189: Chapter 189 Are you sure you want to continue to level nine?
The second stage.
Massive oral bleeding, field of vision obstructed.
Lu Chen used a suction device to clear the bleeding area, but it wasn't completely cleared.
While blood was still slowly gushing out, he inserted the scope directly, precisely capturing the location of the glottis during the brief gaps when the blood wasn't obstructing his view.
The tube entered on the first attempt.
18 seconds.
Zhou Haoran was watching from the side, his mouth opening and then closing.
18 seconds.
The second stage.
This speed is a bit absurd.
"Pass."
The third stage.
Cervical spine immobilized, head cannot be tilted back, midline intubation with a video laryngoscope.
Lu Chen switched to a video laryngoscope, and the image on the screen was so steady in his hands that there wasn't the slightest tremor.
The tube entered precisely along the midline of the glottis.
24 seconds.
"Pass."
The fourth stage.
Laryngospasm.
During the intubation process, the simulated patient's glottis suddenly clamped shut.
Lu Chen's tube stopped just as it reached the glottis.
He didn't force it.
He immediately withdrew the tube while administering intravenous propofol to the simulated patient to deepen sedation, combined with succinylcholine for muscle relaxation.
He waited for eight seconds.
The system indicated that the laryngospasm had resolved.
Lu Chen inserted the tube again.
Success on the first attempt.
35 seconds in total.
The reason most people failed this stage earlier was that they forced the tube in, causing glottic injury.
Lu Chen's handling was clean and efficient, without any unnecessary movements.
"Pass."
The fifth stage.
Edema following airway burns, with only a narrow slit remaining at the glottis.
Lu Chen immediately chose a 5.0 thin tube.
Guided by the fiberoptic bronchoscope, he precisely inserted the tip of the tube into that glottic slit, which was less than 4 millimeters wide.
21 seconds.
Instructor Sun Gubei stared at the simulation monitor for three seconds.
The tube position was perfect, without touching any of the edematous tissue.
"Pass."
The sixth stage.
Massive airway bleeding complicated by coagulation disorders, with the glottis almost invisible.
Lu Chen also used the fiberoptic bronchoscope, but his operational rhythm was completely different from the students who used it earlier.
When others used the fiberoptic bronchoscope, they would repeatedly adjust the lens and search for the direction.
After Lu Chen's lens entered the airway, there was almost no unnecessary shaking.
He found the glottis in the blood extremely quickly.
It wasn't because he was lucky.
It was because his hand was too steady.
The tip of the fiberoptic bronchoscope in his hand seemed to have eyes of its own; every tiny turn had a clear purpose.
The glottis was found.
The tube slid into the glottis, guided by the fiberoptic bronchoscope.
28 seconds.
Several of the students present had already stopped talking.
He had succeeded on the first attempt in all six previous stages without any mistakes, and his time for each stage was far lower than everyone else's.
"Pass."
The seventh stage.
Foreign body aspiration complicated by airway burns.
This was the same stage where both Zhou Haoran and Chen Hao had suffered setbacks earlier.
Inside the simulated patient's trachea was a foreign body simulator, located about two centimeters below the glottis.
The airway mucosa above the foreign body was severely edematous.
The operator needed to insert the tube through the gap between the foreign body and the edematous airway wall without touching the foreign body.
This gap was only about three millimeters.
With three millimeters of space, combined with the edematous mucosa and airway bleeding, the field of vision was extremely poor.
Lu Chen first used the fiberoptic bronchoscope to examine the position of the foreign body and the width of the surrounding gap.
Then he performed an action that none of the previous students had done.
He withdrew the fiberoptic bronchoscope and, based on the examination results, made an extremely slight adjustment to the bending angle of the tube's tip.
This adjustment was only two millimeters.
But that two-millimeter bend allowed the tip of the tube to perfectly pass through the gap between the foreign body and the edematous wall when it re-entered.
It didn't touch the foreign body.
It didn't touch the edematous mucosa.
The tube successfully reached the safe position below the glottis.
32 seconds.
This time, Zhou Haoran's mouth really couldn't close.
He had failed the seventh stage.
Chen Hao had passed the seventh stage, but it took him one minute and thirty-eight seconds.
Lu Chen used 32 seconds and succeeded on the first attempt.
Instructor Sun Gubei's expression finally showed a noticeable change.
