111: Chapter 111 Chen Minghao is about to show off his skills! Oh no, a mistake!
Lu Chen watched the ultrasound screen without speaking.
[Eye of Truth scan complete]
[Patient Information: Female, 36 years old]
[Chief Complaint: Sudden chest tightness and shortness of breath accompanied by hypotension]
[Eye of Truth Diagnosis: Systemic lupus erythematosus-related acute pericarditis with complex septated pericardial effusion, acute cardiac tamponade; the left parasternal approach is dynamically obstructed by lung tissue, the fluid cavity in front of the right ventricle is narrow and close to coronary artery branches, routine Puncture carries extremely high risk]
[Danger Level: SS-class]
[Current Symptoms: Hypotension, tachycardia, dyspnea, insufficient peripheral perfusion, limited ventricular diastole]
[Suggestion: Prioritize ultrasound-guided modified lateral apical micro-window Puncture; the end-expiratory breath-hold window is approximately 1.6 seconds, needle insertion angle 23 degrees, depth 4.2 cm; avoid lung margins and septations; first aspirate 40 to 60 ml of fluid from the high-pressure lateral apical cavity, then adjust the guidewire to enter the main cavity for catheter drainage]
[Warning: The left parasternal approach has a low success rate; if it mistakenly enters the anterior wall of the right ventricle or damages coronary artery branches, it could induce intrapericardial hemorrhage, ventricular arrhythmia, and circulatory collapse]
Lu Chen's brows twitched slightly.
The approach chosen by Associate Chief Physician Chen Minghao carries high risk.
Director Li Sen clearly had concerns as well.
"The left parasternal lung obstruction is significant, the patient's breathing is rapid, and the window is unstable."
Associate Chief Physician Chen Minghao said, "We can have the Department of Anesthesiology come over to provide appropriate sedation and control the respiratory amplitude."
Zhao Yaqin said immediately, "The patient's blood pressure is already very low; the risk of sedation is not small."
Associate Chief Physician Chen Minghao glanced at her.
"That's why we need to be fast; we cannot delay any longer."
Section Chief He Zhongfeng arrived at this moment, panting, but did not forget to speak.
"Associate Chief Physician Chen Minghao is a Puncture expert from the Provincial Peoples Hospital with rich experience. The patient's condition is critical, so let's let Associate Chief Physician Chen Minghao try."
Upon hearing this, the patient's husband immediately said, "Expert, please save my wife!"
Associate Chief Physician Chen Minghao nodded.
"I will do my best."
Director Li Sen was silent for two seconds.
"Associate Chief Physician Chen Minghao, if you are the primary operator, I will assist from the side."
Associate Chief Physician Chen Minghao did not refuse.
"That works."
Lu Chen suddenly spoke up.
"Associate Chief Physician Chen Minghao, the left parasternal approach carries high risk, and the lung margin obstruction is not a static issue."
"Every time the patient takes a rapid breath, the lung tissue will cover the needle path."
"Furthermore, the fluid cavity width in front of the right ventricle is insufficient, and the margin for error for the needle tip is too small."
Associate Chief Physician Chen Minghao looked at him.
"Dr. Lu, do you have any suggestions?"
Lu Chen pointed to the ultrasound screen.
"There is a brief window on the lateral apical side that opens at the end of expiration; we can insert the needle from there."
Associate Chief Physician Chen Minghao frowned.
"The lateral apical side?"
"There are more septations there, and the path is longer."
"Young physicians should not just look at the instantaneous window on the ultrasound image; in actual practice, the patient's breathing, heartbeat, and needle deflection will all affect the results."
Lu Chen said calmly, "That is why full-course ultrasound guidance is needed, inserting the needle at the end of expiration, and keeping the needle tip in-plane."
Associate Chief Physician Chen Minghao's tone hardened slightly.
"Anyone can talk about theory, but actual practice is not like answering questions by looking at pictures."
The atmosphere in the Resuscitation Room stiffened for a moment.
Sun Ji cursed in a low voice from behind.
"This guy is really stubborn."
Wu Fan glared at him.
"Quiet."
Director Li Sen looked at Lu Chen.
Lu Chen did not continue to argue.
The patient is on the bed now; arguing cannot save a life.
Associate Chief Physician Chen Minghao began disinfection and draping.
The doctors who came from the Provincial Peoples Hospital also gathered around, while the people from the Central Hospital stood on the periphery; everyone was staring at the resuscitation bed.
Associate Chief Physician Chen Minghao picked up the Puncture needle and stood on the patient's left side.
"Local anesthesia."
The Nurse assisted.
The patient's breathing was becoming increasingly rapid.
"Doctor, I feel so uncomfortable..."
Associate Chief Physician Chen Minghao said in a deep voice, "Don't move, try your best to coordinate with your breathing."
The patient's husband stood by the door, his hands trembling.
Shen Xiaoning glanced at Lu Chen, her eyes showing clear worry.
Lu Chen stood by Director Li Sen's side, his gaze constantly on the ultrasound screen.
Associate Chief Physician Chen Minghao inserted the needle for the first time.
The needle tip appeared under ultrasound.
The angle looked relatively steady.
But the patient suddenly gasped violently, the lung margin moved down, and the originally narrow channel was obstructed.
Director Li Sen immediately reminded him.
"The lung margin has come down."
