godfather of surgery

Both directors and trainees are very interested in this case of cobalt poisoning.

I am particularly interested in the diagnostic process of this case because it has given everyone some inspiration.

Why did the patient go to many hospitals and see many doctors? Judging from his medical experience, these hospitals are all large hospitals in the province, and some are heavyweight experts in rheumatology, immunology and tumors, but unfortunately, none of them have received After getting a clear diagnosis, I went to the Cardiovascular Medicine Department of Sanbo Hospital and received symptomatic treatment for two weeks, but still no diagnosis was obtained.

At that time, he was admitted to the CCU due to severe heart failure. After resuscitation treatment and his vital signs stabilized, he was transferred out of the CCU. At this time, the cardiologist was at his wits' end and could only use the last resort - a general consultation in the hospital.

The Department of Orthopedics was the most active after receiving the consultation order, and the chief resident decided to check out the situation in advance. As a result, the difficult disease was solved directly.

Why was it that everyone couldn't come up with a diagnosis even if they tried hard before, but orthopedic surgeons could easily figure it out.

As Director Tan said, the problem lies in the blind spots. Whether they are rheumatology and immunology experts or oncology experts, they are just limited to their own specialties and have been working in circles within their own specialties.

Almost all tests related to infection, tumors, rheumatism and immunity were done, but the concentration of metal ions in the blood was not checked.

Because I couldn't think of this at all and lacked knowledge in this area.

Yang Ping sat in the first row and remained silent. He listened quietly to everyone's discussion. Director Zhao had already noticed Yang Ping's arrival.

Now Yang Ping can no longer keep a low profile. He is almost a god in Sanbo Hospital. No matter what, Director Zhao will ask Yang Ping to come out and say a few words. Even if Director Zhao lets him go, how can so many young doctors let him go? .

"Professor Yang is also an orthopedic surgeon. Could you please tell us a few words about this case?"

Director Zhao walked up to Yang Ping with the microphone in hand.

The young doctors at the venue all looked at Yang Ping eagerly, waiting for him to speak, because every time Yang Ping could always say something similar to mathematical axioms and theorems, which was very useful.

After saying a few words, Yang Ping walked to the podium and Director Zhao handed him the microphone.

He thought for a while and said, what can I say? The case has been solved and the diagnosis and treatment are clear. Let's just talk about how to think about difficult and complicated diseases.

Some of the young doctors at the venue have already taken out their notebooks and started taking notes, especially graduate students and graduate students. Most of them will leave Sanbo Hospital after completing their studies. They may not have so many opportunities to listen to Professor Yang's lectures in the future, so they cherish this very much now. Chance.

"Let me have a few words with the young doctor. In fact, the difficult and complicated diseases we encounter can be roughly divided into several categories: first, the symptoms are atypical, second, they are beyond the scope of knowledge, and third, they are not recognized by medicine at present, regardless of whether they belong to In any case, the most important thing is to grasp the important clues of the disease, so you must have comprehensive knowledge. Director Zhao just said that you should read more books and study. Once you have a blind spot in knowledge, you will lose some clues, and important clues are in the diagnosis. It’s very important, it’s like a thread on a piece of clothing, if you grab the thread and pull it, the entire suture can be easily removed.”

"Traditional Chinese medicine attaches great importance to the role of clues in diagnosis. When experienced traditional Chinese medicine doctors encounter difficult and complicated diseases, they will chat with the patient after looking, smelling, asking, and talking about everything about the condition. It seems like small talk, but in fact they are waiting for that clue. As we chat, clues will naturally appear. The old Chinese medicine practitioner will have an idea, immediately seize the clue, follow the clues, and obtain the final syndrome differentiation and treatment of the disease."

"This is the secret of old Chinese medicine doctors. I don't tell ordinary people. We Western medicine should learn from this secret of traditional Chinese medicine. When faced with difficult and complicated diseases, we repeatedly go to the medical records, repeatedly improve the medical records, and read more about the patient's past medical records. Get in touch with patients more and ask more about their medical history. Maybe a thread will pop up during the questioning, and that thread is missing from the diagnosis of difficult and complicated diseases."

"Also, when we diagnose a disease, we first consider common and frequently-occurring diseases, but do not miss rare diseases. Every time we diagnose a disease, we go through all the possible diseases in our mind. How to go through them, according to our pathophysiology Go through the classification of causes, so as to form a rigorous and comprehensive thinking habit, and it will not be so easy to miss important clues. Especially before a diagnosis is obtained, every abnormality may be a clue. Anyway, faced with so many threads, where exactly is it? Each one is a clue, try mentioning each one."

