Community Hospital Surgery Center.

Murphy is performing surgery on a middle-aged white lady with radical early lung cancer.

Because Zhou Qiao explained, when they were asked to have surgery, they also brought Nanako Chiba with them and let her learn to understand it.

Therefore, Murphy called Nanako Chiba this time.

Because of this operation, Murphy was quite sure that he did not involve Stephanie.

If you want Stephanie to be on the same stage with her, there are only two situations, one is that Zhou Qiao is there and asks both of them to assist, and the other is that the operation is too difficult or too long for one person to do.

It's the same with Stephanie.

Now that Zhou Qiao is in Boston, there are no particularly difficult cases, so they are naturally fighting their own battles.

Zhou Qiao is a member of the top ten shareholders and board of directors of Boston Medical, and he needs to stay there for a while to learn more about the company's operations, and Boston Medical has also arranged a special office for him, and has also given him the title of SVP (senior vice president), and is also equipped with a secretary with a sweet smile.

Of course, with Zhou Qiao's habits, that is, to understand it, most of them will still be in charge of the shopkeeper after that.

However, he can not go to work there, but the other party cannot help but arrange an office and a title for him.

That secretary is very beautiful, but it is four beauties with irises, no, now it is five beauties, one comparison, it is too much worse.

Therefore, Zhou Qiao didn't have much idea about the secretary. It made the sweet secretary a little resentful.

……

Murphy's patient was found to have a nodule in the lower lobe of the right lung during regular physical examinations, and after follow-up, it was considered to be early lung cancer.

The preoperative examination image showed that the patient's nodule was located in the posterior basal segment of the lower lobe of the right lung, about 1 cm away from the pleura, and was a pure ground-glass nodule, and local resection was the best option.

However, it is very important to accurately locate the location of this lung nodule.

In order to avoid the risk and discomfort of traditional CT puncture positioning, Murphy used the magnetic navigation bronchoscopic fluorescence positioning method, and then performed single-port minimally invasive resection after positioning.

At the same time, after evaluation by Nancy's anesthesia team, Murphy finally decided to use tubeless, that is, no endotracheal intubation, no urinary catheter, and no traditional chest drain.

This can further reduce the patient's postoperative adverse effects.

"Such a major operation, not intubated?" Nanako Chiba pursed her lips, feeling that this iceberg little beauty is so bold.

However, Nanako Chiba also understands one sentence, that is-"the artist is bold", it is estimated that this iceberg little beauty is sure to be so determined.

In order to ensure postoperative analgesia, Murphy performed an ultrasound-guided intercostal nerve block on the patient before surgery, using only a small incision 2 finger width.

During the operation, the location of the pulmonary nodule was located by magnetic navigation bronchoscopic fluorescence, and with the cooperation of Nancy's anesthesia team, ventilation was controlled only at the time of resection, and the nodule was accurately and completely removed, and only a very small pigtail tube was placed.

The whole surgical process is done in one go, like flowing water, giving people a pleasing feeling to the eye.

After the operation, the patient did not feel incision pain, recovered quite quickly, and was discharged from the hospital only one day after the operation.

It's just a god speed, and Nanako Chiba was stunned.

The postoperative pathology showed that it was adenocarcinoma in situ, and the middle-aged white lady was overjoyed and personally bought a large bouquet of flowers for Murphy, thanking Murphy for his superb medical skills.

Of course, this disease, although Murphy is very confident and has been removed very cleanly, will still have to be rechecked regularly in the future.

However, there is nothing to worry about, because Americans are almost accustomed to regular medical check-ups, and basically, as long as they are not bankrupt or poor, they will do it.

Nanako Chiba was full of praise for Murphy's superb surgical skills, and Stephanie was not convinced.

Then, Stephanie also received a patient who needed surgery, who was referred from another clinic.

So, Stephanie also took Nanako Chiba with her, and also let her see her surgical level.

Stephanie wants to tell Nanako Chiba that she doesn't only know psychological counseling, but she is very strong in many ways.

In fact, she was just competing with Murphy.

Chiba Nanako also felt this "undercurrent", felt very helpless, and at the same time was very happy, fortunately, the two of them just competed with each other, but don't get yourself involved.

