My medical skills add experience

Chapter 478 Closed Chest Drainage, Good Teacher

Pneumothorax can be divided into two categories: primary and secondary from the etiology.

This patient had a pneumothorax for the first time after roaring, which is a primary pneumothorax.The disease is more likely to occur in men than women, about 6 to 1.

The main cause of pneumothorax in men is the rupture of subpleural bullae.

Especially some thin and tall people are more prone to spontaneous pneumothorax.

Through the diagnosis, Zhou Can has determined that this patient belongs to left spontaneous tension pneumothorax.

He just used an 18-gauge thick needle to pierce the thoracic cavity at the second intercostal space on the left midclavicular line of the patient.At present, the patient's pneumothorax symptoms are still severe after treatment.

I thought it was a simple case that could be cured, but I didn't expect something to happen.

He took the X-ray chest plain film taken by the patient and checked it again, thinking about the solution quickly in his mind.

"It may be a good treatment to perform closed left thoracic drainage on the patient to expel the gas."

After careful consideration, he decided to use this technique to treat the patient.

There are two important indications for closed chest drainage. First, the lungs are compressed by more than 30%.Second tension pneumothorax.This patient met both indications and was completely fine procedurally.

There are two methods of drainage and intubation for closed chest drainage, one is the cannula method, and the other is the incision method.

The incision is not a major operation, it only needs to make an incision of about 1.5cm.

The two methods are basically the same in principle, each has its own advantages and disadvantages.

Zhou Can prefers the incision method.

This method is more direct and quicker to achieve results.

After communicating with the family members, the family members trusted him very much and agreed to receive further treatment.

This trust is very rare.

Because the first puncture treatment did not work, most family members will begin to question the doctor's level.

Zhou Can is so young, it is easier for the family members to feel that there is no hair on their lips and that they can't do things well.

It has to be said that the mutual trust between doctors and patients is indeed very important, which can greatly enhance the enthusiasm and autonomy of doctors in treatment plans, and dare to let go of rescue.

If the family members are difficult to deal with and question the doctor everywhere, this will lead to the doctor's instinctive self-preservation.

In the treatment plan, it must be based on conservative treatment.

Director Xue cooperated with all his strength and quickly allocated a room for Zhou Can to use temporarily during the operation.

After infiltration anesthesia is applied to the patient's pleura, surgery begins.

This does not need to go into the operating room, it can be done directly in the ward.

With the assistance of an instrument nurse, he held a willow-shaped traditional scalpel and directly made an incision of about 1.5 cm on the skin of the patient's chest. After cutting the subcutaneous tissue, he bluntly separated the muscle layer to the pleura with long curved vascular forceps.

The whole operation was done in one go, fast and good.

After separating to the pleura, he carefully sent the drainage tube into the chest cavity along the separated hole.

It seems easy, but there are superb surgical techniques throughout the operation.

1 minutes on stage, ten years off stage.

After all, this minor operation requires a drainage tube to be placed in the chest cavity, so the danger is self-evident.

Not to mention blunt separation of the muscular layer of the chest to the pleura.

If the tearing is not good, a large gap can be torn out of the patient's chest.

After the drainage tube was successfully placed, he fixed the drainage tube firmly, and then connected the drainage tube to the connecting tube.

"Can you hear me clearly?"

Zhou Can looked at the patient.

"can!"

The patient's voice was still a little weak.Chest pain is easily pulled when talking.

After a pneumothorax, breathing is painful.

Many people describe the feeling after falling out of love, saying that they are so heartbroken that they can't breathe.Symptoms are actually quite similar to pneumothorax.

"Try taking a deep breath!"

Zhou Can asked the patient to take a deep breath.

There are two purposes for doing this. The first is to observe the fluctuation of the water column in the water-sealed bottle.Second, the patient's deep breathing is conducive to the early recovery of the compressed lungs.

The patient's left lung was compressed by more than 90%, which is already very serious.

Allowing the patient's left lung to expand as soon as possible is beneficial to the recovery of the condition.

"It hurts, it hurts!"

The patient tried to take a deep breath, and halfway through, he cried out for pain and gave up.

"Procaine is still acting as anesthesia! Even though it's only local anesthesia, it can relieve some of your pain. If you can't stand such a little pain, that's not okay. Continue to take a deep breath, you're a man. Don't worry, I'm here Watch here, nothing will happen to you."

Zhou Can encouraged the patient to try to take a deep breath again.

For many patients, pain is one of the hurdles they have to endure.

The patient took another deep breath and still complained of pain, but it was much better than the first time.

"Okay, stop taking a deep breath first!"

Zhou Can stopped, while observing the water-sealed bottle with a frown.It is obvious that the tube has been successfully inserted and connected to the connecting tube, why does the water column in the bottle not fluctuate?

Fortunately, there is negative pressure.

If the water column does not fluctuate and there is no negative pressure, it means that the drainage tube has leaked or protruded from the chest cavity, and it must be dealt with in time.

