This doctor is already middle-aged, and he's only just started practicing medicine.

Chapter 176: Skill Points Cleared!
[Overall Level: Attending Physician]

[Basic Theory: Basic Theory of Trauma Surgery (Specialization 0/20), Emergency Medicine (Specialization 5/20)...]

[CT scan interpretation (proficiency 10/20), physical examination (proficiency 20/20)...]

[Suturing (Expert 20/200), Hemostasis (Specialist 20/20)...]

[Basic Surgical Procedures: Closed Reduction of Fractures (Specialization 10/20), Closed Reduction of Joint Dislocations (Specialization 12/20)...]

Specialized Surgical Procedures: Spleen Preservation Surgery (Specialization 20/20), Gallbladder Preservation Surgery (Specialization 20/20)

[Suturing Technique (Expert 2/200)]

[Basic Suturing Skills: Tendon Repair (Specialization 16/20)...]

【缝合系专科技能：血管端端缝合术（专精0/20），肌腱未命名缝合技法（专精15/20）、未命名肌腱缝合术（专精8/20）、神经外膜-束膜缝合（专精0/20）、未命名脾缝合技法（专精20/20）……】

Lu Cheng glanced at his skill panel subconsciously, and then quickly followed the crowd toward the operating room.

The patient's current diagnosis is unclear and difficult to observe with the naked eye. Given the current vital signs, it would be unreliable to delay further examination.

Zhang Tiesheng and Lu Cheng were responsible for transporting the patient, while Han Xiaoping led the patient's family to the doctor's office: "Sister, brother, come with me to sign the papers."

"Doctor, what forms do I need to sign?" The middle-aged woman asked listlessly.

"Surgical risk, critical condition, and serious illness disclosure form. Your husband's condition is very dangerous; his life is in danger. Even if he goes into the operating room, he may not survive," Han Xiaoping said.

"Even surgery can't save him? Then what kind of surgery is it?" The middle-aged woman paused.

Han Xiaoping asked, "You've chosen not to do it, right? If you're not going to do it, I'll call them and tell them to bring the person out, and you can take them away yourselves?"

Han Xiaoping couldn't be sure if the woman was pretending to be confused in front of him, but as an emergency room doctor, he had considerable experience in handling such cases.

"I am now clearly informing you of this situation: if you do not sign this consent form, it will be considered a refusal of surgery. Your husband will not have the surgery until this consent form is entered into the operating room."

"If you have any doubts, you can call our hospital's medical affairs department or the police to confirm this regulation!" Han Xiaoping quickly explained the medical rules.

"If we don't sign the consent form, we won't perform the surgery. What if the patient dies?" the patient's brother complained.

Han Xiaoping said, "Then your family agrees to the surgery. If you don't care about the patient's life or death, what are we doctors supposed to do?"

As Han Xiaoping spoke, he pressed the record button in the office: "Patient's name, Niu Quandong. You're the patient's wife, right? What's your name?"

"My name is Liu Linxiang. Doctor, what is my husband's condition like now?" Liu Linxiang asked.

"I don't know. All I know is that the situation is extremely dangerous. It's open hemorrhagic shock, and I could lose my life at any moment."

"The surgery he needs to undergo now is an exploratory laparotomy, because there is no time to give him a detailed diagnosis, so we have to save time."

"But the patient was already in shock before entering the operating room, with very low blood pressure and a lot of bleeding. Even if emergency surgery is performed, the patient may still lose both their life and their money."

"I don't have that much time to explain the more detailed things to you."

"The patient's risk of death is higher if they have surgery now, and the risk of death is 100% if they don't have surgery. You have three options."

"First, refer the patient to a higher-level hospital."

"Second, agree to surgical treatment and sign."

Third, refusing treatment.

"Choose one!" Han Xiaoping quickly took control of the conversation.

"What if something goes wrong if I have the surgery?" Liu Linxiang was still hesitant.

Han Xiaoping interrupted: "Choose one! Sign, referral, or refusal. Don't ask about anything else. The time you're wasting now could have been spent signing the papers already."

"I also need to send the informed consent form into the operating room."

