56: Chapter 56: To deny a diagnosis made by a department head leading a team—that's incredibly audacious!
Deputy Director Qin didn't say a word, turning his head to glance at the Attending Physician.
The Attending Physician immediately stepped forward to explain.
"Director Qin, we performed a detailed physical examination upon admission. McBurney's point tenderness was atypical, Rebound tenderness was not obvious, and the CT scan didn't report any appendix abnormalities. The opinion from the Department of Gastroenterology's consultation also leans towards Irritable Bowel Syndrome."
Deputy Director Qin nodded and then turned to Lu Chen.
"You heard that. The physical exam is atypical, imaging shows no abnormalities, and the gastroenterology consultation supports our diagnosis. On what basis do you believe it's appendicitis?"
"Based on my clinical judgment," Lu Chen said.
As soon as these words were spoken, the expressions of several doctors from the General Surgery Department changed.
A Resident Physician, during a cross-departmental ward round, in front of so many people...
...saying he relied on his clinical judgment to deny a diagnosis from a department led by a director.
This was incredibly audacious.
The corners of Deputy Director Qin's mouth curled up slightly.
That smile was not a kind one.
It was a condescending scrutiny.
"Your name is Lu Chen, right? The one who recently blocked those thugs on the internet?"
"Yes."
"I heard your Suturing is quite good, and you're quite famous in the Emergency Department."
"Thank you, Director Qin."
"But being good at Suturing doesn't mean you're qualified to question the diagnostic results of other departments. It's good for young people to have drive, but you must also consider the occasion. Don't you think so?"
Once things reached this point, it was no longer a simple academic discussion.
This was a reprimand.
And it was a very skillfully delivered one.
Praising you first and then suppressing you, making you back down on your own.
If Lu Chen took a step back now and said something like 'Director Qin is right to teach me,' the matter would pass.
But Lu Chen did not back down.
"Director Qin, I understand what you mean, but I still stand by my judgment. This patient needs further investigation into the appendix."
Deputy Director Qin's smile vanished.
He looked toward Director Li Sen.
"Director Li, the Resident Physicians in your department are well-educated; they certainly have strong opinions."
These words were laced with thorns.
Director Li Sen glanced at Lu Chen and then turned to Deputy Director Qin.
"They're young; if he has ideas, let him speak. Whether he's right or wrong can be discussed further."
"Fine, then let's discuss it."
Deputy Director Qin walked to the Hospital bed and personally performed a physical examination on the patient.
His hand pressed on the patient's McBurney's point in the right lower abdomen.
"Does it hurt?"
"A little," the patient said.
"How does this level of pain compare to your usual abdominal pain?"
"About the same. Sometimes it hurts, sometimes it doesn't."
Deputy Director Qin lifted his hand, suddenly releasing the pressure.
A Rebound tenderness test.
"Does it hurt when I let go?"
"Not really."
Deputy Director Qin straightened up and turned to look at Lu Chen.
"You saw that. McBurney's point tenderness is atypical, and Rebound tenderness is negative. Is this how appendicitis presents?"
Lu Chen was not shaken by this result.
"The physical signs of an Acute flare-up of chronic appendicitis can be atypical. Especially in patients who are overweight or have an anatomical variation in the appendix's position, McBurney's point tenderness might not be obvious, but that doesn't mean there's no inflammation."
"Then you check him."
Deputy Director Qin stepped aside.
"You come and find the positive signs of appendicitis for me."
This was a blatant challenge.
If Lu Chen found them, he would be slapping Deputy Director Qin's face.
If he couldn't, he would be humiliating himself.
It was a dilemma.
But Lu Chen didn't hesitate and walked straight forward.
He stood by the bedside, looking at the patient.
"Sir, I'm going to do an examination. It might be a bit uncomfortable, so please bear with me."
"Okay."
Lu Chen placed his hand on the patient's right lower abdomen.
He didn't press McBurney's point directly.
Instead, he first performed a Psoas sign test.
He had the patient lie on his left side, passively extended the right thigh, and over-extended the right hip joint.
"Does it hurt?"
The patient's brow furrowed slightly.
"A little."
Then he performed an Obturator sign test.
He had the patient lie supine, flexed the right thigh, and passively rotated the right hip joint internally.
"How about this?"
"Mm, that also hurts a bit."
Lu Chen straightened his body.
"Both the Psoas sign and the Obturator sign are positive."
He turned to look at Deputy Director Qin.
"Positive results for these two tests indicate that the position of the appendix might be pelvic or retrocecal."
"With an appendix in such positions, it's normal for McBurney's point tenderness to be atypical, but it doesn't mean there's no issue with the appendix."
Deputy Director Qin's expression changed.
