Dr.
Yang Weiguo, who was classified by Chen Wenqiang as a doctor who knows current affairs, has had mouth ulcers in his mouth one after another in recent days, and he has not completely broken the roots.He didn't dare to eat some cold porridge and rice with some salty and light flavors.Director Luo still felt very sorry for his husband, and when he saw that he was so hot that he was restless at bed, he deliberately went to the ward on the twelfth floor to persuade him when he was on the night shift."
Children and grandchildren have their own blessings.I think Xiaoyu is also a child with ideas, he is still young, and it is a different scene to wait two years to get his undergraduate diploma.If he still has the heart, he can also go to graduate school. ”"How can he go to graduate school with a college promotion like this?""
Those who graduate from junior college can be admitted to graduate school, not to mention that he can read the college promotion book.""
The medical conference accepts graduate students who have graduated from junior college?""
Yes.Like my batch of graduate students, almost all of them are workers, peasants, and soldiers.However, there are more undergraduates now.If the University is able to find better quality students, it will generally not recruit any more specialist students from other hospitals.Even if Xiaoyu gets a bachelor's degree from a college upgrade, without a score of 350 or higher, it is impossible for the Medical University to accept him.I think it is a more realistic goal for him to be admitted back to the provincial medical school. ”Dr.
Yang has never paid attention to the postgraduate entrance examination, but he still knows very well the common sense that graduate students of the Medical University are more difficult to take than undergraduates.When he saw his wife say this, he no longer thought about the medical university.turned to ask his wife: "Since junior college and undergraduate can be admitted to graduate school, can Xiaoyu go directly to graduate school?"
Then you don't have to waste another two years to study for a college upgrade. ”"That's not a waste, but the two years of study without a college upgrade, and it is impossible for him to pass the comprehensive medical course.If you think that those undergraduates in the medical university are called stressful course schedules, junior college students take two years to learn, and they still use the same textbooks, so the junior college students have learned a fur in a flash.If the teacher doesn't have time to talk about the knowledge points, they will not be able to grasp them.He had to make up for the missing part of the undergraduate first. ”For Director Luo's statement, Dr.
Yang can still accept it.He also understood that his wife came to accompany him on duty to comfort himself and let him stop worrying about his son's affairs.He understood his wife's affection, but he still said melancholy: "Xiaoyu, this child is not sensible."
But seeing that Lao Li and his family can live their lives as the envy of the gods, the daughter of Lao Li's family will not be bad.Alas, this kid is not sensible. ”Director Luo's heart was in favor of Yang Yu's statement to her husband, and the two of them couldn't think of going together.But after he had finished persuading him, he changed the topic and asked him: "I heard that there are people dying again because of ultrasonic lithotripsy, what's going on?"
”"Alas.I often walk at night and bump into ghosts. ”Dr.
Yang was distracted, and he said with mixed feelings: "One case is that the stone happened to be stuck at the junction of the ureter and the iliac blood vessels, and the blood vessels in the back were also damaged when the stone was crushed.Probably because of the weakness of the injury, there was no accident when he was hospitalized for observation after surgery, and he went into hemorrhagic shock after returning home only overnight.By the time he arrived at the emergency room, he was already cold. ”"Where's this today?""
It's a bit more complicated.It was directly referred from the following hospital after the rubble.Dean Chen said that it should be discussed in the hospital. ”"What does he suspect?""
Dean Chen called Lao Shi, and I listened to what he meant by Lao Shi, as if there was not enough inspection at the grassroots level, and the stone was broken directly."
Director Luo's eyes widened in surprise: "Are you saying that the diagnosis and treatment of the district hospital were wrong?"
”"I don't know the specifics.When the patient came, he was sent to the ICU for rescue.When I took over, I went with Lao Shi to see the patient after the vascular replacement surgery, and I happened to know more about the death of the patient.If there are no surprises, the death cases should be discussed tomorrow afternoon. ”"Now the medical records are sealed?""
yes.The ICU reported the death, and the medical department sealed the medical records as usual.If only I had a few glances in the ICU.This is a patient in urology. ”Dr.
Yang regretted it a little."
Are all clinicians going to be involved in the death case discussion?"
Director Luo has been here for almost a year, and he has not experienced this kind of hospital-wide discussion of death records."