He took out paper and pen, handed them to Liu Linxiang, and continued to ask professionally, "Can you write? If you can't write, you can leave your fingerprint."

These words may seem like nonsense, but they are actually meant to leave a record and prevent patients from later claiming they can't write or something, so they use the excuse that the doctor didn't provide enough options and wasted time.

Experienced emergency room doctors will ask this question.

"I can write, but..."

"Then write it down: Agree, sign your name; Reject, sign your name. Hurry up, time is precious."

"I've already given you the pen." Han Xiaoping placed the pen in Liu Linxiang's hand.

Liu Linxiang's hands were trembling. She couldn't contain the current atmosphere and was feeling uneasy, with many thoughts running through her mind.

But after much hesitation, she still wrote down her name.

"It says 'surgery is required' in the front," Han Xiaoping continued, pointing to the blank space.

After Liu Linxiang did as instructed, Han Xiaoping took the documents and left.

Turning around, she continued, "Prepare your husband's ID number and ID card, and have him sign the power of attorney later."

"Your husband is currently in a coma and lacks independent thought and decision-making ability, so your signature is the most effective."

"If you have enough money on hand, go and pay the fee first, 20,000 yuan."

“It’s okay if we don’t have any right now…we’ll save the person first…you can wait outside the operating room,” Han Xiaoping replied professionally.

For emergencies like Niu Quandong's, we cannot refuse to treat patients simply because they haven't paid for surgery. In these absolute emergencies, we must treat them first and then collect payment.

Elective or scheduled surgeries are exceptions, as they do not endanger life and therefore payment can be requested in advance.

……

Emergency operating room.

Lu Cheng and Zhang Tiesheng had just lifted the patient onto the operating table when the anesthesiologist rushed over. After glancing at the patient's vital signs, he cursed, "Damn it!"

"I'm going out to wash my hands and disinfect the towels," Zhang Tiesheng said.

Although he is a doctor in the emergency surgery clinic, there are not enough staff at the moment, and Lu Cheng definitely cannot handle the workload by himself.

Only after Han Xiaoping arrives can he go out to work his shift again.

Lu Cheng said, "It's too late, Brother Zhang, get the iodine complex directly, we need to open the abdomen immediately to stop the bleeding!"

"Aren't you going to disinfect anymore?" Han Xiaoping asked.

"It's too late," Lu Cheng said.

"The patient's blood pressure was already very low..."

"Transfer the patient to the operating table and prepare the wound cleaning kit!" Lu Cheng quickly instructed the circulating nurse.

As they spoke, Lu Cheng and the circulating nurses carried the patient to the operating table.

Seeing that the circulating nurse was a little flustered, Lu Cheng violently tore open the wound cleaning kit himself, and then took a sterile glove and put it on.

Even after working in the emergency department for so many years, Zhang Tiesheng had never seen Lu Cheng so "anxious".

"Lu Cheng," Zhang Tiesheng wanted to say a word of advice.

“Brother Zhang, I know. You put the razor blade on first. As soon as Han Xiaoping comes in, we’ll immediately perform an abdominal incision to stop the bleeding,” Lu Cheng said.

Before the patient's informed consent form for surgery was received, Lu Cheng dared not rashly open the abdomen.

With the patient's family members right beside him, the on-call supervisor couldn't make decisions for them. So, no matter how anxious Lu Cheng was, he could only wait!

The patient is dead, that's it.

The law is set in stone, and ordinary people can only obey it; they have no right to question it.

Because when law enforcement officers are acting in accordance with the law, they will not consider your questions.

The right to informed consent is just as important as the right to refuse informed consent; patients' families have the right to choose whether or not to resuscitate the patient.

Longxian People's Hospital is just a county hospital; there are higher-level hospitals that patients can be transferred to. Patients' families can change their minds at any time and choose to transfer.

Once you sign the consent form, the surgery begins, and there's no going back!

"Put your clothes on first," Zhang Tiesheng said to Lu Cheng.

Lu Cheng then walked to the table where the sterile surgical gown was located, put on sterile surgical gloves, and picked it up.

"The patient has signed the consent form." Han Xiaoping's voice preceded his arrival.

