Chapter 176: Skill Points Cleared!
【Comprehensive Level: Attending Physician. 】
【Basic Theory: Trauma Surgery Basic Theory （Mastery 0/20 ）, Emergency Medicine （Mastery 5/20 ）… 】
【CT Reading Technique （Mastery 10/20 ）, Physical Examination （Mastery 20/20 ）… 】
【Suturing （Expert 20/200 ）, Hemostasis （Mastery 20/20 ）… 】
【Basic Surgical Procedures: Closed Reduction of Fractures （Mastery 10/20 ）, Closed Reduction of Joint Dislocations （Mastery 12/20 ）… 】
【Specialty Surgical Procedures: Spleen Preservation Surgery (Mastery 20/20), Gallbladder Preservation Surgery （Mastery 20/20 ）】
【Suturing （Expert 2/200 ）】
【Suturing Specialty Basic Skills: Tendon Suturing （Mastery 16/20 ）… 】
【Suturing Specialty Skills: End-to-End Vascular Suture （Mastery 0/20 ）, Tendon Unnamed Suturing Technique （Mastery 15/20 ）, Unnamed Tendon Suturing Technique （Mastery 8/20 ）, Perineural-Epineural Suturing （Mastery 0/20 ）, Unnamed Spleen Suturing Technique （Mastery 20/20 ）… 】
Lu Cheng subconsciously glanced at his skill panel, then quickly joined the crowd heading towards the operating room.
The patient’s current diagnosis is unclear and difficult to ascertain visually. Given the current vital signs, further examination would be unreliable and delay crucial time.
Zhang Tiesheng and Lu Cheng escorted the patient for transfer, while Han Xiaoping led the patient’s family members to the doctor’s office: “Elder Sister, Big Brother, please come with me to sign.”
“Doctor, what do I need to sign?” the middle-aged woman asked listlessly.
“Surgical Risk and Serious Illness Notification. Your husband’s condition is very dangerous, life-threatening. Even if he makes it to the operating room, he might not be saved,” Han Xiaoping explained.
“Even surgery can’t save him? Then why have surgery?” the middle-aged woman stopped.
Han Xiaoping asked, “You choose not to proceed, right? If you don’t, I’ll call for them to push him out, and you can take him yourself?”
Han Xiaoping couldn’t be sure if the woman was deliberately feigning ignorance in front of him, but as an emergency department doctor, he had considerable experience in handling such situations.
“I am now explicitly informing you of this situation. Until you sign, it will be considered a refusal of surgery. Your husband will not undergo surgery until this informed consent form enters 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 protocol.
“If we don’t sign, he won’t have surgery. What happens if he dies?” the patient’s younger brother said with some resentment.
Han Xiaoping replied, “Then your family agrees to the surgery? If you don’t care about the patient’s life or death, what can we doctors do?”
As Han Xiaoping spoke, he pressed the recording button in the office: “Patient’s name, Niu Quandong. You are the patient’s wife, what is your name?”
“My name is Liu Linxiang. Doctor, what is my husband’s condition exactly?” Liu Linxiang asked.
“I don’t know. I only know the situation is extremely dangerous, it’s an open hemorrhagic shock, and he could lose his life at any moment.”
“The surgery he needs now is an exploratory laparotomy. Since there’s no time for a precise diagnosis, we need to save time.”
“However, before entering the operating room, the patient was already in shock with very low blood pressure and significant bleeding. Even with emergency surgery, it’s still possible to lose everything.”
“I don’t have much more time to explain the finer details to you.”
“The patient’s surgical mortality risk is higher now. The mortality risk without surgery is 100%. You have three choices.”
“First, transfer to a higher-level hospital.”
“Second, agree to surgical treatment and sign.”
“Third, refuse treatment.”
“Choose one!~” Han Xiaoping quickly took control of the conversation.
“What if something goes wrong during surgery?” Liu Linxiang was still hesitant.
Han Xiaoping interrupted, “Choose one! Sign, transfer, or refuse. Don’t ask anything else. The time you’re wasting now, you could have already signed.”
