184: You're not going to get the highest score in the entire class for Chapter 184, are you?

At lunch, Lu Chen sent a message to Shen Xiaoning.

[Lu Chen: Got the highest score in the anatomy assessment this morning.]

[Xiao Ning: Ahhhh! You're so amazing!!!]

[Xiao Ning: Although I don't really understand what exactly you do in anatomy class, the highest score means you're number one, right!!]

[Lu Chen: I suppose so.]

[Xiao Ning: Then did you eat a proper lunch?]

[Lu Chen: I ate at the Cafeteria.]

[Xiao Ning: Was it good?]

[Lu Chen: It was okay.]

[Xiao Ning: Don't just say "it was okay," you're just brushing me off.]

[Xiao Ning: You must be missing my cooking, right!]

Lu Chen looked at the message and thought for a moment.

[Lu Chen: A little.]

About three seconds passed.

[Xiao Ning: Taking a screenshot and saving it! That's the second time!]

Some things don't need to be said too much.

Two short words were enough.

After finishing lunch, Lu Chen returned to his dorm to rest for half an hour.

The class at two in the afternoon was a special lecture on Pathophysiology.

It was held in the lecture hall of the Training Center.

Unlike the hands-on practice in the morning, this was purely a theoretical class.

But Lu Chen knew that a purely theoretical class didn't mean it would be easy.

Especially since the instructor was Professor Luo Zhenyu from the Emergency Department of Peking University Third Hospital.

The lecture hall was spacious, capable of accommodating eighty people; after the fifty trainees sat down, there were still plenty of empty seats.

The topic for today was already projected on the large screen at the front of the classroom.

"Pathophysiological Mechanisms and Clinical Decision-Making for Multiple Organ Failure in Extreme Environments."

Lu Chen found a seat near the front.

Zhou Haoran sat down right next to him.

"You aren't planning to get the highest score in the whole class for this theoretical course too, are you?"

"We'll see."

"You sound so insincere."

Two o'clock sharp.

Professor Luo Zhenyu walked into the classroom.

He looked to be in his early fifties and was slightly chubby.

He wore round-rimmed glasses and a plaid shirt.

He didn't look much like a professor; instead, he resembled a retired high school math teacher.

But the moment he started speaking, the atmosphere in the entire classroom changed.

"I won't be using a PPT for this class."

Professor Luo Zhenyu stood in the center of the podium, his hands in his pants pockets.

"You can download the PPT and look at it yourselves later; I have one thing to do today."

He turned around and pressed the remote control.

A medical record appeared on the big screen.

It was a very detailed medical record.

Patient information: Male, 47 years old, construction worker.

Chief complaint: Admitted to the Emergency Department 6 hours after a fall from a height.

Injury mechanism: Fell from a 12-meter high scaffold, landing on the left side of his body on a concrete floor.

Initial vital signs: GCS score 8, blood pressure 72/45 mmHg, heart rate 138 bpm, respiratory rate 28 bpm, oxygen saturation 81%.

Preliminary imaging: Left multiple rib fractures (4th to 9th ribs), left hemopneumothorax, Grade III splenic rupture, multiple comminuted pelvic fractures, left femoral shaft fracture.

Laboratory tests: Hemoglobin 61g/L, platelet count 72×10^9/L, prothrombin time 21.4 seconds, creatinine 187 μmol/L, pH 7.18.

Diagnosis: Polytrauma complicated by hemorrhagic shock, traumatic coagulopathy, early MODS.

Professor Luo Zhenyu let everyone look at it for two minutes.

Then he spoke.

"This case is real."

"Three years ago, the Emergency Department of a Grade A tertiary Hospital in a province in the Northwest admitted this patient."

"From admission to the Emergency Department until the final declaration of death, a total of fourteen hours passed."

"The patient died."

The classroom went quiet for a moment.

"Now, I need you to do one thing."

Professor Luo Zhenyu clicked the remote, and the complete treatment record appeared on the screen, detailing the entire process from admission to death.

"You have two hours to re-analyze the entire treatment process of this case."

"Identify all the steps you believe were problematic."

"Then propose your own plans."

"If you think this patient could have been saved, tell me how."

"If you think this patient truly couldn't be saved, tell me why."