Upon hearing this, Lu Cheng immediately threw down the clothes he was holding.

The circulating nurse, who was about to tie Lu Cheng's collar, exclaimed "Eh!"

"Brother Zhang, give me the knife!" Lu Cheng said.

The anesthesiologist reminded him, "I haven't started the anesthesia yet."

“I know, but this patient can’t wait.” Lu Cheng glanced at the patient’s recent blood pressure readings.

65/42 mmHg!

The blood loss was very rapid.

“Actually, you’re not responsible if you don’t save him,” said anesthesiologist Liang Yaozhong.

Lu Cheng glanced at Liang Yaozhong: "Since we can't save him and we bear no responsibility, what's there to be afraid of?"

Liang Yaozhong did not answer.

Lu Cheng's answer was very standard.

Without the patient's family's signature, Lu Cheng cannot perform invasive procedures, but with a signature, things are different.

Han Xiaoping entered the operating room and said, "Brother Zhang, why don't you go to the clinic for your shift first, and give me a look around the department while you're at it."

Han Xiaoping works the night shift in the ward. The patients' conditions are relatively stable, and there are generally no major issues.

But the emergency surgery clinic is different; there's a good chance a major case will come in.

Zhang Tiesheng glanced at Lu Cheng. Although he really wanted to stay and see what Lu Cheng would do next, he had no choice but to leave.

With a mission in hand, he could not leave his post without a rescue mission.

In principle, Zhang Tiesheng should not leave the consultation room, but the county hospital is not a general hospital, and the principles here are different from those outside.

With only so many people, what can we do?
The county hospital cannot be so overstaffed, because if there were too many people, everyone would starve, and the hospital would not hire so many people.

……

Lu Cheng extended the surgical incision along the patient's existing window. After opening the abdomen, Lu Cheng immediately used an abdominal expander to stretch the skin open.

There were dark-colored hematomas in clusters inside the abdomen, mainly concentrated in the upper right abdomen.

"Trainee, get another set of equipment. We're just temporarily stopping the bleeding," Lu Cheng quickly ordered.

Opening the abdomen now is a temporary measure to stop the bleeding. If another surgery is needed later, this set of instruments will not be usable.

They are contaminated.

However, when it's time to save a life, aseptic principles can be temporarily disregarded.

Save lives first, then treat illnesses!
If you're dead, bacteria or not doesn't matter.

"Liver contusion and laceration, open wound in the right lobe of the liver, with a large bleeding site."

"Full liver blood flow isolation!" Lu Cheng made the decision immediately after just one glance.

Total hepatic blood flow isolation (an upgraded version of Heaney) is a four-tube occlusion method:

These are the inferior vena cava below the liver, the superior and inferior vena cava below the liver, the hepatoduodenal ligament, and the abdominal aorta.

"Anesthesiologist, could you please get some nitroglycerin for the patient to restrict fluid intake?" Lu Cheng's voice came quickly.

Similarly, Lu Cheng acted swiftly.

This patient's active bleeding was not the unfamiliar arteriovenous bleeding, but a very typical case of liver rupture bleeding, so it was necessary to immediately stop the blood flow to the entire liver.

The more time you save, the more time you can gain.

Han Xiaoping and Lu Cheng worked together quickly and stopped the blood flow in just a few minutes.

Han Xiaoping murmured as she looked at Lu Cheng, "Brother Lu, what should we do now? If Professor Chen were still here, that would be great."

"Can?"

"Let's wait for the general surgery consultation first."

"After blocking the blood flow, continue to pack the wound to stop the bleeding, check the patient's coagulation function, and administer FFP and platelets as needed."

"What is the patient's temperature now?" Lu Cheng continued to ask anesthesiologist Liang Yaozhong.

"We can't test now!" Liang Yaozhong only had two hands. He was responsible not only for general anesthesia, but also for monitoring vital signs, adjusting the norepinephrine infusion rate, and managing the patient's airway. Just then, someone walked in: "How is the patient?"

"Liver contusion, direct open injury to the liver. I have already performed a temporary occlusion of blood flow to the liver. I am waiting for your consultation opinion from the general surgery department." Lu Cheng recognized the person who came.