“I still need to take the informed consent form into the operating room.”
He took out paper and a pen and handed it to Liu Linxiang, continuing professionally, “Can you write? If you can’t, you can also make a thumbprint.”
These words, though seemingly redundant, were actually to create a record, preventing the patient from later claiming they couldn’t write or that the doctor didn’t provide adequate choices, causing delays.
Experienced emergency physicians always ask this extra question.
“I can write, but.”
“Then write. ‘Agree,’ and sign your name; ‘Refuse,’ and sign your name. Hurry, time is very precious now.”
“I’ve already given you the pen.” Han Xiaoping placed the pen in Liu Linxiang’s hand.
Liu Linxiang’s hands trembled; she couldn’t handle the atmosphere and felt uneasy, her mind racing with many thoughts.
Yet, in her indecision, she still wrote her name.
“Write ‘Request Surgery’ at the top,” Han Xiaoping continued, pointing to the blank space.
After Liu Linxiang complied, Han Xiaoping took the document and left.
Turning back, he added, “Please prepare your husband’s ID number and his ID card. You’ll also need to sign the power of attorney later.”
“Your husband is currently unconscious and lacks the ability for independent thought or decision-making, so your signature is the most effective.”
“If you are financially able, please go and pay the fees first. Pay twenty thousand for now.”
“It’s okay if you can’t for now… We’ll save the person first… Please wait outside the operating room,” Han Xiaoping replied professionally.
Emergency cases like Niu Quandong’s cannot be refused treatment due to unpaid surgery fees. For such absolute emergencies, rescue comes first, then payment.
Elective or time-sensitive surgeries are exceptions, as they are not life-threatening, and payment can be requested beforehand.
…
Emergency Operating Room.
Lu Cheng and Zhang Tiesheng had just moved the patient onto the operating table when the anesthesiologist rushed over. After a brief look at the patient’s vital signs, he cursed.
“I’ll go wash my hands and prepare the sterile drapes,” Zhang Tiesheng said.
Although he was an emergency surgery clinic doctor, they were short-handed, and Lu Cheng couldn’t manage alone.
He could leave for his shift only after Han Xiaoping arrived.
Lu Cheng said, “There’s no time, Brother Zhang. Bring the iodophor directly. We need to open the abdomen and stop the bleeding immediately!~”
“Aren’t we going to sterilize?” Han Xiaoping asked.
“No time,” Lu Cheng replied.
“The patient’s blood pressure is already very low…”
“Move the patient to the operating table, bring the debridement kit!” Lu Cheng quickly instructed the circulating nurse.
As he spoke, Lu Cheng and several circulating nurses moved the patient to the operating table.
Seeing the circulating nurse looking a bit flustered, Lu Cheng tore open the debridement kit himself and then put on a sterile glove.
Even after years in the emergency department, Zhang Tiesheng had never seen Lu Cheng so “anxious.”
“Lu Cheng,” Zhang Tiesheng intended to advise him.
“Brother Zhang, I know. You put the scalpel on first. As soon as Han Xiaoping comes in, we’ll immediately open the abdomen and stop the bleeding,” Lu Cheng said.
Lu Cheng didn’t dare to proceed with the laparotomy before the patient’s family’s informed consent form arrived.
The patient’s family was right beside them, and the on-duty supervisor couldn’t make decisions for them. Therefore, no matter how anxious Lu Cheng was, he had to wait!
If the patient died, he died.
The law was in place, and most people had to abide by it, with no right to question.
Because law enforcers act according to the law, they wouldn’t consider your doubts.
The right to informed consent is as important as the right to refuse treatment. The patient’s family has the right to choose whether or not to save the patient.
Long County People’s Hospital is just a county hospital. There are higher-level hospitals for referrals, and the patient’s family can change their mind and choose to transfer at any time.
Once they sign and surgery begins, there’s no turning back!
“You go get gowned first,” Zhang Tiesheng told Lu Cheng.
Lu Cheng walked towards the sterile surgical gowns, picked one up with sterile surgical gloves.
