Now Wang Liangan, in fact, is also a little irritable.

Even more so than Wu Guonan and Xue Tao.

Wang Liangan is the deputy chief physician of the Department of Joint Surgery, Li Junfeng, the deputy chief physician. But Director Li Junfeng, although he is the director of joint surgery, has always liked to lie flat and does not like to fight for any position.

But Wang Liangan felt that if you have the ability, Director Li, the director of the Department of Orthopedics is not the self-reserved place of trauma surgery, so you should grab it, why give it to Wu Guonan, you don't even have such a mind.

Li Junfeng exposed the brachial artery much faster than Wu Guonan, so after tying up the brachial artery, Wang Liangan, as an assistant, continued to speed up his movements while thinking, at your level Wu Guonan, do you still have the heart to fight for the position of director of orthopedics?

Do you think that you are Director Zhang Mingcan, and the position of the director of the Department of Orthopedics is specially designed for your trauma surgery?

Even a simple amputation is so grinding and chirping-

The action of advancing the amputation of the upper limb is too fast!

Two and a half muscles have been neatly disconnected! Almost broke off three of them. There is one more than Wu Guonan.

But now he was embarrassed here, and hurriedly covered the incision with a salt water pad, then raised his head, looked around quietly, and stood on tiptoe to look in the direction of Fang Ziye's leg......

Amputation is simply understood as the cutting off of a limb.

But it has its own absolute definition.

Treatment of necrotic, mutilated, severely diseased, painful and life-threatening limbs, or amputation of limbs that are completely discarded and impediment.

The aim is to treat.

Amputation is inevitably disabling and should not be used lightly.

As an orthopedic surgeon, the surgical indications for terminal surgery such as amputation need to be recorded in the bones, which is the first lesson in the formal introduction of orthopedics.

Use sparingly and sparingly.

Amputation is intended for treatment and has its strict indications:

For example, the main blood vessels of the limb are damaged, the time for repair is missed, the limb has avascular necrosis, and if it is not amputated, its necrotic toxin will be absorbed, which will be life-threatening, such as vascular angiitis and other factors.

At the time of amputation, you should try to choose the right length:

For example, foot amputation should be in the metatarsal, not shorter than the talus scaphoid joint, otherwise it is difficult to resist the contraction force of the flexor muscle, which will cause foot drop and hinder weight bearing due to insufficient dorsiflexor attachment......

The lower 1/3 of the lower leg has poor blood transfusion, and the broken end cannot bear weight, so it is generally not selected as the amputation site......

It is clear that this patient has one of the indications for amputation - thrombosis!

It is a persistent, long-distance arterial thrombosis.

The indications for amputation are very clear.

The production and harm of blood clots are actually similar to the stones stuck in the water pipe, resulting in no blood supply at the distal end of the blockage.

This is equivalent to cutting off the blood supply to distant cells and tissues.

Limb salvage and amputation, although there is only one word difference, is an extremely complex and multidisciplinary operation.

It is not strictly a procedure similar to fracture fixation.

To save limbs, there are also indications, not to mention other things for the time being, the first thing to ensure is blood supply......

It's like our plumber checking what is blocked and then taking it out.

However, in the human body, because the patient does not have time for a preoperative examination, you simply do not know where the blockage is.

If you can't find the place, you can only try your luck if you want to find the location of the blood clot.

Therefore, even the directors of the Department of General Surgery, Peng Yuanming, who is attached to the Department of Vascular Surgery, did not dare to guarantee that they would be able to carry out limb salvage surgery and remove the thrombus, so they simply amputated their limbs first to save their lives......

Fang Ziye also does not know how to salvage.

Fang Ziye's initial idea was just to move the scope of the amputation downward, originally planned to amputate the middle of the thigh, if it could be moved to the lower end of the thigh knee joint, it would be a good thing.

Fang Ziye thought, I can't order a big skill like limb salvage, let's order some small skills first.

Extend the blood vessel plane as far down as possible.

Keeping an extra limb allows the patient to function more.