It's not.Only department directors are eligible to participate in cross-disciplinary discourse discussions on death records.Then go back to Corey to convey the results of the discussion and remind everyone to pay attention to relevant matters. ”When Dr.
Yang said this, he couldn't help but have a gloating expression on his face: "Luo Ying, let me tell you, in the discussion of death cases attended by the directors of various departments, there is a tradition that whoever is the youngest will say it first, that is, whoever has the lowest qualifications will say it first.It used to be Guan Lan, then Xie Xun, but this time it was Li Min's turn. ”Director Luo disagreed, in any case discussion in the hospital, no matter which department and what patient, the lowest qualified person spoke first, otherwise the director and professors would suddenly open the hole cards, and the young doctor would have one less chance to use his brain to think.She reached out and patted Dr.
Yang's face in exchange for Dr.
Yang's exaggerated, grinning pain."
What do you want?
Isn't your Corey consultation and death discussion the order of intern, inpatient, and attending doctor?
”"It hurts, it hurts."
Dr.
Yang covered his cheeks and exclaimed: "I have several ulcers here." ”Director Luo was amused by his exaggerated exhalation, she blew a few breaths on Dr.
Yang, calmed her husband's emotions and said: "You want to see Li Min's jokes today, haven't you thought that when you are promoted to deputy high school, or after you are promoted to the independent department of urology, you can get a position as deputy director, and you are qualified to participate in such a discussion, you want to speak before Li Min?"
”Dr.
Yang immediately collapsed.He patted his head and said, "Alas."
Do you think I'd rather never be qualified to do so?
Or are you looking forward to this day coming sooner?
”Director Luo joked and said, "Why do you have to speak before Li Min." ”* The two husbands and wives were talking about the consultation in the duty room, and Director Hong of the ICU had just left the provincial hospital and returned home.After announcing the patient's death, he first informed Chen Wenqiang by phone and then the medical office.This is the request of the medical director Chen Wenqiang, no matter which department has a death case, he must be informed as soon as possible.The patient who was transferred during the lunch break at noon began to be rescued when he entered the department, and Director Hong personally handled the rescue of the patient, without looking at the medical records, he also remembered it clearly.After listening to his report, Chen Wenqiang first affirmed: "The rescue of your department was timely, but the death of the patient could not be avoided.This week, there were two consecutive cases of patients dying after lithotripsy.The cause of death in the previous case was clear and simple, but this case is more complicated.So, tomorrow afternoon, the directors of each department will go to the large conference room to participate in the death discussion, and your department should prepare for the medical record report. ”Director Hong answered, and then informed the general duty that night.* Leaving the phone, Chen Wenqiang told Xiao Yin about the matter."
This ultrasonic lithotripsy has become a project that any level of hospital dares to do.The person in charge of making lithotripsy also dares to touch any kind of kidney stone.If you don't brake this trend, I don't know how many things will happen. ”"The main thing is to introduce patients to Zhenbo lithotripsy, and there is a referral fee.Besides, if the machine is bought, it must be recovered quickly. ”"Yes.There are interests in this, and it is not uncommon for accidents to occur.Xiao Yin saw that he was depressed, so he asked, "Have you arranged the operation that Lao Zhao said?"
”"Well, all the test results are back this afternoon, and I am scheduled to go to the emergency room on Saturday."
Chen Wenqiang spoke and dialed the switchboard."
Hey, I'm Chen Wenqiang.You put me in touch with the directors and deputy directors of all the clinical departments. ”The notice of the death discussion was sent.Chen Wenqiang rubbed his eyebrows, his face didn't look so good, in Xiao Yin's eyes, it was exhaustion that made Chen Wenqiang a little upset.She stood up, walked to Chen Wenqiang's side, and rubbed his temples on both sides."
Don't push yourself too hard.""
Hmm.Today is special.Not usually. ”Chen Wenqiang said that it is special because every Thursday, he has surgery in the morning and goes out to the clinic in the afternoon, which is the fullest and most intense day for him and Li Min.On this afternoon of each week, in addition to the patients who come for follow-up examinations at the outpatient clinic, it is necessary to confirm the patients who will be admitted to the hospital for surgery the following week and on the weekend.With the improvement of his professional reputation, first-time patients from provincial cities and other cities in the province will also hang his outpatient number on this day.Today is no exception.But the morning operation was unexpected, and it was already more than one o'clock when I stepped down from the stage.I hurriedly ate lunch, and it was the time to go out of the clinic in the afternoon.I was too busy to drink water all day.After a while, Chen Wenqiang said to Xiao Yin, who rubbed his head: "It's okay." ”Xiao Yin stopped, and Chen Wenqiang relaxed her fingers again.Then he picked up the phone and called Li Min and said, "The death record discussion that I attended in the big conference room at 3 p.m. tomorrow is a patient who died in the ICU tonight."