“The patient has signed,” Han Xiaoping’s voice arrived before he did.
Upon hearing this, Lu Cheng immediately dropped the gown he was holding.
The circulating nurse, who was about to tie the collar for Lu Cheng, let out an “Eh.”
“Brother Zhang, give me the scalpel!~” Lu Cheng said.
The anesthesiologist reminded him, “I haven’t started anesthesia yet.”
“I know, but this patient can’t wait.” Lu Cheng glanced at the latest blood pressure reading.
65/42mmHg!
The bleeding was rapid.
“Actually, if he doesn’t make it, you’re not responsible,” anesthesiologist Liang Yaozhong said.
Lu Cheng looked at Liang Yaozhong, “Since there’s no responsibility if he doesn’t make it, then what is there to fear?”
Liang Yaozhong did not reply.
Lu Cheng’s answer was standard.
The patient’s family hadn’t signed, so Lu Cheng couldn’t perform invasive procedures. But with the signature, things changed.
Han Xiaoping entered the operating room and said, “Brother Zhang, you go back to the clinic to cover, and keep an eye on the department for me.”
Han Xiaoping was on the night shift in the ward, and the patient’s condition was relatively stable, usually without major issues.
But the emergency surgery clinic was different; there might be another big case.
Zhang Tiesheng glanced at Lu Cheng. Although he wanted to stay and watch Lu Cheng’s subsequent actions, he had to leave.
He had a duty to perform and couldn’t leave the clinic without a rescue mission.
In principle, Zhang Tiesheng shouldn’t have left the clinic. However, a county hospital wasn’t like an external general hospital; the principles here differed from those outside.
With such limited staff, what else could they do?
The configuration of a county hospital couldn’t be so extensive. If there were too many people, they would all starve, and the hospital wouldn’t hire so many.
…
Lu Cheng extended the surgical incision along the existing window in the patient and, after opening the abdomen, immediately used a retractor to spread the skin.
Clumps of dark, black hematoma filled the abdomen, concentrated mainly in the upper right quadrant.
“Circulating nurse, bring another set of instruments. We are only temporarily controlling the bleeding right now,” Lu Cheng quickly instructed.
Opening the abdomen now was an emergency measure. If another surgery were needed later, this set of instruments couldn’t be used.
They would be contaminated.
However, when saving a life and racing against time, the principle of asepsis could be temporarily disregarded.
Save the life first, then treat the illness!
If the life is gone, bacteria are irrelevant.
“Liver contusion and laceration, open liver trauma on the right lobe, massive bleeding source.”
“Isolate the entire liver’s blood flow!~” Lu Cheng decided immediately after a brief glance.
Complete hepatic inflow occlusion （Heaney Upgrade ） involves four points of occlusion:
Specifically, the infrahepatic inferior vena cava, suprahepatic inferior vena cava, hepatoduodenal ligament, and abdominal aorta.
“Anesthesia, please administer some nitroglycerin and restrict fluid input,” Lu Cheng’s voice was rapid.
Similarly, Lu Cheng’s actions were fast.
This patient’s active bleeding was not a familiar arterial or venous hemorrhage, but a very typical liver rupture bleed, necessitating immediate occlusion of the entire liver’s blood flow.
The more time saved, the more time can be gained.
Han Xiaoping and Lu Cheng coordinated quickly, and within a few minutes, they had occluded the blood flow.
Han Xiaoping murmured, looking at Lu Cheng, “Brother Lu, what do we do now? It would be great if Professor Chen were still here.”
“Understood?”
“Let’s wait for the general surgery consultation.”
“After occluding blood flow, continue packing to stop bleeding, check the patient’s coagulation function, and administer FFP and platelets as needed.”
“What is the patient’s current temperature?” Lu Cheng asked anesthesiologist Liang Yaozhong.
“Can’t measure it now!~” Liang Yaozhong only had two hands. He was responsible for general anesthesia, monitoring vital signs, adjusting the norepinephrine infusion rate, and managing the patient’s airway.
Just then, someone entered from outside: “What’s the patient’s condition?”
