232. Two-use

Kawei admitted that there was a mistake in his judgment.

There are many reasons, and in addition to the disturbing suggestions around him added his options, the 19th-century medical environment also brought him extra concerns. However, shirking responsibility is not his style of conduct. Using this as a guide, it is certainly more meaningful to learn lessons from everyone than to maintain some unnecessary self-esteem.

In the absence of examination, whether to directly open the chest to bear the risks of major surgery or to do pericardial incision first bet on the success rate of conservative treatment is actually not wrong.

The mistake is that Kawei's incision selection is not good.

When cardiac repair has been listed as a substitute option and repair needs to be written into the surgical process at any time, the choice of incision becomes very important.

The pericardial fencing incision chosen by Kavi was a 5cm longitudinal opening under the xiphoid process. Here, the bone structure on the lateral side of the thoracic cavity can be successfully avoided, and the incision path can also reach the posterior wall of the pericardial wall, making it easy to aspirate and clean enough.

If you encounter a situation where you need to open the chest urgently for cardiac surgery, the longitudinal incision under the xiphoid process can directly expand the sternum upward. The incision usually extends from the concave of the sternum to the xiphoid process, and is cut and separated by a sternum saw.

This is the most widely used surgical incision outside the heart and chest, and the median sternum cleavage [1].

Combined with the sternum retractor, the four chambers of the heart and the ascending aorta can be well exposed, and external circulation can be established if necessary. If the injured person has a thoracic and abdomen combined with trauma, this incision can continue to go downward and open abdominal investigation.

Unfortunately, it is now the 19th century, and how to split the sternum and how to pull the sternum to both sides to fight against the huge rebound force has become a difficult problem that Kavey cannot solve.

He does not have a retractor that can fix the surgical field. Although it can be done by human power, human muscles cannot be stable for a long time like machinery.

Besides, splitting the sternum is not as easy as expected. It is difficult for an ordinary bone saw to complete the correct median sternum cleavage.

It is just a trivial matter, which affects the prognosis of sternum closing after surgery. But once the force is too strong, it will be a big problem, because the right ventricle is in addition to some shallow fibrous tissue under the sternum.

This is a flaw in surgical tools. The scarcity of cardiothoracic surgery has not given Kawei the experience of practicing existing tools, and it cannot be compensated by his own technology.

In comparison, the left anterior exterior chest incision made with the fourth and fifth ribs as the entrance is much more moderate. [2]

This traditional approach will encounter many vascular nerves, and surgical operations will inevitably cause intraoperative injuries. Moreover, because the injured person lies flat on the operating table, when he aspirates blood and fluid in the pericardial cavity, there will definitely be residuals, that is, he cannot be absorbed cleanly.

When faced with major surgery for heart repair, in order to expand the field of vision, a considerable part of the bone structure is also needed to be removed.

There are many shortcomings in the rib incision on the left chest, and many trauma centers have long been abandoned. However, in today's surgical environment, it can handle two surgeries of pericardial tamponade and heart repair without using a sternum retractor, so as to achieve dual use of one mouthful.

If the surgery requires an increase in central vision, this incision can also reversely break the sternum and increase exposure.

In fact, there are many advantages. In summary, it is quick and convenient to enter the chest, and the postoperative recovery should be faster. Kavey's modern surgical thinking ignores this point. Although it will not produce much bad results, it will cause Rogerini to be hit again.

"There was a problem with the surgical incision under the xiphoid process just now. I'm now re-opening an incision. Prepare for bone biting forceps and bone scissors."

Kavey asked Lucius and Goram to process the incision under the xiphoid process, and quickly cut the skin on the fifth rib: "From this position to directly enter the left heart, solving the pericardial tampon and heart rupture."

Everyone around had never seen such a large chest incision, and the surgery had already developed in a direction that everyone could not imagine.

As surgeons, they are in a complicated mood. On the one hand, they believe that the heart is so dangerous, and they will definitely not be able to repair it through surgery. On the other hand, they also want to see if Kavi's inhuman skills will produce new miracles after colliding with such serious trauma.