Half an hour after the gravel, he was transferred to our hospital for rescue. ”"Then I'll prepare well tonight.""
That's right.This death discussion, you are going to be the first to speak.It is necessary to have something to say, and it must stand up to the questions of other directors. ”"Yes."
Li Min nodded on the other end of the phone.She said to herself, is this the second test that will follow?
*In the afternoon of the next day, Li Min followed Director Shi and arrived at the large conference room two or three minutes early.This point is the time when the directors of each section arrive, and the sound of greeting each other and asking each other about the information of the deceased fills the large conference room.The place where the whole house meeting usually seems to be crowded, but now there are only these dozens of directors present, and it suddenly seems empty.In the medical department, Director Qin assigned Section Chief Lu to open all the windows, and the fresh air pouring in from the outside drove away the echoes of these buzzing discussions.At three o'clock, Chen Wenqiang appeared.He turned off the microphone, stood in front of the lectern and said, "Let's just a few dozen of us, big guys sit forward."
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In this discussion of deaths, the principle is one, only for the case, not for anyone.History is reported in the ICU. ”Director Hong of the ICU stood up and said, "Dean Chen, the patient's test sheet was made into film with the assistance of the medical department, which can be projected. ”"Then put on the projection."
Chief Lu of the Medical Section hurried to draw the curtains.The materials projected on the wall allow participants to know the patient's medical history, past medical history, and diagnosis and treatment history at the same time.One after another, the test sheets were continuously put on the wall.The results of the imaging examination are also projected directly on the wall with a slide projection.Speaking from the heart, the ICU has been very well prepared for this death discussion in a short period of time.All the abnormalities in the inspection form are circled with a red pen.Li Min worked hard to write while reading, and she wanted to record all the anomalies.Ten minutes later, the ICU completed the presentation of the medical history and treatment, and turned off the projector.Simple history features: older woman, previously healthy.Sudden left lower quadrant pain, chest tightness and discomfort after lithotripsy; Hypotension, oliguria, repeated slowing of heart rate with impaired consciousness, and repeated resuscitation eventually did not prevent death.Chen Wenqiang stood in front and said, "Let's follow the old rules."
The first to speak was the last person in the room to be mentioned as director.Xiao Li, tell me what you think. ”Li Min stood up and said, "I have a few questions about this case.First, in the projection data of the ICU just now, there is a color ultrasound report of the patient.Why does color ultrasound not provide the exact location of the stone, only a general sentence of ureteral stone?
Is there a more detailed description of the location and size of the stone?
Second, did the patient's blood and urine routine before lithotripsy be sent along with the transfer medical records?
Thirdly, after the patient was admitted to the hospital, was there any excreted lithotripsy found in her urine?
”The doctor who reported the medical history in the ICU replied: "There is only a color ultrasound report, no photos, and no detailed description of the stones."
There was also no routine blood and urine on the transfer medical records sent to the hospital.We also did not find excreted lithotripsis in the patient's urine. ”Li Min was stunned, and she subconsciously asked: "Can you do lithotripsy without blood urine routine?"
If there is an abnormal blood picture after lithotripsy, how can I tell whether it is an infection before or after lithotripsy?
Also, if this patient is over 60 years old, if there are many white blood cells in the urine, he cannot immediately lithotripsy. ”"What do you have to do then?"
Chen Wenqiang asked."
Do a urine culture to rule out pyelonephritis.The most serious complication of ultrasound lithotripsy is infection, and I think it is best to treat lithotripsy when there is no UTI or if the UTI is under control. ”Chen Wenqiang nodded and said, "Go on." ”"This patient has no previous medical history.I don't think it's credible enough to just say she's healthy.Because the X-ray and CT that were shown in the ICU just now were done in our hospital, and they all showed bilateral pleural effusions, which I don't think is easy to explain.The patient was transferred to our hospital for rescue half an hour after the end of lithotripsy, what caused the pleural effusion?