It wasn't the embarrassment of being proven wrong, but a genuine sense of surprise.
He hadn't expected a Resident Physician to be able to make such a judgment.
The Psoas sign and Obturator sign were auxiliary diagnostic methods specifically used when the position of the appendix was abnormal.
They were taught in undergraduate textbooks, but in clinical practice, many doctors wouldn't take the initiative to perform them.
Because for most cases of appendicitis, McBurney's point tenderness and Rebound tenderness were very typical, making these two tests unnecessary.
Only when the physical examination was atypical would these two tests be needed to assist in the judgment.
And this patient was precisely the type with atypical physical signs.
Deputy Director Qin was silent for a few seconds.
The Attending Physician nearby became a bit anxious.
"Director Qin, the false positive rate for these two tests isn't low either."
"Shut up," Deputy Director Qin said.
The Attending Physician immediately fell silent.
Deputy Director Qin looked at Lu Chen again.
"You're saying that the patient's appendix might be in a pelvic or retrocecal position, causing the typical signs to be inconspicuous, right?"
"Yes. I suggest performing a Contrast-enhanced CT or an Appendix ultrasound to confirm."
Deputy Director Qin didn't respond immediately.
He was thinking.
If Lu Chen was right, it meant that the General Surgery Department's diagnostic direction for the entire week had been completely wrong.
A Resident Physician correcting the diagnosis of a General Surgery Department in a Grade A Tertiary Hospital...
...this would be quite a loss of face.
But if Lu Chen was wrong, performing a Contrast-enhanced CT wouldn't result in any loss.
Deputy Director Qin made a decision.
"Arrange for a Contrast-enhanced CT; do it this afternoon."
He turned to glance at his Attending Physician.
"You go and write the order."
"Director Qin, this..."
"Write it."
The Attending Physician didn't dare say anything more and turned to leave.
Deputy Director Qin looked at Lu Chen again.
"What if the CT results confirm it's not appendicitis?"
Lu Chen's expression was very calm.
"If it's not, I will apologize to you and your team in person."
"Good, you have accountability."
There was a hint of something subtle in Deputy Director Qin's tone—not hostility, but interest.
"Then what if it is?"
"If it is, I suggest surgery as soon as possible."
"Will you perform it?"
Deputy Director Qin suddenly threw this question out.
It sounded like a joke, but not entirely.
Director Li Sen spoke up from the side.
"Director Qin, you must be joking. Letting a Resident Physician be the lead surgeon in your department's ward?"
"I'm not joking."
Deputy Director Qin looked at Lu Chen with a scrutinizing gaze.
"I heard you've done a Laparoscopic Appendectomy, the one where Director Li personally served as the first assistant, completed in 23 minutes with zero blood loss. Is that true?"
The news had spread this fast?
Lu Chen glanced at Director Li Sen.
Director Li Sen's expression remained unchanged.
"It's true," Lu Chen said.
"Then if the CT results confirm it's appendicitis, do you dare to perform a surgery in our General Surgery Department's Operating Room?"
The corners of Deputy Director Qin's mouth curled up slightly.
"I can arrange for the entire department to observe."
A department-wide observation.
The weight of these four words was not light.
Deputy Director Qin's meaning was clear.
If Lu Chen's diagnosis was correct, he would let him perform the surgery in front of the whole department.
If he did well, Lu Chen would become famous.
If he messed up, what would be lost wasn't just Lu Chen's face, but also the face of the Emergency Department and Vice President Zeng.
It was a setup.
Zhao Yaqin gently pulled on the corner of Lu Chen's white coat from behind.
Her meaning was: don't be impulsive.
But Lu Chen had already spoken.
"I can."
Deputy Director Qin smiled.
"Good. Then we'll wait for the CT results. The notification won't be later than 4:00 PM today."
The ward rounds effectively ended there.
Leaving the General Surgery Department, the group walked silently down the corridor.
Zhao Yaqin was the first who couldn't hold it in.
"You're really bold."
Lu Chen didn't speak.
"Do you know what a department-wide observation means? Over thirty doctors and Nurses from General Surgery will be watching you. As long as you make one tiny mistake, those people can magnify your error tenfold and spread it throughout the entire Hospital."
"I know."
"You knew and you still agreed?"
"Because I am certain that patient has appendicitis."
Zhao Yaqin opened her mouth but said nothing more.
Director Li Sen walked at the front and hadn't spoken the whole time.
It wasn't until they entered the elevator that he finally said something.
"If you can do it, go for it; if you can't, back out. Don't force it. I can back you up."
"I don't need backing up, Director."
Director Li Sen glanced at him.
"Fine. Then let me see what you've got."