He is Dr. Tan Yuan, the attending physician in general surgery. He is 41 years old this year and has not yet been promoted to associate senior physician because the number of positions in general surgery is limited.

Tan Yuan was stunned for a moment, and saw that Lu Cheng had already opened his abdomen. He glanced at Lu Cheng a few times in surprise, but didn't say anything.

After standing on tiptoe and looking at it for a few more seconds, he suddenly gasped: "I suggest a referral!"

"We can't handle this level of liver damage here."

The condition of this liver is now a complete mess; it's nothing like the small laceration he imagined, the kind that could be easily treated and save the patient's life.

This requires liver-preserving surgery or partial hepatectomy, and even Dr. Du, the head of general surgery, couldn't perform it.

“We can’t transfer him. Please check the patient’s blood pressure,” Lu Cheng said.

Tan Yuan turned his head and saw that the patient's blood pressure was less than 70, and his brows furrowed instantly.

Almost instinctively, he yelled, "Have you signed the statement that you're critically ill?"

"It's signed. Our emergency department staff are still working with the patient's family to get the necessary signatures," Lu Cheng nodded in response.

"Han Xiaoping, go wash your hands and disinfect the towel."

"Dr. Tan, let's try our best to get it done and see if we can do something simple to give the patient a chance to be transferred to another hospital."

“If we just transfer patients like this, they won’t be able to leave Long County,” Lu Cheng said.

Although the patient has now undergone blood flow occlusion, the shock has not yet been corrected. It is necessary to continue the surgery while simultaneously administering blood transfusions to correct the shock and raise blood pressure.

The hepatic portal vein cannot be completely blocked indefinitely.

“Alright.” Tan Yuan couldn’t refuse Lu Cheng’s suggestion.

The patient is too late to be transferred to another hospital, and the informed consent form for the surgery has already been signed. So either he will die directly, or we need to create conditions for 'transfer'. We can't just let it go like this.

Even if a general surgeon feels they lack the ability, they must still do their best.

……

Lu Cheng went outside to wash his hands!

Because I had just entered the patient's abdomen while wearing gloves, my arm was stained with mucus and blood, which almost formed a scab.

So Lu Cheng washed himself quite carefully in front of the mirror.

After a while, Lu Cheng smiled helplessly, tilted his head, and looked at himself in the mirror.

He murmured, "If you can't compete, then don't... This is your fate. If you give up today for the sake of the competition, even if you win, you won't be able to overcome your mental block..."

【清创术（专精15/20）（技能的-15）、保肝术（专精20/20）（技能点-40），切开术专精20/20（技能点-30）】

Skill Points Balance: 11.1

After spending over ten days saving up 96 skill points, I'm now down to only 11. I guess I'm out of luck during the competition.

The prize money from the competition was no longer of much interest to Lu Cheng.

However, Lu Cheng wasn't saddened, since he had genuinely acquired the technology.

After washing his hands, Lu Cheng reverently clasped his hands together in front of his chest, then stepped on the automatic sensor-operated foot-operated door of the operating room and turned to enter the operating room.

Upon seeing Lu Cheng enter, Tan Yuan politely said, "Dr. Lu, my suggestion is to first examine the open area of ​​the liver to see if the bleeding can be stopped by a suitable method."

"Once the bleeding is effectively stopped and the patient's signs of shock are corrected, the surgery will be completed, and the patient will be advised to be transferred to the State People's Hospital."

Du Qiang's cousin was pulled back from the brink of death by Lu Cheng. People in other departments might not know Lu Cheng's abilities, but Tan Yuan had to know them.

Because he might also need Lu Cheng's help.

“Okay, Dr. Tan, let’s do it together. I’ll assist you,” Lu Cheng said politely.

“It’s a collaboration, Dr. Lu.” Tan Yuan smiled. “I’ll go wash my hands first. Thank you and Dr. Han for disinfecting and draping the towels.”

When Tan Yuan returned to the operating room, Lu Cheng was already meticulously cleaning the area around the liver contusion and open wound.

As he approached the operating table, Tan Yuan's muscles began to tremble slightly.