This time, Stephanie went straight to the University of California Medical Center, where there was the advanced Prometheus-3000 surgical robot.

Although Zhou Qiao is not there, this is donated by Zhou Qiao, so the doctors of the Iris Clinic have the right of first refusal, and it is not limited to Zhou Qiao alone.

Stephanie's patient had a cough that had not been cured for a long time and had not been relieved after taking medicine for a week, and then the clinic arranged for a chest CT scan and tracheoscopy.

It was found that the patient's left lower lobe opening near the left main bronchus had a new creature about 9 mm in length and diameter, which was confirmed by biopsy to be a malignant tumor.

The Iris Clinic is now a veritable top performer in California, and it can be called the ceiling of the industry in terms of cardiac and vascular surgery, neurosurgery, and radical resection of various tumors.

Or, directly invite Zhou Qiao and them to participate in the consultation in the past.

Iris Clinic, never referrals, only referrals!

After receiving the patient, Stephanie took the information and discussed the patient's condition and surgical plan with Nanako Chiba.

This kind of endotracheal tumor has insidious symptoms and special location, and the operation is extremely difficult, and after full discussion and evaluation, Stephanie formulated a surgical plan.

What she was going to do for this patient was a robotic-assisted sleeve resection of the lower lobe of the left lung.

Chiba Nanako is also the first time to see the world's most advanced surgical robot to do surgery, Stephanie alone, no need for an assistant, manipulate this three-headed and five-armed robot, and perform a variety of difficult fancy operations, which makes Chiba Nanako amazed.

Stephanie's surgical level is naturally very good, and she has long been promoted to the peak level of the master level by Zhou Qiaojia, and the operation is very successful, and it is also done in one go.

Because it is a robotic operation, in terms of "ornamentality", it is more than the previous Murphy's.

Postoperative pathology showed that the patient had invasive non-mucinous adenocarcinoma without lymph node metastasis. He was discharged from the hospital three days after surgery, but he needed to come for two follow-up examinations two weeks later and one month later.

Judging from the situation three days after surgery, it is not a big problem.

Nanako Chiba admires it quite a lot, doesn't it mean that the two of them are the second and third place in heart surgery? How do you do lung cancer surgery?

Moreover, according to Nanako Chiba's understanding, these techniques are internationally leading, even if Japan does not do much.

As everyone knows, Murphy and Stephanie have conducted a series of prospective clinical studies on magnetic navigation visualization of the diagnosis and positioning of pulmonary nodules, preoperative three-dimensional reconstruction of pulmonary nodules, AR-assisted lung puncture landmarks, how to accurately anatomically resect lung segments, and how to use robots to assist lung cancer surgery, and have published many articles in top international academic journals, with a cumulative impact factor of more than 500 points.

Moreover, publishing academic papers with high impact factors can no longer satisfy these two girls, and they plan to write books and speak.

Recently, for example, Murphy has been using his spare time to write a monograph: "Lung Cancer Visualization and Precision Surgical Diagnosis and Treatment System and Quality Control of Robot-Assisted Lung Segment Surgery for Early Lung Cancer".

Not far behind, Stephanie plans to write a trilogy of clinical psychology, namely: "Clinical Child Psychology", "Clinical Adolescent Psychology" and "Clinical Psychology of the Elderly".

Nanako Chiba followed them to the operation and chatted with them, and after learning about this, while deeply admiring, she once again inexplicably felt a huge pressure.

How? Competing for men here, not only rely on posture and gentleness, but also fight for medical skills and academic level? That's too much, isn't it?

Oh my God, the King of Volumes!

She was a little envious of Elena and Ava, but the two twins had a special status and a transcendent status in the clinic, which was not comparable to them.

Immediately, Nanako Chiba also rose with a competitive spirit, and said in her heart, she is not bad, the doctor of medicine from the University of Tokyo may not be weaker than UCLA and Johns Hopkins University.

No, I have to make some achievements too! Don't let Murphy and Stephanie get too far behind.

Murphy said, who wouldn't use a surgical robot, come on, Nanako, I'll let you see it too.

So, at the next operation, I also took Nanako Chiba to the University of California Medical Center and did a robotic surgery, which also showed exquisite skills.