“Liver contusion, direct open liver injury. I’ve already temporarily occluded the liver’s blood flow. Waiting for your general surgery consultation opinion,” Lu Cheng recognized the person.
It was Tan Yuan, a senior attending physician from general surgery, forty-one years old, and not yet promoted to deputy senior due to limited positions in general surgery.
Tan Yuan paused, saw that Lu Cheng had already opened the abdomen, and looked at Lu Cheng with surprise but said nothing further.
After peering for a few more seconds on tiptoe, he gasped: “I suggest transferring the patient!~”
“We cannot handle this level of liver damage here.”
The liver was a complete mess, not the minor laceration he had imagined, which could be simply managed to save the patient.
This would require liver protection surgery or a partial hepatectomy, which even Director Du of General Surgery couldn’t perform.
“Transfer is not possible. Take a look at the patient’s blood pressure,” Lu Cheng said.
Tan Yuan turned and saw the patient’s blood pressure was below seventy, and his brow furrowed instantly.
Almost instinctively, he roared, “Has the critical illness been signed for?”
“Yes, it has been signed. Our emergency department staff are still with the patient’s family completing the follow-up signatures,” Lu Cheng nodded in reply.
“Han Xiaoping, go wash your hands and prepare the sterile drapes.”
“Dr. Tan, we will try our best to stabilize him and see if we can perform simple repairs to give the patient time for a transfer,” Lu Cheng added.
“Transferring him like this, the patient won’t make it out of Long County,” Lu Cheng stated.
Although the patient’s blood flow had been occluded, shock had not been corrected. They must transfuse blood, correct shock, raise blood pressure, and continue surgery simultaneously.
The hepatic portal vessels cannot remain completely occluded indefinitely.
“Alright.” Tan Yuan couldn’t refuse Lu Cheng’s suggestion.
The patient was out of time for a transfer, and the surgical informed consent had been signed. Therefore, either he would die, or they would create conditions for ‘transfer,’ but they couldn’t just let him go.
Even if the general surgery department felt they lacked the capability, they had to do their best.
…
Lu Cheng went out to wash his hands!
Because he had only entered the patient’s abdomen with gloves on, mucus and blood stains had contaminated his arm, almost forming a scab.
So Lu Cheng washed his hands carefully, looking in the mirror.
After a while, Lu Cheng smiled helplessly, tilted his head, and looked at himself in the mirror.
He murmured, “If I can’t compete in the competition, then so be it… This is your fate. If you had given up for the competition today, even if you won, you wouldn’t overcome the psychological barrier…”
【Debridement （Mastery 15/20 ）（Skill -15 ）, Liver Protection Surgery （Mastery 20/20 ）（Skill Points -40 ）, Incision Mastery 20/20 （Skill Points -30 】
【Skill Point Balance 11.1】
The 96 skill points accumulated over more than ten days were now reduced to just 11. He estimated there was no chance of winning the competition.
The prize money for the competition seemed to have little connection with Lu Cheng anymore.
However, Lu Cheng wasn’t sad, as he had genuinely acquired the skills.
After washing his hands, Lu Cheng clasped his hands in front of his chest in a gesture of reverence, then stepped through the automatic sensor-activated sterile door of the operating room and entered.
Upon seeing Lu Cheng enter, Tan Yuan politely said, “Dr. Lu, my suggestion is to first explore the area of the open liver injury and see if bleeding can be controlled through appropriate methods.”
“Once bleeding is effectively controlled and the patient’s shock symptoms are corrected, we will conclude the surgery and recommend transferring the patient to the Prefectural City Hospital.”
Du Qiang’s grand-nephew had been pulled back from the brink of death by Lu Cheng himself. Other departments might not know Lu Cheng’s capabilities, but Tan Yuan had to be aware.
Because he might also need Lu Cheng’s help someday.
“Okay, Dr. Tan, let’s do this together. I’ll assist you,” Lu Cheng replied politely.
“It’s a collaboration, Dr. Lu,” Tan Yuan smiled. “I’ll go wash my hands first. Thank you and Dr. Han for sterilizing and preparing the drapes.”