"You have a two-hour limit; when time is up, I will listen to your reports."

After finishing, Professor Luo Zhenyu walked to the back of the classroom, found a seat, took out a book, and started reading.

He left the time to the trainees.

Low-voiced discussions began in the classroom.

Some trainees flipped through the medical records alone, while others gathered together to exchange opinions.

Lu Chen quickly browsed the entire treatment record.

The post-admission treatment process was standard: massive blood transfusion, fluid resuscitation, Closed Thoracic Drainage, and damage control surgery.

The Emergency Department team completed the thoracic drainage and abdominal exploration, removed the ruptured spleen, and performed external fixation for the pelvic fractures within 40 minutes of admission.

There were no obvious errors in the procedure.

But the patient's condition continued to deteriorate after the surgery.

Two hours post-surgery, blood lactate rose from 12.8 to 18.7.

Four hours post-surgery, disseminated intravascular coagulation appeared.

Eight hours post-surgery, kidney function failed completely, and blood creatinine soared to 487.

Ten hours post-surgery, liver function began to collapse.

Fourteen hours post-surgery, cardiac arrest occurred, resuscitation failed, and the patient died.

It was a standard death process from multiple organ failure.

Lu Chen read the treatment record from beginning to end three times.

Then he began to analyze the treatment details of every time point one by one.

When half of the two-hour discussion time had passed, several mainstream viewpoints had already formed in the classroom.

The first viewpoint held that the initial surgical treatment was not thorough enough, and there might have been a residual active bleeding source in the abdominal cavity after the splenectomy.

The second viewpoint held that the early blood transfusion strategy was incorrect, and the ratio of component transfusion was unreasonable, leading to a further deterioration of coagulation function.

The third viewpoint held that the treatment for pelvic fractures should have involved interventional embolization earlier rather than external fixation, to reduce occult blood loss.

Every viewpoint made sense, and corresponding improvement plans had been proposed by some.

But Professor Luo Zhenyu kept sitting in the back, and whenever a trainee took the initiative to discuss their plan with him, he just shook his head.

"Wrong, keep thinking."

One hour and forty minutes had passed.

The atmosphere in the classroom became somewhat anxious.

Basically, all the viable plans had been proposed, but none were approved by the mentor.

Chen Hao stood up to speak once, proposing a plan to increase the dosage of norepinephrine combined with early ECMO support.

"Your direction is wrong; you haven't found the core problem."

Chen Hao's face didn't look very good, but he had no way to refute it.

Zhou Haoran tried to propose a plan regarding early CRRT intervention; after hearing it, Professor Luo Zhenyu said, "You're getting close, but it's not enough," and then continued to shake his head.

When the two hours were almost up, Professor Luo Zhenyu stood up from the back row and walked back to the podium.

"Time is almost up."

He looked around the classroom.

"Your discussions were very active, and the proposed plans all have a certain degree of rationality."

"But you overlooked one thing."

He pressed the remote control, and a page from the treatment record was enlarged on the screen.

Laboratory follow-up records.

"You were all looking at the major treatment strategies: how to perform surgery, how to manage blood transfusion ratios, how to handle pelvic fractures."

"But no one looked carefully at these numbers."

He pointed at the dense test data on the screen.

"Something happened to this patient between the 2nd and 4th hour post-surgery; this event was not discovered at the time, nor was it treated."

"It is precisely because this matter was not treated that the subsequent irreversible MODS occurred."

"In other words, if there had been timely intervention during that window period, this patient might not have died."

The classroom went quiet.

"But my conclusion today is."

Professor Luo Zhenyu's tone became very solemn.

"Under current technical conditions, based on all the information in this medical record, there was indeed no possibility of reversing the outcome for this patient."

"Because that critical window period had already passed; no matter what you did afterward, it was just remedial action after the fact, and he couldn't be saved."

"This is the cruelest part of Emergency Medicine."

"For some patients, it's not that you don't know how to save them, but that you discovered the issue too late."

"Alright, that's it for today's class."

He was just preparing to turn off the screen.

"Professor Luo."

A voice came from the left side of the fifth row.

It wasn't loud, but it was very clear.

Everyone's gaze turned toward it.

Lu Chen stood up.

"I have a different opinion."