients with ulcerative colitis can develop acutely. Some severe cases of ulcerative colitis can cause high fever and bloody stools. This is consistent with the patient's condition. The patient was just admitted to the hospital today. Even if he wants to undergo an emergency colonoscopy, it takes some time to prepare the intestinal cavity. In particular, the residual blood in the intestinal cavity is estimated to be quite serious and will seriously affect the examination results."
Director Shang was very cautious when diagnosing the cause of the disease.
From his various statements, it has been basically diagnosed that the patient has typhoid fever, and may also be accompanied by lower gastrointestinal bleeding.
This was not the first time that Zhou Can had witnessed director-level diagnostic thinking, and he was very much envious of this high level.
Over the next two days, the patient underwent further relevant examinations.
Includes gastric aspiration monitoring.
The patient's body temperature remained between 37.7 and 38.9 degrees, and the fever did not subside.
The gastric juice extracted on the first day was light yellow and relatively turbid, and a small amount of old blood was found in the gastric juice.
The gastric juice extracted on the second day turned clear.
At this point, massive upper gastrointestinal bleeding can basically be ruled out.
Yesterday, the patient's stool was still black, indicating that blood in the stool still exists.
There is no bleeding in the upper gastrointestinal tract, but the patient is still passing black stools. There is no doubt that there is still heavy bleeding in the lower gastrointestinal tract.
After passing black stools, the patient passed dark red bloody stools twice this morning.
This is consistent with the situation when Zhou Can first performed a digital examination on the patient.
At that time, dark red blood was found on the gloves.
The patient's blood bacterial culture was indeed negative.
After the peak period of blood bacteria, the result will basically be the same when checking again.
The results of the patient's routine bone marrow examination have also come out, and no abnormal immature cells and tissue cells were found. This is just the result of a routine bone marrow examination. The specific diagnosis depends on the results of the bone marrow culture.
This morning, the patient's blood pressure has dropped to 60/42 mmHg, his pulse has become very weak, and his heart rate is about 120 beats/minute.
This is a very bad sign.
This means that the bleeding cannot be controlled and is continuing.
If we don't find the source of bleeding and stop the bleeding immediately, the patient may not be able to be saved.
This morning happened to be the day when Zhou Can was seeing patients in the emergency room. As the patient went into shock again, the emergency room was worried that something might happen to the patient, so they had no choice but to invite Zhou Can over.
After Zhou Can arrived at the emergency room, he immediately performed intramuscular vein puncture and catheterization on the patient and measured the central venous pressure, which was only 0.78KPA.
I didn't expect the patient's condition to deteriorate so quickly.
In just two days, after having transfused 1,000 ml of blood and receiving multiple treatments, he still went into shock again, and his blood pressure dropped to a very worrying level.
At this time, the source of bleeding is unknown and there is no effective means of stopping bleeding. The use of pressor drugs can only accelerate bleeding.
Zhou Can quickly directed the nurses and doctors to expand the patient's volume and give blood transfusions to fight shock. After three bags of blood were transfused, his blood pressure was finally raised again.
"Doctor Zhou, the patient must be bleeding. Please help me think of a solution! I think it's difficult to stop the bleeding by relying on internal medicine treatment. I'm afraid we have to use surgical treatment to stop the bleeding."
Dr. Ellie has been looking haggard these past two days.
She was worried sick about this patient.
Every doctor is afraid of receiving difficult-to-treat patients, especially this extremely difficult gastrointestinal bleeding patient, which she, an ordinary attending physician, could not handle.
I just saw the patient go into shock again. She is fifty years old, but she is still stamping her feet in anxiety.
"Don't worry. It has been basically confirmed that it is lower gastrointestinal bleeding. The color of the patient's blood in the stool is dark red, which should be bleeding in the ileum and colon. However, the patient's current physical condition does not allow for colon barium contrast and colonoscopy. Even if a laparotomy is performed, the bleeding point must be determined first so that we can be targeted."
Zhou Can has quite a lot of experience in dealing with such difficult patients.