By the time Tan Yuan re-entered the operating room, Lu Cheng had already begun meticulously debriding the area of the liver contusion and open trauma.
As he got closer to the operating table, Tan Yuan’s muscles involuntarily trembled slightly.
He hadn’t realized until he saw it that Lu Cheng had already occluded the liver’s blood flow before officially starting the procedure.
What is the difficulty of liver protection surgery? It lies in timely hemostasis, occluding blood flow within the liver through appropriate hemostatic techniques.
It sounds simple: just clamp the major vascular systems.
But is it really that simple in practice?
If surgical operations were that simple, then if Du Qiang and he, Tan Yuan, general surgery doctors, didn’t know how to do it, wouldn’t they just be able to hit their heads against a wall?
What kind of operation is this?
Could Lu Cheng have learned all the surgical essence of Professor Chen Song from Xiangya Second Hospital in just a few months?
This is too unbelievable.
Regardless of what Tan Yuan was thinking, Lu Cheng had already begun local debridement.
The core principle of liver protection surgery lacks specific standards and is conceptual. It involves choosing techniques with the smallest hemostatic range, while ensuring safety (ischemia time, vascular integrity), to maximize the preservation of functional liver parenchyma.
Although Tan Yuan couldn’t perform liver protection surgery, he had done liver-related surgeries. He could see that Lu Cheng’s debridement was very delicate, almost perfectly removing necrotic tissue without damaging healthy liver parenchyma.
Moreover, Lu Cheng’s speed was fast, seemingly to save time and restore blood flow to the liver as soon as possible.
And how to restore blood flow?
It is to reconnect the ruptured liver.
Suture and reconstruct hepatic ducts, blood vessels, etc., one by one. Once anastomosis is done correctly, restoring blood flow will allow the patient’s circulatory and liver systems to function normally.
This is the basic principle of hepatectomy or lobectomy.
However, the actual operational difficulty is immense, and it cannot be performed without a certain level of skill.
“If only Professor Chen Song were still here,” Tan Yuan repeated what Han Xiaoping had said earlier.
Lu Cheng glanced at Tan Yuan and did not reply.
They spoke of hypotheticals, but reality was not hypothetical.
Lu Cheng was conflicted because he knew Professor Chen Song was in Long County, but Professor Chen Song was currently on full-time research leave.
He had no clinical duties, and might even be drinking right now. Should he disturb him?
If he disturbed Chen Song, wouldn’t others also know about Chen Song’s presence in Long County? Would they frequently disturb Chen Song in the future?
Could he perform liver debridement and repair + hepatectomy + cholecystojejunostomy on this patient?
Lu Cheng assessed himself; the probability was not small.
However, Lu Cheng couldn’t do these things yet because no deputy senior physician had entered the operating room. Lu Cheng could only perform simple procedures.
Hemostasis and debridement are Class I procedures, basic procedures…
Finally, five minutes later, Director Lin Qianlong entered the operating room.
“Lu Cheng, how is it?” Lin Qianlong, who had already been briefed, spoke formally.
“Director Lin, please come up to the table and lead the surgery,” Lu Cheng replied politely.
Lin Qianlong didn’t question further and immediately went out to wash his hands.
Lu Cheng and Lin Qianlong had an agreement: if Lu Cheng’s title was unsuitable for the surgery, he would step in to support.
Lin Qianlong was a deputy senior physician, which was a senior professional title and the highest in Long County People’s Hospital.
Long County People’s Hospital had very few chief physicians with senior professional titles; deputy senior was the peak.
Deputy senior physicians could also lead Level IV surgeries!
Lin Qianlong was a seasoned deputy senior physician.
As Lin Qianlong took his place, anesthesiologist Liang Yaozhong brought good news: “The patient’s blood pressure has improved slightly, indicating the hemostasis is effective.”
“The systolic pressure is now 72, and the blood has arrived.”
Lin Qianlong looked at the patient’s condition and said, “The blood oxygen saturation is still a bit low.”