The distance between the skin and the ribs is very short. Kawei separates the subcutaneous tissue and muscles. He quickly frees the ribs and uses scissors and bite forceps to remove the rib cartilage between the sternum and the ribs about 4cm, and enters the anterior cardiac area through the ribbed. [3]

This time my vision is much better than before. I can see large pericardium and more blood clots and loose connective tissue.

Kawei carefully used tweezers to remove the blood clots and pushed away the connective tissue, asking, "How is the suture tension below you?"

"The tension is a little problem." Lucius's first suturing of the pericardium, let alone experience, he hadn't even touched the anatomy much. "The suture may take time."

"Can't sew it?"

“The bleeding is a bit too much, and”

"Forget it, don't need to stitch it first, just put it there." Kavi quickly made a decision. "Goram was responsible for attracting bleeding, so the incision was simply disinfected and covered with wet gauze. Come up and help me, I need manpower here."

The incision is just in case, and multiple openings can have one more operation method. Although this method is not routine, since it has been cut, it is simply wrong.

Besides, the pericardium is something that can be sewn or not. Forced suture is a constraint on the heart and may cause unpredictable other damage. Opening the pericardium can actually give the suction a gap, at least not refilling the pericardium.

Kawei replicated the surgical method of handling the pericardial just now, but the traction wire used for suspension was changed to two, located on the left and right sides of the incision, and gently cut it with a scalpel in the middle after lifting it.

Suddenly, the nurse beside him reported Rogerini's vital signs: "The heart rate suddenly increased, now 145 times per minute."

In fact, it is not necessary for the nurse to explain that Kawei, the naked eye and other surgeons on the operating table alone can see how crazy Rogerini's heart is beating: "Re-test blood pressure, is the blood matching done? I'm going to have a blood transfusion now!"

"It should be getting better soon."

"The infusion is enlarged." Kawei used a finger to penetrate the pericardial notch he had cut. While scraping off the blood clots, he assisted the suction device to suck them all away. "Where is the blood pressure? Report your blood pressure, and your heart rate."

"Heart rate 147, blood pressure 87"

The nurse's measurement speed was already very fast, and being able to access Lucius' operating table already showed her excellence. Before Carvey proposed to take a blood pressure measurement, she had already tightened the blood pressure sphygmomanometer airbag and gave her systolic blood pressure in less than half a minute.

Just wait for the mercury liquid to drop flat, and the diastolic pressure reading will come out.

Krozelini's heart and Kavi's fingers didn't have time to wait for this value, and a soft "hiss" sounded, and a straight dark red blood curtain ejaculated from the center of the operating table.

[The height is estimated to be half a meter. Maybe it is higher or one meter. I can't remember it anymore, but it's too exaggerated! If it were me, I wouldn't know what to do]

This was the impression left by the scene in the eyes of the onlookers of the surgery. Although the bleeding was quickly stopped, such an exaggerated amount of bleeding is still fresh in memory.

However, Kawei's next operation is even more difficult to let go.

He saw the location of the bleeding in an instant, and after successfully avoiding the gushing blood, he pressed the rupture at the tip of the left heart with just one index finger of his left hand. [4]

When someone else's head was troubled by problems such as "The big thing is not good", "Why did it suddenly bleed", "It's over", "What should I do", he had easily solved the problem and asked the nurse beside him for a stitching needle and thread.

"Give me a needle and thread, hurry!"

“.Well, okay.”

"blood pressure?"

“.Press down 35.”

“Speed ​​up infusion.”

Kavi's fingers gently pressed against the surface of the heart rupture, and the height was rising and falling with the rapid beating heart. He looked back at the other doctors around who were already excited, but called Salson alone, "Salson went to wash his hands and took over Goram's lower incision."

"good."

"Goram came up and sucked up the blood clots and blood around the rupture, exposing the situation around the heart."

"yes."

"Lucius, do you want to try to suppress the gap?"

"I?"

Lucius worked in surgery for more than ten years and took on such an exaggerated operation for the first time. He pressed the rupture of the heart with his fingers and maintained the original beating of the heart. This was something he had never thought about before.

The word excitement is hard to describe his current mood, and there is only one word left: confusion.

"Can you do it? If not, forget it."

Lucius swallowed and nodded repeatedly: "Okay, I'll give it a try."