Sure enough, it was Professor Yang. He just said a few words and it was a golden rule. This thread theory was really full of philosophical truth. The young doctors took note of this thread theory seriously.

Yang Ping then explained to everyone the issues related to metal implants.

Metals are widely used in medicine, especially in orthopedics. Most implants for the spine and joints are made of metal, such as spinal internal fixation, artificial intervertebral discs, artificial joints, etc.

After metal is implanted in the human body, wear will cause metal particles and metal ions. These metal particles are at the microscopic level. They spread in the surrounding soft tissue, causing local reactions, activating macrophages and inflammatory responses.

Metal ions will enter the blood circulation, then travel throughout the body and be deposited in end organs. Some metal ions themselves are toxic, such as heavy metals represented by cobalt metal; some metal ions are deposited in organs, causing organ damage; and some metals Ions have the potential to cause cancer in the human body. For example, high levels of titanium may have a high potential risk of causing cancer.

These are issues that must be faced squarely. Medical treatment methods have always been double-sided swords. While we use one side of the sword for treatment, we must also study the damage caused by the other side of the sword.

Regarding the impact of metal implants on the human body, in fact, in the British Medical Journal (BMJ) in 1973, Dr. Coleman reported in the magazine that the levels of cobalt and chromium in the blood and urine increased after metal total hip replacement, thus It was pointed out that the long-term effects of chromium accumulation in the body need to be studied urgently. This is a study by doctors officially focusing on the impact of metal implant particles or ion release on the human body. Since then, doctors have published articles in this area one after another.

Cobalt poisoning is not only seen in artificial joints, but also sometimes in patients with dental implants, because some dental implants also contain cobalt-chromium-molybdenum alloy. Once excessive wear and tear exposes the cobalt metal inside, it can easily cause cobalt poisoning.

In the case of vitamin B12 deficiency, protein and alcohol intake, the symptoms of cobalt poisoning will be more obvious, especially in patients with alcoholism.

Cobalt enters the blood and travels throughout the body, causing damage to various organ systems, such as the nervous system, cardiovascular system, respiratory system, digestive system, thyroid, lymphatic system, etc., thus causing a series of symptoms.

There are so many symptoms. If the key thread of artificial hip replacement is not grasped, it is difficult to think of any disease that has so many symptoms.

Time is limited, so Yang Ping will briefly chat with everyone.

Several departments later also came up with some difficult cases. With Yang Ping's "Thread Theory" as a guide, the young doctors were obviously bolder and more active in facing these difficult cases. They paid very serious attention to the medical records and often Ask the reporter lots of questions.

There was a difficult and complicated disease in the Department of Gastroenterology. A trainee from the Department of Rotation relied on his simple interdisciplinary knowledge to grasp a clue that everyone ignored and successfully deduced the diagnosis, which surprised the doctor who made the report.
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After the meeting, it was already evening in China, but it was morning in Germany. Song Zimo and Xu Zhiliang briefly reported on the previous day's itinerary via video.

Zhang Lin and Xiao Wu have not yet finished their operations. Through these days of experience, their operation speed has improved. Now they can perform four or five operations a day. After accumulating a certain amount of experience as the surgeon, their proficiency has improved slightly. , and I am much more courageous.

Dr. Li Min was on the phone in the dressing room. Seeing that he looked very anxious, Yang Ping didn't know what happened. "Professor Yang, can I take a week off?"

Li Min put down the phone and spoke to Yang Ping in a pleading tone.

Yang Ping wondered if something happened at his home: "Is there something wrong? Can we help?"

Li Min said anxiously: "After our old dean performed an emergency operation last night, he suffered an acute lumbar disc herniation and suffered sciatic pain on the left side all night. Even taking a shot of pethidine didn't help. Rush back and take a look."

During the period of Li Min's training, the old director endured the pain in his back and undertook the entire hospital's surgeries by himself. Several young doctors lacked work experience and did not know how to perform surgeries. They could not even do a good job of pulling and hooking. Min called the old dean. Every time, the old dean said everything was fine, that he was in good spirits, that his waist didn't hurt and his legs were not numb.

But yesterday Li Min called the old dean and heard that the tone of the old dean's words was not right, but the old dean still agreed.

Li Min had doubts, so he called other colleagues in the hospital early this morning. The colleagues said that the old dean had suffered from sciatica for several days and was rolling in bed every night. He relied entirely on pethidine for pain relief last night. I didn't sleep all night and took a shot of Demerol to no avail. This morning I dragged one leg and was still undergoing surgery.

"Have you used mannitol and dexamethasone?"

Li Min knew that every time the old dean had an attack, he always used dehydration medicine and hormones to cope with it.