There is also a chest x-ray, which is atelectasis in the lower lobe of the right lung, pleural effusion, and the shadow of the lungs suggests pneumonia, which is not like the imaging changes that can occur in a short period of time. ”Director Hong asked, "Xiao Li, what do you think it is?"
”"The patient has pleural effusion and lung infection, and is admitted to the hospital with heart failure, shock and blood pressure, is it possible that there is an underlying lesion at the grassroots level without physical examination, and when the lithotripsy occurs, the patient's existing heart failure is aggravated?
Another point, after being admitted to the hospital, the abdominal ultrasound found ascites, but there was no kidney contusion and laceration.Therefore, I consider that this patient has a chronic underlying disease, which is aggravated by a blind lithotripsy of a ureteral stone on the basis of heart failure. ”"You mean there are no ureteral stones?""
The ultrasound did not provide us with photos of the stones that described the size and exact location of the stones.What I want to say is that even if the pain of acute abdomen caused by urinary stones can be determined by fluoroscopy or ultrasound after pain relief, and the stones that are not visible can be photographed.And not like it is now.I'm not sure if there are stones. ”Li Min is using the greatest malicious speculation about the lithotripsy treatment in the hospital below.This color ultrasound, which does not have a clear size and location, does not meet the requirements of gravel.If the hospital didn't contract out ultrasound lithotripsy, then the relevant personnel should be replaced.But she couldn't say anything other than what was required by the death discussion."
Anything else?"
Chen Wenqiang then asked."
I don't think there is anything inappropriate for the remaining ICU anti-heart failure, anti-shock, and anti-infection symptomatic treatment, including four cardiopulmonary resuscitations."
Li Min believes in the ICU very much.When there is no ICU, every time a critically ill patient after surgery has to be guarded in the intensive care unit.Now, as long as the patient does not have a special condition that must be guarded by a specialist doctor, he can be handed over to the ICU, and I don't know how much worry has been saved.Li Min calmly finished talking about her considerations and sat down, and Director Shi encouraged her with a smile: "That's right, it's very organized." ”She smiled at Director Shi and wiped the fine sweat from her palms onto the back of her hands.* For those who follow, the clinical experience gradually increases.There was a statement that caught Li Min's attention."
In urology, urinary stones in the elderly are accompanied by a lot of bacterial infections, and gram-negative bacilli enter the blood after lithotripsy, and the bacteria multiply in the blood of the elderly with very low immunity, which eventually leads to septic shock."
There is also a saying, "This patient is obese, but has never had a history of seeking medical treatment, and it is unknown whether he has underlying diseases, such as hypertension, coronary heart disease, diabetes, etc."
Older people in this age group, even without these underlying diseases, have varying degrees of arteriosclerosis.If there is damage to the iliac artery during lithotripsy, as in the previous fatal patient, then her persistent shock and hypotension could be found.If a thoracentesis or peritoneal puncture has been done, understanding the nature of the effusion will prove this. ”Li Min was immersed in shorthand, and he didn't have time to see who was speaking."
Lithotripsy causes renal contusion, hematoma, hemorrhagic shock.""
Lithotripsy causes colon rupture, septic shock.""
The process of lithotripsy caused the pus on the stone to fall off and enter the blood.Bacteria from the urinary system enter the bloodstream, not after lithotripsy, but at the beginning of lithotripsy.The lithotripsy is over, and the bacteria in the urinary tract or intestines have been multiplying in the bloodstream for 3 hours, and it is entirely possible to induce septic shock. ”…… Li Min carefully jotted down every speech and circled the line that the capillaries could burst and bacteria could enter the bloodstream at the beginning of the rubble.This is something she didn't expect."
Stones combined with urinary tract infections are common.Even if there is a pre-gravel positioning, if the stone is hard or has a special shape, it is very easy to cause damage to adjacent tissues during ultrasonic vibration.such as the colon and pleura.Finally, gram-negative G-bacilli enter the bloodstream and multiply rapidly in large quantities. ”Li Min remembers the director's speech very clearly: such septic shock is easily complicated by MODS (multiple organ dysfunction syndrome), which cannot be cured.The director then emphasized MODS.1.
Immediate type: within 24 hours of onset, two or more organ systems have dysfunction at the same time.2.