Without a preoperative examination, he was only able to do a basic medical examination, and then by improving the tactile sensation of his hands, according to the results of the examination and his anatomical knowledge.

With vasotomy, some of the thrombus can be removed.

……

But after Fang Ziye did four arterial tomys and thrombectomy, he first came to the middle and lower part of the thigh, and then he was a little greedy, in case this patient can maintain the amputation plane at the calf segment, then he will become extremely comfortable when he installs the prosthesis after surgery.

So Fang Ziye took out the thrombus of the anterior tibial artery of the lower leg again.

At this time, Fang Ziye made an unexpected discovery!

The dorsalis pedis artery is still open!

Because Fang Ziye's original purpose was to go for amputation, he just wanted to stay longer.

Men, they all like thick length, but Fang Ziye's length is a bit too long......

Seeing this scene, even Wu Guonan, who was standing on the opposite side, had the urge to strangle this Fang Ziye for a moment.

Because now Fang Ziye has brought the operation to a stage with an uncertain future.

At least, on Fang Ziye's side, there is no amputation for the time being, and it may have to be changed from amputation to more complicated limb salvage.

"I'll see how it goes." Wu Guonan threw the things in his hand into the curved plate gently.

Xue Tao hurriedly used his hand to probe the dorsal foot artery.

Whether the blood vessels are patency or not, the most direct and gold standard examination is vascular arteriography!

But the simplest and most straightforward way is palpation.

Patients cannot do the gold standard examination before surgery, and now they can only be verified with the simplest palpation.

The arteries of the human body are continuous, so they will strictly follow a law!

That is, the distal arterial pulse was felt, which absolutely proves that the blood vessels proximal to the distal artery are at least partially patencious.

Otherwise, the blood pumped by the heart will not come to the far end.

Xue Tao's fingertips, even through the glove layer, still felt the faint beating of the arteries.

The amplitude and strength of the pulsation are not large, and they are not big.

The patient is about to go into shock, how much can you expect the dorsalis pedis artery to pulsate?

But having it is enough.

Xue Tao immediately thought of another kind of examination on the operating table that was easy to use to prove that blood flow was smooth.

It is also a favorite examination for men.

Poke bleed.

"Traveling teacher, open a syringe needle and go on stage." Xue Tao immediately asked the itinerant nurse for equipment.

"It's on stage!" The two tours are ready at any time, and they don't care about the process of the operation, but they just respond as soon as possible, which is very professional.

"Here, syringe needle."

As soon as Xue Tao shouted, everyone in the orthopedic department stopped their work, and Wang Liangan was still more professional in covering the severed muscle layer with moist gauze to avoid the surface being too dry.

It's such a profession, it's a bit of a pain.

But he still looked at Fang Ziye's side, and it was difficult to hide the helplessness in his expression.

If you had said earlier that you could save your limbs, Director Li Junfeng and I would prick the arteries, step down and have a chicken feather amputation.

However, Wang Liangan also knew that Fang Ziye's appearance was an accident, and from Xue Tao's eyes and Fang Ziye's expression, it could be found that it was an accident.

Even Fang Ziye wasn't sure if he could have such an operation.

Wang Liangan felt that his buttocks were numb at this time, so he twisted his buttocks from side to side to relieve the embarrassment and entanglement in his heart.

It's like being halfway through the and having to force it back by yourself......

But fortunately, Fang Ziye was fast.

Wang Liangan's heart immediately thought of happiness.

If Fang Ziye's surgery progress is slow, much slower than theirs.

Then he and Li Junfeng amputated both upper limbs, Wu Guonan also amputated his lower limbs, and finally Fang Ziye's leg was still there! And the limb salvage was successful.

bingo！

Perfect 4 guarantees 1!

Isn't that Bengbu lived?

What should I do then?

Wang Liangan didn't know what to do then, but fortunately, such a thing had not happened yet, and before that, a good 'accident' happened.

The eyes of Li Junfeng, Wang Liangan, and Wu Guonan kept glancing at Xue Tao and Fang Ziye, but Wu Guonan was a little unconvinced that Fang Ziye had really opened up his blood vessels, so he reached out and touched it himself.

