This miracle doctor just wants to be fired!

On the morning of the third day, Zhao Sisi added the last batch of data to the spreadsheet.

There is still no answer in the office that can explain all the complications.

Zhao Sisi stared at the computer screen for a long time before finally closing the statistics window.

"There are no common variables."

When he said this, there was no sense of defeat in his voice; it was more like he was stating a fact that he had to accept.

Li Mingyuan was watching the nineteenth surgery when he heard this and stopped the video.

"Is the sample size too small?"

"Of course it's small, but it's not a matter of significance right now." Zhao Sisi pushed her chair back a little. "Even looking at the original distribution, there's no consistent trend. The complication group didn't have higher pressure, larger balloons, more insufflations, or more complex lesions. In fact, two cases used pressures that were even lower than the mean in the no-complication group."

"What about the sorcerer's experience?"

"None of them are junior technicians."

"Underutilization of video footage?"

"It is indeed insufficient," Zhao Sisi said. "But most of the 28 cases did not routinely use IVUS, and only four cases of complications occurred. This factor can explain why the surgeons did not make a sufficient judgment on the lesions, but it cannot explain why these four cases were the ones that had complications."

Lin Feng stood in front of the whiteboard and circled the question mark after "insufficient image" again.

"In other words, we can now confirm three issues. First, the indications for treatment are broader than before; second, intravascular imaging is underutilized; and third, primary care hospitals have less room to handle complex complications. However, while these three issues are true, they are not the common cause of those four cases of complications."

No one responded.

Zhou Cheng sat at one end of the conference table, with printed materials on four cases of complications in Linjiang City in front of him.

From the morning onwards, he stopped repeatedly looking at the instruments and pressure that had already been checked. Instead, he redraws the complete timeline of each surgery on paper, connecting each node with a straight line from the moment the patient enters the catheterization lab to the passage of the guidewire, the first pre-dilation, the second treatment, stent implantation, or the occurrence of complications.

Even after drawing all four timelines, the differences still exist.

The perforation occurred after the second high-pressure balloon dilation.

The dissection occurred after the replacement of the balloon with a larger one.

Poor stent apposition occurs after the surgeon believes the lesion has been adequately pretreated and directly implants the stent.

In the case of acute stent thrombosis, insufficient local expansion was found during the postoperative follow-up. Upon reviewing the original video, it was discovered that the surgeon had performed two dilation procedures before implantation.

On the surface, they don't even occur at the same stage.

"Release all four cases at the same time."

Zhou Cheng spoke.

Li Mingyuan displayed the four videos on four screens and scaled them according to the surgery time, trying to make each video start before the last critical procedure.

"We'll start from where we first achieved the desired effect," Zhou Cheng said.

Li Mingyuan turned to look at him.

Which one qualifies as meeting expectations?

"Based on our earliest minimum standards."

This sentence made Lin Feng immediately understand what he meant.

When they were developing the technology in the early days, they never made "doing it the best" their only goal. Instead, they first defined a minimum standard that was sufficient for the safe implantation of stents.

As time went on and the technology matured, the cases the team had became increasingly complex. What was originally the "minimum standard" to ensure safety gradually became the basic requirement in teaching materials.

A truly experienced practitioner knows that reaching the minimum standard only gives them the option to continue or stop, and does not mean that they must complete every subsequent step. However, for someone who is just learning this technique, the arrows on the flowchart often only point in one direction.

Li Mingyuan dragged the four videos again.

In the first case of perforation, after the first balloon dilation, the previously obvious lumbar signs had basically disappeared. During the re-angiography, the blood flow was stable and there was no obvious tear in the lesion segment. Although residual stenosis still existed, the conditions for stent implantation were met.

In the second case of aortic dissection, the degree of opening of the lesion was not perfect after the first treatment. However, the connection between the proximal and distal vessels was acceptable, and the blood flow in the branches was normal. If a more conservative instrument size had been chosen at that time, or if further dilation had been stopped directly, the surgery might not have been impossible.

In the third case of poor stent apposition, the lesion pretreatment had already achieved the basic goals, but the surgeon performed an additional dilation because the local balloon shape was not symmetrical enough. This caused uneven local vascular wall response, resulting in insufficient expansion on one side during subsequent stent implantation.

In the fourth case of acute stent thrombosis, the lesion had already developed a crack before the final pre-dilation, and the vascular condition was sufficient to proceed to the next stage. However, the operator followed the "gradual and sufficient dilation" path taught in the training and completed the original steps. Subsequently, the stent was implanted. Local damage and insufficient dilation coexisted, which ultimately became the basis for thrombosis.

The four videos stop at four different points in time.

The lesions have already been opened up; they haven't reached the most ideal state, but they have reached a state where new choices can be made.

Zhou Cheng looked at it for a long time: "Put it back."

The video continued, and none of the four practitioners showed any obvious hesitation.

The actions were correct, the equipment was correct, and the pressure was not excessive; they simply completed every step of the plan.

Chen Yu sat in the last row, with a table in front of her recording the decision-making points for nearly sixty surgeries.

She looked down at her notes, then back at the screen, and finally managed to articulate the feelings she had been struggling to articulate for the past two days.

"They know exactly what to do next at every step."

Lin Feng turned his head.

Li Mingyuan stared at the four videos, his expression gradually changing.

His initial focus was on indications, device selection, and pressure and frequency.

He always believed that as long as the operating parameters were clearly identified, the deviation could always be found somewhere.

Looking back now, the real problem wasn't whether a particular operation exceeded the standard, but rather that the practitioner treated the standard as a path that had to be followed completely.

The surgery was performed according to procedure and should not have been considered a mistake.

But blood vessels never grow according to a flowchart.

With the same degree of calcification and the same balloon pressure, the response will not be exactly the same in patients of different ages, with different blood vessel walls, and with different lesion lengths.

The procedure can only tell the surgeon what tools are available and in what order they are usually used, but it cannot replace the surgeon's ability to reassess whether the blood vessel needs to withstand the next operation after each step.

The video continues to play.

Similar pauses were common in the first thirty surgeries.

Sometimes it lasts only a dozen seconds, sometimes it lasts a minute or two.

Sometimes Zhou Cheng would explain why he stopped, sometimes he would just stare at the screen and eventually change his original plan.

More importantly, he does not have a completely fixed set of stopping conditions.

Even with 30% residual stenosis, some patients continue treatment while others proceed directly to stent implantation.

Similarly, if the balloon waist sign does not completely disappear, sometimes we change the device, and sometimes we accept this result.

"Because the blood vessels are different," Li Mingyuan said in a low voice.

"The patients are different too," Lin Feng added.

Chen Yu flipped through her records, "In your early surgeries, the plans often changed."

"That's right," Zhou Cheng said. "In surgeries in Linjiang City, the plans rarely change."

The meeting room fell silent again.

The answer has emerged, and it's even more unacceptable than they originally imagined.

It's not that the primary care physicians didn't follow the training; quite the opposite, they followed the training too thoroughly.

……

This is the latest chapter.