"I have used it, but it still doesn't work. I just went to see him and he was biting the towel. We persuaded him to go to the county for a checkup, but he didn't agree." Colleagues were also very anxious.

Li Min was very worried about the health of the old dean. He wanted to take leave for a few days. Yang Ping happened to come in. He mustered up the courage to ask Yang Ping for leave.

"How long has your old director had a lumbar disc herniation? What examinations have you had? Have you had a CT or MRI?"

Yang Ping felt it was necessary to ask a few more questions.

Li Min shook his head: "Our hospital only has an X-ray machine, and he only had an X-ray machine, which showed bone hyperplasia in multiple vertebrae and narrowing of the waist 4/5 and waist 5/sacral 1 gaps."

This matter may not be that simple. Even if Li Min goes back, given the medical conditions in the mountainous area, it may not be of much use. Yang Ping thought for a while and said, "Li Min, let's do this. You don't have to go back for the time being. Your old director will take good care of himself." Check it out and I'll arrange an ambulance to pick him up from your place and bring him to our hospital for treatment."

This is definitely the best, but Li Min still has to go back. The old director came to the provincial capital for treatment, and the hospital was almost empty. Several young doctors couldn't do anything, so he had to go back to take charge.

"But - I still have to go back - only the old director and I are experienced in the hospital, and the others are novices who cannot make visits."

Li Min was very embarrassed. This was the embarrassment of rural hospitals in remote mountainous areas. Young people jumped away after becoming more proficient. They either found connections to be transferred to counties or towns with abundant resources, or simply resigned and went to work outside.

Yang Ping felt that the matter was easy to handle: "Let's do this. I'll send two doctors to your place for a while. You can pick up the old director with the ambulance, and the doctor I sent to take over the shift will also go with the ambulance."

It was not easy for Li Min to get an opportunity to study. Yang Ping didn't want to waste his time. Besides, he couldn't solve the matter on the spot when he returned.

Hearing Professor Yang's arrangement, Li Min was very grateful. If it could be like this, what else would there be to say? The old dean had been sick for so many years, but he was a doctor, but he never checked. When the disease broke out, he just tolerated it. Relying on a few painkillers, it would be a good thing if he could be contacted here for systematic examination and treatment.

"Thank you, Professor Yang!" Dr. Li Min was very touched.

"It's okay, I'll think about who to send." Yang Ping thought about the candidates to go to the countryside to support.

Zhang Lin and Xiao Wu can't leave for the time being, and it's not appropriate to go to either of them. Separating them will greatly reduce their combat effectiveness.

Yang Ping thought about it. Xia Shu's master's degree and doctorate degree were both majoring in cardiac surgery, while Dr. Jin and Dr. Wen's master's degree and doctorate degree were both majoring in orthopedics. The three of them were not talking about obstetrics and gynecology surgery, even general surgery. They probably wouldn't be able to cope with the surgery.

The more doctor you have, the more the technology is focused on a small area, so you can't handle it at rural hospitals. Although the patients handled by rural hospitals are not complicated and not difficult, they are quite complex.

You must find a doctor who has been systematically trained by a surgical institute. Li Guodong is good. Although he is young and is still a resident doctor, he has at least been trained by surgical research.

Yes, send Li Guodong. He has participated in almost all types of surgeries in the trauma emergency center and has received primary training in various specialties at the Institute of Surgery. Let alone go to a township hospital, go to a municipal hospital, and he can start his own business independently.

Yang Ping immediately put on his wash clothes and went to the operating room with Li Min, where Li Guodong was performing surgery on the stage.

"Guodong, I will assign you a task. There is an emergency. Li Min's old dean is ill and bedridden. Now he has to be taken to our hospital for treatment. Once the old dean is taken to our hospital, their hospital will lack the ability to A doctor on his own is going about his business, and Li Min can't go back now, so I plan to send you to the countryside to provide medical support at the hospital where Li Min works. You are about to leave, and the time of return is to be determined. Is there any problem?" Yang Ping asked Li Guodong.

Others may not be willing to do this kind of task, but Li Guodong is very happy to go to the countryside to support him. Isn't this his own independent business? Like Zhang Lin Xiaowu, he can handle patients and perform surgeries independently. Even if the surgery in a rural hospital is simple, he still performs the surgery independently.

Besides, Li Guodong is single now and has no girlfriend to tie him down, so he can leave as soon as he wants.

"No problem!" Li Guodong agreed immediately.

"Okay, I'll call the emergency department ambulance now. You can get off the operating table now, switch to another retractor, and set off with Li Min." Yang Ping was straightforward and without delay.

Another observing doctor in the operating room immediately came to the stage to replace Li Guodong.