You wouldn't know unless you looked closely. It turns out that Lu Cheng had actually blocked the blood flow to his liver before the show even officially started.

What is the difficulty in liver protection surgery? It lies in timely hemostasis, which involves blocking blood flow to the liver through appropriate hemostasis techniques.

It sounds simple: just shut down the major blood supply systems.

In practice, it's not that simple.

If surgery were this simple, then Du Qiang and Tan Yuan, these general surgeons, wouldn't they be better off just banging their heads against a block of tofu and dying?

What kind of operation is this?
Could it be that Lu Cheng learned all the surgical techniques of Professor Chen Song from Xiangya No. 2 Hospital in just a few months?
This is just too outrageous!

Regardless of what Tan Yuan was thinking, Lu Chengdu had already begun localized debridement.

The core principle of liver protection surgery is conceptual, without specific standards. It means that, under the premise of ensuring safety (ischemia duration, vascular integrity), the technique with the smallest blood control range is selected to preserve functional liver parenchyma to the greatest extent.

Although Tan Yuan did not know how to perform liver-preserving surgery, he had performed liver-related surgeries. He could tell that Lu Cheng's debridement technique was very delicate, removing necrotic tissue almost perfectly without damaging the normal liver parenchyma.

Moreover, Lu Cheng moved very quickly, seemingly to save time and restore blood flow to the liver as soon as possible.

So how do we restore blood circulation?

It involves repairing a ruptured liver.

The hepatic ducts, blood vessels, and other organs are sutured and reconstructed one by one. Only after the anastomosis is done properly can blood flow be restored, allowing the patient's circulatory and hepatic systems to function normally.

This is the basic principle of liver segment and lobe resection.

However, the actual operation is too difficult, and it is impossible to do without a certain level of skill.

"If Professor Chen Song were still here, that would be great." Tan Yuan also repeated what Han Xiaoping had said before.

Lu Cheng glanced at Tan Yuan but did not reply.

They were saying "if," but reality is not "if."

However, Lu Cheng was quite conflicted because he knew that Professor Chen Song was in Long County, but the problem was that Professor Chen Song was now working full-time on scientific research.

He doesn't have any clinical duties, and he might be drinking right now. Should I bother him?

We've bothered Chen Song, and now others know he's in Long County too. Will they bother him frequently in the future?
Can this patient perform liver debridement and repair, liver resection, and bile duct-jejunostomy on their own?
Lu Cheng weighed the pros and cons himself and concluded that the chances were not small.

However, Lu Cheng cannot do these things yet, because no associate professor has entered the operating room. All Lu Cheng can do is perform simple procedures.

Hemostasis and wound cleaning are both primary and basic surgical procedures...

Finally, five minutes later, Director Lin Qianlong entered the operating room.

"Lu Cheng, how is it?" Lin Qianlong, who had already found out everything, asked in a very formal tone.

"Director Lin, we need you to come up and perform the surgery," Lu Cheng replied politely.

Lin Qianlong had no other doubts and immediately went out to wash his hands.

Lu Cheng and Lin Qianlong had made an agreement that if Lu Cheng's professional title was not suitable for a surgery, he would step in to support him.

Lin Qianlong is an associate senior professional, which is the highest professional title in Longxian People's Hospital.

Longxian People's Hospital has virtually no chief physicians; associate senior physicians are the highest level they can reach.

Even associate senior physicians can perform level 4 surgeries!
Lin Qianlong is also a senior associate professor.

When Lin Qianlong took the stage, anesthesiologist Liang Yaozhong brought good news: "The patient's blood pressure has risen a little, proving that the hemostasis was effective."

"The blood pressure is now 72, and the blood has arrived."

Lin Qianlong glanced at the patient's condition and said, "The blood oxygen saturation is still a bit low."

Liang Yaozhong explained, "Your circulatory systems aren't particularly smooth, so of course your blood oxygen saturation won't be high!"

"Ninety-three percent is good enough now."

"Please note that the patient's blood potassium is a bit high, which may cause arrhythmia. I have already called the cardiology department over."

"Okay, sure..." Lin Qianlong continued to act as his tool.