Although Carve attaches great importance to his previous puncture performance, he is not now performing this oral intercourse with a teaching mentality, but because he needs to free up his hands to find the bullet that entered Rogerini's chest.

Judging from the ballistic position, the bullet should have passed through the left lung and entered the pericardium, and then created a gap in some positions above the apex of the left heart.

There is the gap below Kawei's finger. The feeling from the belly of his finger is a tangent rather than a bullet hole. This means that the bullet just rubs against the tip of his heart, causing a tangent injury, but the angle of the injection is obliquely lowered, and the warhead is likely to go further down.

Residual warheads are a troublesome thing, and may cause sequelae to soldiers, but they may not.

If you are doing conservative treatment like those common chest firearm injuries, there is no need to remove the warhead. However, Kavi has opened Rogerini's chest cavity. At this point in the operation, the warhead should be removed.

"Have you tried to find it or get it" and "Is it not found", "Can you get it" are completely different things.

"With my fingertips, yes, just use force!" Cave and Lucius' two fingers pressed together, "Turn down slowly, yes, slow, stop!"

The handover was temporarily stopped, and Kawei quickly removed his finger and continued to cover the cracked mouth with his left index finger: "Your fingers are too stiff. I asked you to use force, but your wrists, not your knuckles, do you understand?"

After hearing this, Lucius looked at the beating heart and nodded: "I understand, the knuckles need to fit the beating of the heart, and you can't press too hard."

"Try again, forget it if you don't."

Kavi didn't dare to joke about the heart. The exaggerated blood ejaculation ability of the left ventricle can allow Rogerini to meet God in a short period of time. Some teaching needs to be carried out, while some teaching is too dangerous and can only be left to the trainees with enough experience to do it.

The two of them continued to do the actions they had just done, and this time Kawei also used his right hand.

The thumb and index finger of the right hand are placed on both sides of the rupture, and follow the heart beating like the index finger of the left hand. Try to align the two sides of the rupture: "Yes, that's it. Use force on your wrists, otherwise your fingers will be bounced away by blood. The metacarpophalangeal joints should be rhythmic and relaxed, but the finger belly must be fit on the surface of the heart, and no gaps are left, right."

It took a full 2 ​​minutes to hand over a finger to a rupture hole that was only 1.5cm.

This contains Kavey's caution, and it also provides Lucius with time to fully familiarize himself with the heartbeat. After all, there is never a genius in surgery. It is difficult for a doctor who has not experienced heart surgery to block the heart rupture with his fingers.

Relatively speaking, Kawei was just an accident, and there was not much talent bonus behind it. He only had the experience and skills obtained from more than 30 years of tireless practice.

Now the situation has gradually stabilized since the beginning of chaos. Although the vital signs are a bit dangerous, the infusion is increasing and blood transfusion is on the way, and everything is developing in a better direction.

However, the better the situation, the less you should not be careless.

Kavi has now successfully freed his hands and began to explain the operation again: "Rogelini is very lucky. The bullet did not enter the heart chamber, but shot from the front left, rubbing the myocardium above the apex and entering the back of the heart.

Now I need to look for bullets and bullets, and that kind of thing stays inside no one knows what will happen next.”

At this time, Salson had already come on the stage and picked up the suction left by Golam. What he had to do was to clean the blood clots in the incision here, and then ensure that the blood flowing out did not accumulate in the incision.

Goram replaced Lucius's position and did the hooking work to protect the incision. Lucius blocked the heart gap, while Kavey gently penetrated the back of the heart with his fingers and started looking for it.

"If he is really lucky enough, the bullet should stay in the pericardial cavity. If he is too lucky, then I will only have it." Kawei's fingers repeatedly stirred the back wall of the heart. While feeling the beating, he suddenly encountered a hard solid. "The bullet seems to be really here, hurry up, give me tweezers."

The nurse sent surgical tweezers.

"Lucius, lift your heart with another hand slightly. Yes, be gentle and don't use too much force."

Kawei penetrated the tweezers into the open pericardial notch, followed the direction and path of his fingers just entering, and paused behind the heart. He leaned on his amazing fingertips to finally touch the bullet in a corner with his tweezers.

"Here, come, hurry up, give me a bend, this evil bullet that seriously injured the Austrian soldiers has finally come out!!!"
Chapter completed!