Zhou Can just made sure to fix the drainage tube.

There is negative pressure, indicating that there is no air leak.

There are only two situations, either the patient's lungs have expanded, or the drainage tube is blocked.

It is unlikely that the patient's lungs have expanded.

He speculated that the drainage tube may have been blocked during insertion.

Try to adjust the drain and ask the patient to take another deep breath.This time the water column fluctuated.

Finally got it.

It seems that the drainage tube may have been inserted too deep just now, and it was blocked by the tissue in the chest cavity.

"Come on, continue to take a deep breath, the situation is good!"

Zhou Can guided the patient to continue to take a deep breath, and everything was normal.

Checked correctly.

Send the patient back to the inpatient ward, and then tell the bed doctor and nurse to monitor the patient's vital signs in time, and actively give the patient oxygen inhalation, anti-infection, bronchial spasm relief, and sputum removal treatment.

Director Xueyan saw that Zhou Can finally managed to deal with this patient, and she couldn't wait for a long time.

A nurse was sent to urge him, and he hurried to the operating ward to help.

For some difficult operations, having Zhou Can by his side is equivalent to having an extra amulet.Zhou Can can replace her as the chief surgeon for many difficult surgeries, or in cases of high timeliness.

In the event of unexpected unexpected situations during the operation, such as cardiac arrest, ventricular fibrillation, and a sudden drop in blood oxygen, with Zhou Can by his side, he can rescue him in time.

In terms of the ability to rescue patients, Zhou Can is already very good.

After studying with Director Feng of the Department of Anesthesiology in the past two years, his ability in this area has become more and more outstanding.

Twice, patients had accidents during surgery, and even Dongfang Xueluo, the chief physician, had to ask Zhou Can for help.

……

The next day, Zhou Can was worried about the patient with pneumothorax. After checking the room in the emergency department early in the morning, he even went to the cardiothoracic surgery ward to check on the patient's condition.

After examination and questioning, the pain in the patient's left chest was alleviated, and the symptoms of dyspnea were greatly improved, which was obviously improved.

The family members are very grateful to Zhou Can. Seeing that the patient's condition has improved significantly after treatment, the patient's mother and sister are very happy.He also looked much more relaxed.

The nurse told Zhou Can that the patient's current body temperature showed low fever.

It is normal to have a low-grade fever.

Zhou Can asked for the nurse's stethoscope and carefully listened to the patient's chest sound.

"His breath sounds in the left chest are still a bit small, but fortunately there are no dry and wet rales, and he can take more deep breaths. Also, don't touch the drainage tube. If it becomes loose, you must find a nurse or a bed doctor in time. .”

In general, pneumothorax treatment still has certain risks.

Zhou Can had seen a pneumothorax drainage patient die when he was training in cardiothoracic surgery.

The lesson that time was very painful, not only because of the carelessness of the nurses, but also because of the negligence of the doctor in charge of the bed, and because the family members and patients did not follow the doctor's advice and moved the water-sealed bottle.

There are many dangers that family members and patients cannot see because they are not professionals.

Even some doctors and nurses with insufficient professional level or low vigilance cannot discover the hidden danger in time.

Even after several years have passed, Zhou Can is still very careful when treating such patients with pneumothorax.

He even took the trouble to repeatedly tell the doctors and nurses in charge of the bed not to be careless.

After more than ten hours of drainage, the water-sealed bottle can still see a moderate amount of gas overflowing, and the drained bloody liquid is as high as more than 900 milliliters, and the color is bright red.

This indicates bleeding.

The doctor in charge did not call him, but effective treatment measures have been taken.

Including blood transfusion, replenish blood volume, intravenous cephradine anti-infection.

At the same time, intravenous aminomethylbenzoic acid was given to stop bleeding.

The timely and reasonable use of these measures also made Zhou Can look at the level of doctors in charge of the bed with admiration.

After more than 20 senior doctors and nurses were poached from the Department of Cardiothoracic Surgery, this department has gained a lot of opportunities to introduce young talents.It also gradually began to glow with new vitality.

After all, it is a powerful department, and Tuya Hospital has a strong background.

There are many graduate students who have completed the regular training and have all the four certificates, and they line up and squeeze their heads to get into this provincial tertiary hospital.

Many of these physicians are general practitioners.

In fact, current clinical medical students are more inclined to general practice when choosing a field of study.Don't look at the many mentors shouting there, you can't chew too much.

That is to stand at the height of a mentor to be qualified to say so.

For ordinary medical students, how to find employment more easily and how to squeeze into the important departments of large hospitals are the most important.

General medical students are more competitive and have more opportunities to enter large hospitals.

In addition, even if a medical student is a PhD student like Du Leng, he still graduated from a famous overseas school.But after working in the hospital, you still have to relearn from the most basic practice.

If you keep raising your head proudly, you will have an embarrassing situation where you will be directly crushed and beaten by an undergraduate like Zhou Can.