Snort.

Snort.

The pulse of the blood vessels in the distal extremity is certainly not as violent as the heart beat and the pulse of the great arteries, but a slight beat can be felt.

But the presence of pulsations is real.

Xue Tao pulled out the needle from the syringe at this time, took off the needle sleeve, and directly pricked the left toe and three toes of Fang Ziye, who had undergone surgery, and then watched the changes-

The syringe is pierced at the distal end of the body to bleed, which is one of the strongest evidence of the presence of blood vessels......

And it is the simplest and most cost-effective, but this method is not suitable in clinical outpatient clinics. Easy to be beaten.

So it only applies to the operating table.

A group of orthopedic people are staring at the toes of the toes.

As if this toe is seductive.

The blood did not ooze out as fast as a normal person, and after a full ten seconds, a small drop came out, like a new daughter-in-law, shy and half-covered face, and would not come out.

But even so!

Everyone still breathed a heavy sigh of relief.

It's good to come out, it's good to bleed.

Nowadays, the patient's blood pressure itself is very low, and the body's self-protection will give priority to the supply of important organs such as the brain and heart.

As long as it's smooth!

If you can deliver a little bit of nutrition to the distal limb without starving the lower limb to death, you can find a way to make up for it after the operation.

Veins don't have to be seen.

It must be bolted, but the venous network of the lower limbs is intricate, and it should not be completely blocked.

Moreover, there are two sets of large reflux venous systems, so the thrombus in the vein can be slowly melted away by postoperative vascular panheparinization!

Thrombosis management in the arteries is a top priority in limb salvage!

Wu Guonan took a deep breath, and after covering up and suppressing the embarrassment in his heart, he said to Fang Ziye: "Ziye, let's change positions, and you can do the right foot again?" ”

"On the left foot, the follow-up debridement and suturing will be done by Xue Tao and I."

"You and Wang Zhongxing take a look at the blood clot in the right foot, can you get it out."

"Good!" Fang Ziye is not obedient, and he has to change positions when he nods.

The reason why he asked Xue Tao so much before was because he was afraid that he was inexperienced, and he made a mistake. And then make a direct proposal, isn't that a problem for the superiors?

Moreover, after all, Fang Ziye didn't know that Wu Guonan was talking to the patient's family, he only signed a standard amputation in the past, and he didn't talk about limb salvage.

Now that it is temporarily transferred to limb salvage, the operation method is different, will it bring any kind of trouble, which has to be decided by Wu Guonan to shoulder the responsibility.

The responsibility is Wu Guonan's, and it is not Fang Ziye's turn to show off his might, so he can only have the right to suggest.

However, when I think about it, it should be that the family members of such an accident patient are willing to accept that they can get off the operating table without amputation.

Moreover, it also coincides with the principle of non-harm in medical regulations.

Amputation is actually known.

It's just that being able to avoid amputation without limb salvage is more in line with the principle of no injury.

But at this moment, somewhere in the operating room, someone poured a basin of cold water: "The dorsalis pedis artery is a continuation of the anterior tibial artery." The anterior tibial artery is just one continuation of the popliteal artery descending. ”

"If you don't carefully examine the posterior tibial artery, you will end up in the palace."

"And it may be a waste of all the work."

The sound came from the direction of the anesthesia monitor.

It was Nie Mingxian from the Department of Anesthesiology, and after he finished speaking at the moment, he was handing over something with Huang Qiaoshan, the director of the Department of Anesthesiology.

Huang Qiaoshan whispered: "Xiao Nie, don't be too troublesome. Director Wu and others will evaluate the results of the operation. ”

But at this moment, Nie Mingxian had already decided to stand up: "It's okay, Director Huang, I'm an anesthesiologist now, and I can't go on stage, but it's not illegal to say a few words on the side, this Dr. Fang's basic operation is very good, if you don't guide it well, it would be a pity." ”

"The peroneal artery of the posterior tibial artery, as well as the middle and lower third of the posterior tibial artery, are the most prone to embolism." Nie Mingxian finally couldn't sit still anymore, so he walked to the operating table.

