“Establish two venous lines. Use indwelling catheters, the largest size—14G!”
“Run fluids wide open. Lactated Ringer’s, hang two bags first!”
“Oxygen, mask, flow rate ten liters!”
“Draw blood. Check blood type, crossmatch, CBC, coagulation profile. Notify the blood bank to prepare blood—at least ten units of packed red blood cells and one thousand milliliters of plasma!”
“Connect the ECG monitor!”
“And notify the on-call doctors from First Surgery and Second Surgery!”
As Kiryu Kazusuke felt the faint pulse beneath his fingertips, he issued a rapid string of orders.
After all, he was no ordinary intern. His experience struggling through the emergency department in his previous life allowed him to remain absolutely calm even in such a chaotic scene.
The nurses were swept along by his momentum and began working swiftly.
Kiryu Kazusuke deftly picked up the laryngoscope, lifted the epiglottis, and accurately inserted the endotracheal tube through the glottis. “Intubation successful. Connect the Ambu bag.”
The stretcher had only just come to a stop.
Then he began the physical examination.
There was no need for a stethoscope. Just by looking at the paradoxical breathing movement, he knew there were multiple fractures in multiple left ribs—a flail chest.
He reached out and pressed on the pelvis.
Crack—
A distinct sensation of bone grating came from beneath his hand. The pelvic ring was loose, like a broken basket.
Extremely dangerous!
Pelvic fractures were often accompanied by tearing of the venous plexus within the pelvis. The blood loss could instantly reach several thousand milliliters, making it one of the main causes of death from shock.
Then he palpated the abdomen.
It was as hard as a plank—a board-like abdomen.
That meant there was definitely a ruptured organ inside the abdominal cavity, with massive ongoing bleeding!
“Don’t insert the urinary catheter yet. Suspected urethral rupture.” Kiryu Kazusuke stopped the nurse who was about to place the catheter, then turned and shouted, “You there, bring the ultrasound machine over! Hurry!”
At this point, there was no time to take an X-ray. They had to perform an abdominal Echo immediately.
He coated the probe with gel and pressed it against the patient’s abdomen.
On the screen, although the resolution was not high, an obvious dark fluid area could be seen in the splenorenal recess.
It was all blood.
Kiryu Kazusuke’s expression grew grave. “Shock index over 2.0. Blood loss is at least above two thousand milliliters.”
Just then, the emergency room door was pushed open again.
A man in a white coat walked in, his hair somewhat disheveled, looking as though he had not fully woken up.
Minamimura Shoji, the on-call specialist from First Surgery tonight. His seniority was even a little less than Takigawa Takuhei’s, but he usually loved putting on airs as a senior.
He had just fallen asleep in the duty room when the phone woke him, and he was already holding back his temper. Only after hearing it was a high fall injury had he reluctantly come over.
“What the hell are you doing? Who told you to touch the patient?”
The moment Minamimura Shoji entered, he wanted to start scolding.
He wanted to pick out a few faults—such as the intern’s delayed management or an error in judgment—to show off the authority of a superior doctor.
But when his eyes swept over the monitor and the IV lines already dripping wide open, the curses that had reached his lips were swallowed back down.
Endotracheal intubation was already complete, and breath sounds were symmetrical.
Two lines of fluid resuscitation were running at full speed.
The blood transfusion request had also been sent.
Even the pelvic binder had already been secured, effectively limiting the pelvic volume and temporarily slowing the bleeding.
This whole sequence was as if someone had just opened the emergency manual and followed it step by step.
It was even faster than if he had done it himself.
“Comminuted pelvic fracture, combined with intra-abdominal organ rupture and flail chest.” Kiryu Kazusuke held the laryngoscope in his hand and reported without looking back. “Blood pressure is still dropping. He needs surgery immediately.”
“You think I need you to tell me that?” Minamimura Shoji stepped forward, pressed on the patient’s abdomen, then looked at the X-ray film and snorted coldly.
He glanced at the blood pressure reading that was still falling: 50/30, heart rate 150.
“Notify the operating room. Prepare to open!”
“Call the people from Second Surgery too!”
Since he could not find a reason to reprimand Kiryu Kazusuke, he gave the order with a stern face.
But this was not him shirking responsibility either.
In Japanese university hospitals in the 1990s, there was a strict “departmental chair system.” Departments were not named according to body organs or regions, but according to the order in which they were established.