"We can't do the examination and we can't locate the patient's bleeding point, but he's still bleeding. What should we do?" Ellie looked worried.
Ordinary doctors have limited skills and really cannot handle this kind of patients.
"Perhaps a better way is to do abdominal artery angiography. Although radiological intervention is somewhat invasive, it is very effective in locating gastrointestinal bleeding of unknown etiology. It is worth taking the risk of doing abdominal artery angiography to save the patient's life. However, this examination requires good timing and must be performed when the patient is bleeding."
Zhou Can gave a better solution.
Timing is very important when doing abdominal angiography.
If the patient's bleeding happens to be temporarily stopped during the examination, it will be difficult to find the bleeding point.
At this time, Zhou Can's level six hemostasis technique came in handy again.
He can basically determine whether the patient is in the bleeding stage just by looking at the patient's skin color, complexion, appearance, and physical condition.
In addition, the patient had just excreted liquid blood twice not long ago, indicating that he was in a state of severe bleeding.
Opportunity is fleeting, once lost, it will never come back.
Zhou Can decisively asked Ai Li to report to Deputy Director Han, and then contacted the interventional room to perform emergency selective abdominal angiography on the patient.
When the doctor in the interventional room saw that the patient was in a bad condition, he was worried that the patient would die during the interventional operation, so he asked Zhou Can to come over for help.
Zhou Can is also well-known. Now many doctors in Tuya Hospital know that he is good at endoscopic surgery and interventional surgery.
From time to time, someone would ask him for help.
The interventional room asked him to come over this time, saying that they wanted his help, but in fact they were afraid of taking responsibility.
Zhou Can didn't expose it and just walked past.
Performing abdominal artery angiography on the patient was an examination plan he proposed.
Someone has to take on the responsibility of protecting the lives of patients.
Of course, the family members must sign the consent form.
It’s okay to let him work hard to save people, but he cannot bear all the risks.
If the family members only want to save the patient but are unwilling to take any risks, and instead let the doctor take all the responsibilities, then I am sorry. Zhou Can has never been a saint. He must be ruthless when he needs to be.
Fortunately, the patient's parents were reasonable and signed the document quickly .
In the interventional room, Zhou Can, wearing a heavy lead coat, carefully inserted the angiography tube into the patient's femoral artery, then into the abdominal aorta, and then into the first-level branches, the celiac trunk, the superior mesenteric artery and the inferior mesenteric artery.
He seemed particularly focused throughout the entire operation.
The celiac trunk and branches of the inferior mesenteric artery were recorded by television, and no abnormalities were found.
His heart sank.
Is it that the timing of the angiography examination was wrong?
Through television images, it can be seen that the diameter of the superior mesenteric artery has generally become narrower, and contrast agent overflow has occurred at the terminal end of the ileocolic artery branch .
Zhou Can was overjoyed.
Finally found the source of bleeding.
"Quick, quick, this is the spot."
Zhou Can signaled to quickly locate the source of bleeding in the patient.
It can be clearly seen that the contrast agent overflowing from the end of the arterial branch of the choroidal artery is extremely dense and gathers into a ball.
After the bleeding was confirmed, 20 U of posterior pituitary hormone was slowly injected through the catheter, and then the tube was removed.
It turned out to be active bleeding in the ileocolic artery. No wonder the amount of bleeding was so huge.
Almost any bleed from an artery that is larger than the average size is terrible.
And it is difficult to stop bleeding automatically.
I finally understood why the combined use of two hemostatic drugs still failed to stop the bleeding.
"This patient must undergo surgery to stop the bleeding. Let's push him back first! I'll talk to Dr. Xu to see if the emergency department can do this surgery directly."
Zhou Can actually already had a surgical plan in his mind.
However, this matter needs to be discussed with Dr. Xu first.
After all, it was Zhou Can who performed the surgery, but it was Dr. Xu who took the responsibility.
After discussion and watching the playback of the angiography images, Dr. Xu agreed to perform the operation.
For Zhou Can, this is a very good training opportunity.