Associate Chief Physician Chen Minghao's hand paused, and he adjusted the angle.
The needle tip deviated from the plane.
On the ultrasound screen, the image of the needle tip became blurry.
He Wenbin said in a low voice, "The needle tip can't be seen clearly."
Sweat began to form on Associate Chief Physician Chen Minghao's forehead.
He withdrew the needle by two millimeters to re-find the plane.
The patient's heart rate rose to 155.
Blood pressure dropped to 68/40.
The alarm sound of the monitor became rapid.
Zhao Yaqin said, "The blood pressure is still dropping."
Associate Chief Physician Chen Minghao gritted his teeth.
"Give me a little more time."
Second adjustment.
The needle tip finally appeared again, but it was too close to the anterior wall of the right ventricle.
Lu Chen spoke up.
"Stop, the needle tip is too close to the myocardium."
Associate Chief Physician Chen Minghao stopped his movement, his expression becoming ugly.
Being reminded in public by a Resident Physician whom he had just critiqued in the Conference Room—this feeling was terrible.
But the image on the screen could not be refuted.
He had no choice but to withdraw the needle.
A young doctor from the Provincial Peoples Hospital on the side whispered, "Associate Chief Physician Chen Minghao, how about changing the approach?"
Associate Chief Physician Chen Minghao glanced at him, and the young doctor immediately shut up.
Section Chief He Zhongfeng stood in the back and also began to panic a little.
He originally wanted to see Associate Chief Physician Chen Minghao demonstrate his skills, but he didn't expect this resuscitation to be so much harder than imagined.
The patient suddenly let out a painful gasp.
"I can't do it anymore..."
On the monitor, blood pressure was 62/38.
Heart rate 162.
Blood oxygen 86.
Director Li Sen said in a deep voice, "Associate Chief Physician Chen Minghao, we cannot delay any longer."
Associate Chief Physician Chen Minghao inserted the needle again.
This time, he was clearly anxious.
After the needle tip entered the subcutaneous tissue, the angle was slightly off, and the loss of the ultrasound plane was even more obvious.
He tried to readjust, but because over a dozen pairs of eyes were staring at him, his movements became increasingly stiff.
Just a moment ago in the Conference Room, he had emphasized standards.
Just a moment ago, he had said that young physicians should not only look at results.
Just a moment ago, he had said that this kind of procedure was not suitable for publicity.
Now, in front of everyone, he himself had lost his most basic rhythm.
Zhao Yaqin said, "The patient's consciousness is deteriorating!"
Shen Xiaoning immediately stepped forward.
"The patient is unresponsive!"
The monitor alarm sounded continuously.
Blood pressure 58/35.
Director Li Sen spoke decisively.
"Stop!"
Associate Chief Physician Chen Minghao's movements froze.
Everyone in the Resuscitation Room looked at Director Li Sen.
Director Li Sen's expression was serious.
"Associate Chief Physician Chen Minghao, the patient cannot wait any longer; withdraw the needle first."
Associate Chief Physician Chen Minghao opened his mouth.
"I can still..."
Director Li Sen's voice was heavier.
"Withdraw the needle!"
Associate Chief Physician Chen Minghao's face turned pale and then flushed, and in the end, he withdrew the needle.
The Resuscitation Room was so quiet that only the alarm sound of the monitor remained.
The next second, everyone's gaze turned to Lu Chen.
This turning of heads happened almost simultaneously.
Sun Ji looked at Lu Chen.
Wu Fan looked at Lu Chen.
Zhao Yaqin looked at Lu Chen.
He Wenbin looked at Lu Chen.
Shen Xiaoning also looked at Lu Chen.
Even the patient's husband followed everyone's gaze and looked at that young doctor.
Director Li Sen did not have any hesitation.
"Lu Chen, you do it."
Lu Chen nodded.
"Okay."
Associate Chief Physician Chen Minghao stood in place, his expression stiff.
He wanted to say something, but couldn't.
Lu Chen walked to the bedside and put on new gloves.
Shen Xiaoning immediately handed over a new Puncture kit.
"Dr. Lu, here is a new kit."
"Thank you."
Her voice was very soft.
"You can definitely do it."
Lu Chen glanced at her.
"Yeah."
Zhao Yaqin immediately took over the process on the side.
"Maintain with a low dose of norepinephrine, increase oxygen flow, keep the defibrillator on standby, and open all resuscitation drugs."
Wu Fan said, "I will help you stabilize the patient's position."
Director Li Sen picked up the ultrasound probe himself.
"I will provide the imaging for you."
Lu Chen shook his head.
"Director, I will do it myself; you help me watch the monitor."
Director Li Sen looked at him.
"Are you confident?"
"Yes."
This word was very light, yet it made everyone in the Emergency Department quiet down.
Lu Chen re-scanned.
He did not rush to insert the needle, but instead asked the patient's husband to come over.
"Family member, the patient currently has acute cardiac tamponade; blood pressure is already very low, and cardiac arrest could occur at any moment."
"I need to perform a Pericardiocentesis immediately to drain the effusion."
"There are risks of arrhythmia, hemorrhage, Puncture failure, and even death during the process."
"But if we don't do it, she won't make it."
The patient's husband's eyes were red.
"Doctor, I will sign, please save her!"
Shen Xiaoning handed over the informed consent form.
"Sign here."
The patient's husband's hands were trembling severely, and his signature was crooked.