Liang Yaozhong explained, “Your circulatory system isn’t particularly open, of course the blood oxygen saturation won’t go up!”
“It’s at 93%, which is already quite good.”
“Pay attention, the patient’s blood potassium is a bit high, which could lead to arrhythmias. I’ve already called for the cardiology department.”
“Mmm, okay…” Lin Qianlong continued to be a tool.
Subsequently, Tan Yuan discovered something was amiss.
Often, Lu Cheng would perform the later stages of an operation, handing over simpler steps to Lin Qianlong.
But with every procedure, 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 of suturing, the final bit of necrotic tissue removal, fine blood vessels during vascular suturing, or small poorly sutured blood vessels, he would let Lin Qianlong coagulate with an ultrasonic knife…
Damn it, I could do that too.
Tan Yuan was not stupid. After watching for a while, he discovered something was wrong.
Although Lin Qianlong was leading this surgery, in reality, Lu Cheng was using Lin Qianlong’s title to perform the surgery.
No one dared to say anything. With Lin Qianlong present, Lu Cheng couldn’t be the chief surgeon, only an assistant, and Lin Qianlong wasn’t doing nothing.
Tan Yuan then recalled Director Du Qiang’s previous regard for Lu Cheng—
Lu Cheng, Emergency Department, Professor Chen Song.
Director Lin Qianlong.
This Lu Cheng is definitely not an ordinary person…
Tan Yuan saw through it but didn’t say anything, honestly appraising the entire surgery with admiration.
Time ticked by. After a full three hours, Tan Yuan couldn’t help but swallow several times: “Director Lin is amazing. In this situation, he could still perform liver protection.”
Tan Yuan’s tone was a bit sarcastic.
But Lin Qianlong ignored him, glanced at Tan Yuan, and replied nonchalantly, “Dr. Tan, do you wish to offer some guidance?”
Tan Yuan quickly shook his head: “I’m just amazed. Director Lin’s skills are truly extraordinary, reaching across our entire Xiangzhou.”
It was almost impossible for anyone in a county hospital to perform liver protection surgery, and even in prefectural city hospitals, few people could.
Lin Qianlong didn’t act overly boastful: “Whether to compete or not is irrelevant; we are all serving the common people.”
“Saving a life, not performing liver protection,” Lin Qianlong replied modestly, mimicking Lu Cheng’s earlier tone.
Then he relayed to the circulating nurse: “Make sure to record this surgery meticulously. Don’t write ‘liver protection surgery.’ Just write ‘debridement liver resection plus liver suturing, plus cholecystojejunostomy.'”
Lin Qianlong only mentioned basic procedures.
There was no liver protection surgery, only basic operations. The patient’s liver was saved due to luck, but such surgical techniques were not yet mature for them.
No one dared to find fault.
The patient was dying; could they not even perform debridement and suturing?
Lin Qianlong was the director, so everyone naturally dared not object, only listening silently without speaking.
However, their gazes kept drifting towards Lu Cheng…
Blood flow restored… no leakage. Lin Qianlong continued to lead the suturing of the liver.
Lin Qianlong could handle this type of superficial liver suturing; otherwise, his director position would be undeserved.
Lin Qianlong left the operating room early, handing over the final stages of the surgery to Lu Cheng and Han Xiaoping. He went out to “boast” directly 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 happiness.
At three in the morning, Zhang Tiesheng’s emergency clinic had no patients, so he came to the department and gave Lu Cheng a bottle of bottled water. Seeing Lu Cheng with his head down and a dejected expression.
He asked, “Xiao Lu, why the long face? It’s like you didn’t save the patient.”
“The ICU said the patient’s vital signs are stable, only the white blood cell count is a bit high, possibly an infection.”
“There are no signs of reperfusion injury.”
Lu Cheng turned his head, his expression slowly composed, and said, “Brother Zhang… I’m just too sleepy…”
Lu Cheng’s inner turmoil was inexpressible.
The choice had been made. As an adult, he had to accept the consequences. He likely had no chance for the microsurgery skills competition this time, not even passing the provincial preliminary round.