Nanako Chiba felt that she couldn't fight these two girls in terms of surgery, so she decided to make use of her strengths and avoid her weaknesses, and planned to put more effort into comprehensive drug administration and pharmacokinetics.

She has been here for so many days, and she has keenly discovered that in terms of comprehensive medication, although the iris clinic is not bad and is considered first-class, there is still room for improvement.

Everyone has also discovered that she has a specialty in this area, so many problems in medication come to her for advice, even Murphy and Stephanie, they tend to hand over the patient's postoperative medication to Nanako Chiba to be responsible.

Nanako Chiba has participated in surgery, understands the patient's condition, and has done a remarkable job in the postoperative medication, with some more subtle changes than before.

Sometimes, some subtle and delicate adjustments in the medication regimen can make a completely different difference.

Rachel recently encountered a little trouble, she had a hypertensive patient, clinically diagnosed with essential hypertension, so, based on her years of experience, she prescribed amlodipine for oral treatment.

However, the patient's blood pressure is not well controlled, the fluctuation range is large, and there are even adverse reactions such as increased heart rate and flushing.

As a result, Rachel changed some other drugs to the other party, such as losartan, but the antihypertensive effect was still not ideal.

She was a little confused, it was impossible to try all the drugs once, right? You must know that there are many antihypertensive drugs for high blood pressure on the market.

There are so many to choose from.

"Looking for Nanako Chiba!"

Rachel came to ask Nanako Chiba for advice.

After Nanako Chiba understood the situation, she gave her an idea: "This can actually be tested for genetic testing." Sometimes the medicine doesn't work well because the drug doesn't match the patient's genes. ”

"Huh? And what's going on? ”

Nanako Chiba nodded, so she took out a pen and paper, drew a picture, made a list, and explained at the same time.

Following Nanako Chiba's suggestion, Rachel arranged for the patient to collect blood samples and test for genetic polymorphisms.

Eventually, based on the results of genetic testing, Nanako Chiba recommended that the patient's medication be changed to irbesartan.

As a result, a miraculous scene happened, almost immediately, the patient's blood pressure quickly returned to normal, there were no adverse drug reactions, and the quality of life was greatly improved!

Of course, high blood pressure is a chronic disease that requires long-term medication to control.

It is precisely because of the need to take medication for a long time that it is very important to find a suitable antihypertensive drug.

Appropriate antihypertensive drugs can not only reduce adverse reactions, avoid the risk of drug toxicity for patients, increase drug safety, but also improve drug efficacy, effectively control blood pressure, and reduce complications.

At the same time, it can also shorten the drug trial cycle and reduce the economic burden.

After this incident, Rachel, the aunt, deeply felt that she had to keep pace with the times and learn more about the current advanced technology.

Experience alone is not enough, because she is old, and some of her previous experiences may not be able to keep up with the times. It's still a young girl now!

Medicine is about living and learning to be old.

……

Iris Clinic, Conference Room.

Murphy, Stephanie, Nanako Chiba, Elena, Ava, and Iris Gomi gather together to discuss a patient's condition.

This is the second consultation meeting.

This patient, whose condition is quite difficult, was referred by a neighboring community hospital.

It was a 14-year-old child who was admitted to the hospital with a high fever and a temperature of up to 40°C (no Fahrenheit conversion, intuitive).

After receiving the doctor, the doctor from the community hospital found that the patient had severe pneumonia with pleural effusion, liver insufficiency, hypoxemia and other symptoms.

The initial diagnosis is pulmonary infection and suspected pulmonary embolism.

However, after symptomatic treatment, the patient's condition did not improve, and he even developed symptoms of heart failure.

The Department of Respiratory Medicine of the community hospital urgently convened a multidisciplinary consultation and further arranged for examinations.

Chest CT showed multiple thin-walled cavities in both lungs, and there was a high suspicion of pneumonia caused by bloodstream infection of Staphylococcus aureus.

At the same time, cardiac ultrasound examination found that the patient's heart tricuspid valve already had a "cauliflower"-like vegetation, and the pulmonary artery CTA also showed a pulmonary artery "bacterial plug"!