He walked over to the simulated patient and lowered his head to check the position of the tube and the state of the foreign body.
The foreign body hadn't moved at all.
The distance between the tube and the foreign body was uniform.
He straightened up and glanced at Lu Chen.
"How did you judge the bending angle?"
"I measured the width of the gap and the direction of the path while using the fiberoptic bronchoscope, and calculated it based on the rebound coefficient of the tube's material."
Instructor Sun Gubei was silent for two seconds.
"Continue."
...
The eighth stage.
Nasal blind intubation, with severe bilateral nasal septal deviation.
Chen Hao had failed at this stage.
Lu Chen picked up the tube.
He didn't enter directly through the nasal cavity.
Instead, he first gently pressed his fingertips on the outside of the simulated patient's nostrils.
This action was to judge the internal spatial orientation of the nasal cavity through tactile sensation.
Then he chose the right nasal cavity.
The tube was gently inserted.
When passing through the deviated section of the nasal septum, his hand used almost no force.
Relying on its own flexibility and under his extremely precise rotational guidance, the tube bypassed the deviated bony protrusion.
After entering the nasopharynx, Lu Chen slightly adjusted the angle of the tube.
He brought his ear close to the tail end of the tube, listening to the sound of airflow exhaled from the tube opening.
This is the most classic positioning method for nasal blind intubation.
When the tip of the tube is directly above the glottis, the sound of the exhaled airflow is the loudest.
At the exact moment he heard the loudest airflow, at the end of the simulated patient's inhalation, Lu Chen decisively inserted the tube.
It entered the glottis on the first attempt.
The cuff was inflated.
Auscultation confirmed symmetrical ventilation of both lungs.
41 seconds in total.
There was a few seconds of silence in the classroom.
Then someone said in a low voice.
"He passed the eighth stage."
Instructor Sun Gubei looked at the data on the monitoring screen.
The tube depth was appropriate, the cuff position was correct, and there was zero damage to the nasal mucosa.
"Pass."
As soon as this word "Pass" was uttered, the atmosphere at the scene changed.
Out of the fifty students present, only Lu Chen had passed the eighth stage.
The words Instructor Sun Gubei had said earlier were still echoing in everyone's minds.
"I haven't seen anyone who could pass beyond the eighth stage."
Now they had seen it.
The ninth stage.
Instructor Sun Gubei hesitated for a moment while setting the parameters.
He turned and glanced at Lu Chen.
"Are you sure you want to continue?"
"I'm sure."
"The ninth and tenth stages are extreme scenarios I designed separately, which were not originally part of the regular assessment."
"It doesn't matter."
Instructor Sun Gubei turned his head and continued to adjust the parameters.
The scenario for the ninth stage appeared.
The description on the screen made the students present gasp.
A patient trapped in a fire, where inhalation thermal injury caused edema throughout the entire upper airway, from the oropharynx to the glottis.
The mucosa was blistered and sloughing off, and the glottis had swollen until only a gap of less than two millimeters remained.
At the same time, it was complicated by a large amount of eschar debris blocking the airway.
To put it in Chen Hao's words.
"If you encounter this in a clinical setting, it's just a situation waiting for an emergency cricothyroidotomy or tracheostomy; why even bother with intubation?"
However, the simulation settings already indicated that there were extensive neck burns, making it impossible to perform a cricothyroidotomy or tracheostomy.
The only way to survive was through oral glottic intubation.
A two-millimeter gap.
Complicated by eschar debris.
Complicated by mucosal blistering and sloughing.
Vision was almost zero.
Lu Chen walked over to the simulated patient.
He first used the suction device to clear the eschar debris and secretions from the oral cavity and pharynx.
He performed this step extremely carefully; the tip of the suction device only stayed in each position for just enough time to clear it, no more, no less.
After cleaning was complete, he switched to the fiberoptic bronchoscope and a 4.0 ultra-thin tube.
A four-millimeter tube had to pass through a two-millimeter glottic gap.
This is physically impossible.
Unless the glottis is gently and extremely slightly pried open under the guidance of the fiberoptic bronchoscope.
This procedure is described in textbooks, but very few people have ever achieved it in practice.
Because the edematous glottic mucosa is extremely fragile; a little too much force would cause it to tear, and a little too little wouldn't allow passage.