Immediately afterwards, Tan Yuan noticed something was wrong.

Often, it was only when Lu Cheng was almost finished with the operation, when the food was almost ready, that he would hand over the simpler steps to Lin Qianlong.

However, for every operation, Lu Cheng would delegate some tasks to Lin Qianlong.

In Tan Yuan's understanding, Lin Qianlong was completely dispensable...

For example, the last few stitches after suturing, the last bit of necrotic tissue removed, the tiny blood vessels after vascular suturing, or small blood vessels that were not properly sutured, were all coagulated by Lin Qianlong using an ultrasonic scalpel...

I could do that too!

Tan Yuan wasn't stupid; after watching for a while, he realized something was wrong.

This surgery, which appeared to be led by Lin Qianlong, was actually performed by Lu Cheng using Lin Qianlong's rank.

No one dared to say anything. With Lin Qianlong around, Lu Cheng could not possibly be the chief surgeon; he would only be an assistant. Moreover, Lin Qianlong was not idle either.

Tan Yuan then recalled how highly Director Du Qiang had regarded Lu Cheng—

Lu Cheng, Emergency Department, Professor Chen Song.

Director Lin Qianlong.

This Lu Cheng is definitely no ordinary person...

Tan Yuan saw through it but didn't say anything, honestly examining the entire surgery with an appreciative eye.

Time ticked by, and after a full three hours, Tan Yuan couldn't help but swallow hard a few times: "Director Lin is amazing! He can even protect the liver in this situation."

Tan Yuan's tone was somewhat sarcastic.

But Lin Qianlong ignored it, glanced at Tan Yuan, and replied casually, "Does Dr. Tan wish to offer some guidance?"

Tan Yuan quickly shook his head: "I'm just amazed. Director Lin's skills are indeed extraordinary. He's almost broken through the entire Xiangzhou."

It's practically impossible to find someone in a county hospital who can perform liver-preserving surgery, and even in prefecture-level city hospitals, there aren't many people who can.

Lin Qianlong didn't put on an overly arrogant act: "Whether we compete or not doesn't matter; we're all serving the people."

"Help, there's no liver protectant." Lin Qianlong replied very discreetly, just like Lu Cheng had done before.

Then he relayed to the circulating nurse: "Please be careful with the surgical record for this operation. Don't write anything like 'liver-preserving surgery.' Just say it was a debridement hepatectomy with liver suturing and cholecystojejunostomy."

Lin Qianlong only mentioned the basic surgery.

Without liver-preserving surgery, all procedures are basic. It's lucky that the patient's liver was saved, but we are not yet mature in this surgical technique.

No one dared to criticize it.

The patient is dying, can't I even do debridement and suturing?
Lin Qianlong was the director, so naturally no one dared to object. They simply listened silently without saying a word.

But their gazes lingered on Lu Cheng...

Blood flow was restored... there was no more bleeding, and Lin Qianlong continued to lead the team to suture the liver.

Lin Qianlong is capable of performing this kind of superficial suturing of the liver; otherwise, his position as director would be undeserved.

Lin Qianlong left the operating room early, leaving the finishing touches to Lu Cheng and Han Xiaoping, while he went out to "show off" to the patient's family.

The patient was later transferred to the ICU...

Lu Cheng returned to the doctor's office and began writing the surgical record, his expression serious, without even a trace of excitement or joy.

At three o'clock in the morning, there were no patients in Zhang Tiesheng's emergency room, so he came to the department and gave Lu Cheng a bottle of drink. He saw that Lu Cheng was hanging his head and looked very dejected.

He then asked, "Xiao Lu, what's with that expression? It's like you didn't save the patient."

"The ICU said that the patient's vital signs are stable, but the blood count is a bit high, which may indicate an infection."

"There are no signs of further perfusion damage."

Lu Cheng tilted his head, his expression slowly returning to normal, and said, "Brother Zhang... I'm just too sleepy..."

Lu Cheng was unable to express the inner turmoil he felt.

The choice has been made, and as an adult, he has to accept the consequences. He may miss the microsurgical skills competition this time, and he won't even make it past the provincial preliminary round.

(End of this chapter)