After Nie Mingxian spoke, in fact, for a moment, the faces of Peng Yuanming, Wu Guonan and others became relatively ugly.

Nie Mingxian's previous non-opening meant that he and the others were not skilled enough, and he was too lazy to talk hi?

Fang Ziye's current level of operation is a waste if he doesn't point, if their technical level is to point out, it's just a waste of mouth?

Nie Mingxian's words were not harmful, not at all, just a little insulting.

However, it seems that Nie Mingxian doesn't care about the expressions of these directors.

Xue Tao was on the opposite side of Fang Ziye, looking at Fang Ziye seriously, and suddenly felt that Fang Ziye had become strange again.

It doesn't seem to be the little party I know in the past half a month.

Wang Liangan saw that the expressions of several directors were wrong, so he immediately turned to the itinerant nurse and said, "Bring me a few No. 3 lines." ”

While Li Junfeng and others were still fighting with Nie Mingxian, he silently performed a little trick - suturing the biceps brachii and brachii muscles after trauma.

Li Junfeng didn't speak.

Wu Guonan hurriedly let Fang Ziye return to this leg, because Wu Guonan was not good at thrombotomy of blood vessels, even if Nie Mingxian said it, he couldn't follow Nie Mingxian's words and continue to do it.

Wu Guonan himself is self-aware of this, even if he thinks to himself, he usually does some hand surgery, but the vascular suturing of hand surgery and the thrombotomy and removal of vascular surgery are different things in both directions, right?

……

"Can you do limb salvage?" When Fang Ziye regained his position, Xue Tao, who had digested some of his emotions, asked Fang Ziye.

This question made Wu Guonan poke his ears in an instant.

And this question made Peng Yuanming, who was not far away, a little embarrassed.

Thrombosis, where to say, is a problem of vascular surgery, and now their department, which has a brand of vascular surgery, can't deal with it, but it is handled by the orthopedic department, although no one is angry with him.

But he felt embarrassed that he existed!

Even when Peng Yuanming saw his subordinates, Deputy Chief Physician Chen Liwei cast strange glances at him, which made Peng Yuanming feel an indescribable sense of shame.

Glared back.

What's wrong?

If you don't have such a thrombectomy, don't you even deserve to be alive?

Lao Tzu is a doctor in the Department of Hepatobiliary and Pancreatic Surgery.

Are you going to chill me too?

Chen Liwei immediately lowered his head and hurriedly cooperated and began to do liver repair.

En's Central Hospital does not have a specialized vascular surgery, and if there was such a vascular surgery specialty, it would have been separated a long time ago......

Fang Ziye first subconsciously shook his head, and then shook his head.

The threshold of limb salvage is a little high, no less than osteotomy and orthopedics, which belongs to textbooks, has not been routine, and is still a theoretical surgical procedure.

He can't talk nonsense if he hasn't been in contact with it.

"No, it won't." Fang Ziye's understanding of limb salvage is only counted after systematic study and research.

"I just thought about being able to have fewer amputations and more if I could."

Fang Ziye is full of sincerity and tells the truth.

Wu Guonan could only smile bitterly helplessly, so Fang Ziye is a blind cat who bumped into a dead mouse, in fact, there is still a slight gap from Wu Xuanqi.

said: "Take a look again and see if the blood clot in the back can be removed." ”

What Fang Ziye said and did was completely fine.

Is vascular bandation a limb salvage? No.

Is arteriotomy thrombectomy a limb salvage? Not exactly.

They're just a minor operation for Fang Ziye!

But these two types of surgery are actually small surgical operations that are more important components of limb salvage, and Fang Ziye turned amputation into limb salvage through this.

This is limb salvage, okay?

Limb salvage is not just a rigorous operation, it is a set of knowledge, as long as the purpose of limb salvage can be achieved, it can be called limb salvage.