Orthopedic surgery, because of its long history, occupied the throne of “First Surgery,” while general surgery, which was responsible for the core organs such as the stomach, intestines, liver, gallbladder, and pancreas, could only settle for being “Second Surgery.”
Between the two departments, resentment had built up over the years due to competition for operating room resources, beds, and funding.
On ordinary days, the two sides often argued fiercely over questions such as “who should be the attending department for multiple trauma.”
Before long.
The on-call doctor from Second Surgery also arrived.
The one who came was Dr. Inoue Kazuki from Second Surgery. He was not tall, but he had a quick temper.
Holding a tube of freshly drawn non-clotting blood, his expression was ugly. “Positive abdominal tap. It’s all blood!”
“It’s definitely a splenic rupture or hepatic rupture. We have to open the abdomen and stop the bleeding immediately!”
Minamimura Shoji immediately objected. “No!”
“The X-ray shows an unstable pelvic fracture. There’s definitely a huge retroperitoneal hematoma.”
“Right now the retroperitoneum is intact, and the pressure can still barely compress the bleeding.”
“If you open the abdomen now, once the abdominal pressure drops, that retroperitoneal hematoma will instantly burst. Blood will spray out like a reservoir with the floodgates opened!”
“How will you stop the bleeding then? Use your hands to plug it?”
“We have to apply an external fixator first and stabilize the pelvis!”
Dr. Inoue threw the syringe in his hand into the tray. “Bullshit!”
“Massive intra-abdominal bleeding is the fatal injury. His blood pressure has already dropped to fifty. If we don’t go in and stop the bleeding, he’ll die of shock first!”
“Do you First Surgery people even understand?”
In the corridor outside the operating room, the doctors from the two departments argued in a tangled mess.
Neither side was willing to give in.
Which one to treat first was the most classic fatal dilemma in trauma surgery.
Bleeding from a pelvic fracture mainly came from the venous plexus and relied on the “tamponade effect.” Once the abdomen was opened and decompressed, the newly coagulated clots would break apart, causing uncontrollable massive hemorrhage. That meant certain death.
But visceral bleeding was arterial and likewise had to be ligated and stopped. Otherwise, if the blood drained dry, death was just as certain.
It was like defusing a bomb.
Cutting the red wire would make it explode. Cutting the blue wire would also make it explode.
But the patient could not wait.
The heart rate number on the monitor was soaring, while the blood pressure continued to fall.
“So you want to watch him die?”
“If he dies of hemorrhagic shock after the abdomen is opened, then that’ll be you Second Surgery people acting recklessly!”
“Hah? What did you say, you bastard?”
Seeing that the two superior doctors were about to start fighting at the operating room entrance, the nurses and anesthesiologists around them exchanged helpless looks, and no one dared to intervene.
Kiryu Kazusuke stood to the side, watching the line on the ECG monitor grow flatter and flatter.
The heart rate had already soared to 160, and the blood pressure could no longer be measured.
If they kept arguing, this person could be pushed straight to the morgue.
Although he was only an insignificant intern and had no right to speak here, if he did nothing, he would make no mistakes.
But he could not stand watching himself watch a patient slide into the abyss of death.
“Use a C-clamp!”
Kiryu Kazusuke suddenly stretched out his hand, blocking the space between the two of them, and spoke calmly.
“What?” Minamimura Shoji turned his head and glared at him viciously. “Do you have any right to speak here? Shut up!”
For an intern to dare interrupt an argument between superior doctors was a major taboo.
But Dr. Inoue froze for a moment. “What clamp did you say?”
“Emergency fixation with a pelvic C-clamp.” Kiryu Kazusuke ignored Minamimura Shoji’s rebuke and explained rapidly.
“The current contradiction is that opening the abdomen will decompress it and cause massive pelvic bleeding, while not opening it means the visceral bleeding can’t be stopped.”
“Then solve the pressure problem first.”
“Use a C-clamp through percutaneous puncture, directly clamping onto the posterior parts of both iliac bones, applying pressure from outside and forcibly closing the pelvic ring.”
“That can rapidly reduce pelvic volume and use mechanical pressure to compress the retroperitoneal venous plexus to stop bleeding, replacing the effect of intra-abdominal pressure.”
“The procedure only takes five minutes.”
“Once fixation is complete, Second Surgery can immediately perform exploratory laparotomy. At that point, even if abdominal pressure drops, it won’t cause massive pelvic bleeding.”
“This is the only solution right now.”