"I'm sorry, I'm sorry, the patient in bed 55 had arrhythmia just now, so I rushed over to deal with it. Doctor Zhou, I'll record what instructions you have given!"

The bed doctor is not the intern who brought the patient from the emergency room yesterday.

It was a young male doctor surnamed Pu.

He is in his early 30s, with a crew-shaven head and a pair of rimless glasses. He has a round face, wide and round forehead, and a square chin.The first impression it gives people is that it belongs to the kind of down-to-earth, down-to-earth, and kind-hearted.

"Did Dr. Pu do the blood transfusion, hemostasis, and anti-infection for the patient last night?"

Zhou Can admired this doctor very much.

"Yes... I did it all. At that time, I considered that it was already one o'clock in the morning, and you had surgery close to twelve o'clock, so I didn't bother you. Is there something wrong?"

Dr. Pu is also a resident doctor, although he is several years older than Zhou Can.

At this moment, it is completely talking to Zhou Can as a subordinate doctor.

It's a gesture.

No one taught him, it was purely a personal decision on workplace survivability.

"You've done a very good job. Patients with pneumothorax should be treated in this way. For patients like this, as long as they are effectively drained and the lungs are recruited to compress the bleeding site, they can basically heal themselves. If continuous bleeding occurs, then We must consider timely thoracotomy to stop the bleeding. When you hand over the shift, you must explain clearly to the doctor who takes over and observe closely."

Zhou Can is really not putting on airs.

Usually, even when the attending physician talks to him, it is basically the attitude of asking for advice.

He also tried to talk to them politely before.Then I found that the other party was flattered, and the conversation was particularly strenuous.

Zhou Can really didn't waste that time for always being verbose and polite.

Moreover, he is more down-to-earth and straightforward, and he doesn't like hypocrisy and politeness.Then it just went with the flow.

"Okay, I'll make it clear."

Dr. Pu carefully wrote it down in his notebook.

"Doctor Zhou, can you tell me the reason for the bleeding of these patients? There is still a big difference between the practice and the content in the book. I just want to learn more practical experience in this area."

He explained with a smile.

"Hemothorax is mainly caused by the tearing of the adhesive tape between the visceral and parietal layers of the pleura. Most of the bleeding is the rupture and rupture of small arteries at the ruptured end of the adhesive tape. Therefore, after the lung expands, it can compress the bleeding site, which can have a hemostatic effect. .Most haemorrhages of pneumothorax can be cured without surgery. You have timely blood transfusion and intravenous hemostatic drugs, which are handled very well.”

Zhou Can not hesitate to praise Dr. Pu while imparting some practical clinical experience.

"Clinically, hemopneumothorax mostly occurs in young male patients, and the left breast is more than the right breast. The occurrence of this disease is often very hidden, it is not easy to find, and the diagnosis is easy to delay. That's why I will explain it to you when I give the doctor's order. Observe the patient's bleeding more."

After performing closed thoracic drainage on this patient yesterday, Zhou Can gave some oral doctor's orders.

It just didn't explain how to deal with the patient's hemopneumothorax.

Because he believed that the doctors and nurses in charge of the bed would definitely report to the superior doctor in time.

At that time, if Zhou Can hadn't rushed to the operating room for the other two major surgeries, as long as Zhou Can had observed for a while, he might have discovered that the patient had a pneumothorax.

Judging from the patient's drainage last night, the bleeding was quite serious.

Hope not to do chest bleeding to stop it.

It's just that sometimes, the disease doesn't follow the doctor's wishes.Not to mention being merciful to the patient's family because they are pitiful.

The disease is ruthless and often extremely cruel to patients.

Therefore, this patient must be closely observed to prevent accidents.

"I would like to ask again, how long will it take for such patients to determine whether they need further surgical treatment after closed thoracic drainage?"

Dr. Pu carefully recorded the key points Zhou Can said in his notebook.

A good memory is not as good as a bad writing.

Doctors have so much to learn, it is definitely a good thing to take more notes.

"Basically, the drainage has not stopped for more than 24 hours, and further measures should be considered. However, for most patients, the gas in the water-sealed bottle continues to be discharged, and it may take three or four days to slowly weaken until it disappears. Only a very small number of patients still have gas discharge for as long as a week, so it is necessary to consider that the rupture is too large, and closed chest drainage is difficult to cure. It requires open chest surgery for repair.”

Whether it is a newcomer or an old comrade, Zhou Can basically knows everything and teaches patiently.

This good character of being a good teacher was passed on to him by Director Hu Kan, Dr. Xu, Director Shen and others.

The teachers that Zhou Can has met, even if they are withdrawn and cold, as long as the questions he asks for advice are on the point, the other party thinks that he is really studying hard, and they will basically take the time to teach him patiently.

At least so far, Zhou Can has never encountered a situation where a superior doctor did not teach him.

Including Director Feng of the anesthesiology department, such a cold doctor, even offered to ask Zhou Can to learn from him.

(End of this chapter)