However, this cannot be said now, and it must be said after stepping down.

……

Fang Ziye no longer kept anything, and after listening to Nie Mingxian approaching with both ears, and relatively carefully pointing out which blood vessels to be examined, Fang Ziye hurriedly used basic physical examination to explore the pulse of blood vessels in the corresponding position.

Moreover, now with the help of Director Wu Guonan and Deputy Chief Physician Xue Tao, as long as they loosen the proximal banded femoral artery, Fang Ziye can probably feel where the arterial pulse is not very good.

"The pulsation of the posterior tibial artery is difficult to palpate and requires absolute sensory talent or a rich physical examination, which only a very, very small number of people can feel on the surface of the body."

"I've never seen such a person, so let's just open it to investigate." Nie Mingxian was beside him, seeing that Fang Ziye wanted to conduct a physical examination like the anterior tibial artery, he directly stopped.

There was a bit of ridicule in his tone, or he felt that Fang Ziye was a little weird.

Anyway, it's not as amiable as his teachers and real brothers, and he speaks well.

But Fang Ziye knows that there is no master-apprentice relationship, there is no teacher-brother relationship, teaching you is a favor, not teaching is duty, in reality, no one can be a dragon arrogant, the tiger's body is shocked, and the Quartet will vote.

"Good!" Fang Ziye didn't doubt him, so he didn't look back, so he directly cut the incision from the side, and then quickly did the exposure surgery.

The posterior tibial artery is the core anatomical structure of the lower leg in orthopedics, so it has long been familiar with it.

After exposing the skin.

Fang Ziye immediately repeated the previous method of catching loaches.

The round knife broke the skin, and the vascular clamp bluntly pierced the muscle gap, reaching the blood vessel shape, and then after seeing the bulge produced by the thrombosis, he immediately swung the knife to cut it!

The blood clot is removed and then sutured, and the proximal ligated vessel is loosened.

And so on.

Naturally, the process is quite complex, and the steps are extremely cumbersome.

Nie Mingxian's experience was right, Fang Ziye made four incisions in a row to open up the four long blood clots in the posterior tibial artery and the peroneal artery.

Xue Tao continued to check blood vessels with palpation and syringe needles.

Suitable!

In this way, Fang Ziye and the others finally completed the limb salvage of the left lower limb!

Fang Ziye looked at Nie Mingxian again.

"Smooth blood flow is the primary guarantee, and the follow-up depends on fate, even if there is no function in the future, it is better than direct amputation, there is blood circulation, and other functions are left alone for the time being."

"Let's go to the other side. Some minor problems can also be referred to postoperative pan-heparinization. Nie Mingxian guided.

Then he said to Director Huang Qiaoshan of the Department of Anesthesiology: "Director Huang, if you take another electrolyte, after the blood flow of the lower limbs is smooth, it may bring back a lot of residual substances in the body, so you should pay attention to the electrolyte disorder." ”

"This is a variant of reperfusion injury."

Nie Mingxian's understanding of theories is quite profound.

Huang Qiaoshan did so, instructed another deputy chief physician to personally draw blood for testing, and after turning the ventilation speed and anesthesia concentration, he reported to everyone: "The vital signs are now close to stabilizing, and the blood pressure has returned a little bit." ”

Wu Guonan and Xue Tao began to stitch together.

Seeing this, Li Junfeng suddenly felt a little uncomfortable.

He just finished stitching up his muscles at this time, and opposite him, Wang Liangan, who also wanted to throw Wu Guonan's arrogant back with him, was stunned after stitching up his muscles, not knowing how to deal with himself.

After all, he actually came to help Wu Guonan, but he didn't help, and he almost made a commotion.

Just now?

himself and Wang Liangan seem to be a little different from each other.

However, the two have completed the exploration of the brachial artery to stop the bleeding......

Li Junfeng straightened his throat and said with a smile: "Director Wu, I have already dealt with it here, and the bleeding is effective, and I won't be able to do it later, or I'll leave first?" ”

Li Junfeng played yo-yo directly.

(End of chapter)