The tricuspid valve is an important valve connecting the right atrium and right ventricle, directly to the pulmonary artery and distal lung tissue, and is an important gateway to ensure one-way circulation of blood flow in the heart.

The situation was quite serious and critical, and the community hospital couldn't handle it, so I invited the Iris Flower Group.

Zhou Qiao was not there again, and Murphy and Stephanie took over.

It is only in such an emergency that Murphy and Stephanie will work together to overcome the difficulties.

In fact, although this kind of heart surgery is difficult, it is nothing to the Iris Tiantuan, because they don't know how many they have done before, and they have won the national award for these surgeries.

Often, it's not worth mentioning.

However, now the patient's high fever does not go away, which brings a huge risk to the operation.

Not only the surgical and perioperative risks, but also the presence of bloodstream infections that would affect the stability of the circulating oxygenation state, so after the first meeting, it was unanimously decided to start anti-infective therapy first, and then perform surgery after the heat peak has dropped and the bloodstream infection has been controlled.

However, anti-infective treatment did not go well.

While in the community hospital, the respiratory physician had already administered piperacillin anti-infective therapy, but the recurrent fever did not improve.

After receiving the iris clinic, the blood culture results also came out, so the medication regimen was adjusted and upgraded to meropenem anti-infective treatment.

At the same time, intravenous fluids are given to target electrolyte imbalances.

Unfortunately, the patient continued to have recurrent fevers, with a fever peak of up to 38.8°C.

His blood routine white blood cell WBC was 29.16 ↑ x 10^9 / L (far higher than the normal value of 3.5-9.5 ×10^9/L) at the time of admission, and now, after antibiotic treatment, it is still high at 20.13 ↑ x 10^9/L.

In other words, according to the results of blood cultures, the carefully selected powerful antibiotic of Amamperol is almost ineffective?

This medication is the responsibility of Nanako Chiba.

In the conference room, everyone looked at Nanako Chiba.

Nanako Chiba's face sank like water, and she was a little panicked, and said in her heart, should I overturn? Giving Murphy and Stephanie a look won't work.

In case the patient delays the operation and dies, it will be ......

She forced herself to calm down, her mind racing, her thoughts racing, her mind going over it carefully, trying to see what the problem was.

At the same time, Stephanie expressed her opinion, saying: "There should be a super drug-resistant bacteria now, or some other pathogenic bacteria that have not been detected, after all, the test results can sometimes be wrong." However, if you do a blood culture again, you can't wait, the patient can't stick to that time, and the blood culture may not be a reference again. Otherwise, let's take the risk of surgery. ”

Murphy shook his head: "It's too risky to risk surgery now." ”

Elena said: "If you don't call Joe back, maybe, with Joe's involvement, the risk of surgery can be reduced." ”

"It's not an alternative plan, but," Stephanie said after a little hesitation, "Or, just be ruthless and administer it with meropenem + vancomycin hydrochloride." ”

Everyone fell into deep thought.

Mainly, vancomycin cannot be used lightly, meropenem + vancomycin, which is equivalent to the king fried level. And there are many irreversible side effects.

However, now that the patient's infection is aggravated, the high fever does not go away, and the responsible bacteria cannot be quickly identified, meropenem + vancomycin is equivalent to empirical anti-infection treatment, and a set of tricks should still be promising.

Moreover, meropenem is used, and vancomycin is not bad.

After hesitating for a long time, Murphy said, "Or vancomycin." ”

In the absence of a way, only that's it.

The fever must be reduced as soon as possible, otherwise if it is delayed, you will only risk the surgery, which will only increase the risk of surgery.

The patient's life is of paramount importance to the misuse of antibiotics.

Although vancomycin is a nuclear weapon, isn't the medicine meant to be used where it's needed?

The patient's condition is also severe and critical, and deserves vancomycin.

It's not a minor disease, just vancomycin.

For such a serious condition, don't use it at this time, when will it be used?

Just when Murphy and Stephanie reached an agreement, Nanako Chiba's eyes lit up, she stood up and said, "Can you give me a day, I have an idea, but I don't know if it will work, just a day, try it and know." ”

Murphy and Stephanie looked at each other.

"Okay, one day at most, if it's too late, I really can't drag it on."

(End of chapter)