Late-onset type: It is the dysfunction of an important organ system, usually the heart, lungs or kidneys, which seems to be stable after a period of treatment, but more organ system dysfunction occurs one after another.All in all, septic shock caused by G-bacilli is highly susceptible to MODS.This is also the reason why the patient repeatedly stopped beating and was successfully rescued during the ICU rescue process, but finally died.Li Min felt that this passage was addressed to herself.Finally, Director Hong of the ICU of the department where the death occurred, said: "The diagnosis given to this patient by our department is urinary septic shock, secondary to MODS.The patient was admitted to the hospital with shock, followed by heart failure and then renal failure with oliguria.But then respiratory failure occurred, and it was a very obvious case of MODS.In terms of treatment, we have just given detailed instructions for symptomatic treatment. ”"Urinary septic shock like this, unlike general septic shock, is a more specific type of shock, often combined with acute myocardial atony, but the specific mechanism is unknown.…… Therefore, every time we receive a patient with a urinary tract infection, we are scared and cautious.But that's it, due to the rapid progression of the disease and the short rescue time window, the prognosis is very poor. ”When Director Hong said this, Li Min raised his hand and asked: "Director Hong, you are all based on the diagnosis that the patient has urinary stones, but there is no evidence to prove that she has stones."
If she has an underlying medical condition, after G-bacillus is in the bloodstream, it will be consistent with the condition you said. ”Li Min refused to admit that the inference of the underlying medical condition was wrong.Chen Wenqiang stood on the rostrum, holding the projector and laughing.This Xiao Li, experience alone can't convince her, she wants real evidence.Director Hong also recognized this, and he admired Li Min's non-blind obedience.He turned to Chen Wenqiang and said, "If the family of the deceased agrees, I will also agree to do an autopsy."
After all, it took less than ten hours from onset to death.Emotionally, it is still difficult for the family to accept. ”Chen Wenqiang said to Director Qin: "Then you go to communicate with the family on behalf of the hospital, and the autopsy will help clarify the cause of death." ”When Director Hong saw that Chen Wenqiang immediately agreed to the autopsy, he couldn't help but be stunned for a moment, is this Dean Chen too partial to Li Min?
Could it be that his diagnosis was doubted by the fledgling Li Min, so he had to do an autopsy?
But what Chen Wenqiang said afterwards made him settle down."
In today's discussion, everyone has expressed their opinions.In general, I am also personally inclined to septic shock caused by G-bacilli, secondary to MODS.However, Xiao Li and several other comrades have different views.In our clinical diagnosis and treatment, there is no matter where the minority obeys the majority.And whether it's right or wrong, I think Xiao Li's idea of conclusive evidence and ruling out the primary disease is worthy of affirmation. ”"If an autopsy can be done and it is determined that the deceased had a primary disease, it will be emotionally acceptable to the family that the death occurred within 10 hours.""
Why did I bring everyone together today to discuss the death, apart from the case itself, I want to remind everyone here through this death that you should not just see that ultrasound lithotripsy is less harmful than surgical stone removal.When you go back to Corey, make it clear to all the medical staff that when anyone refers a patient for lithotripsy, they must also emphasize the importance of preoperative testing to the patient.It's a matter of life.Whether it is anti-infection before lithotripsy or observation after lithotripsy, no step can be neglected.In the future, patients who have undergone ultrasound lithotripsy must stay for 24 hours.There is also the careful selection of indications.Is the introduction fee for superraw gravel in our provincial hospital 50 or 100?
Director Hu, you have to be strict over there.If extracorporeal shock wave lithotripsy is not suitable, it is necessary to explain the contraindications to the patient, and there can be no more secondary injury and death. ”When it comes to the selection of indications for extracorporeal shock wave lithotripsy, Director Hu is very embarrassed.However, the patient who died of hemorrhagic shock after lithotripsy sent back yesterday is obviously inseparable from the inappropriate selection of indications in the radiology department.He stood up and responded to Chen Wenqiang's reminder and promised: "Dean Chen, I will strengthen the management of the department in the future." ”Chen Wenqiang nodded and said, "That's good."
Meeting. ”* Li Min followed Director Shi's side and followed the flow of people back to the twelfth floor.The directors on the seventeenth floor crowded into an elevator, and Director Wang of the Department of Orthopedics said with a smile: "Our provincial hospital counted this case this year, but it is the third autopsy." ”"Normally, any death should be autopsied."
Director Liang strongly supported Li Min."
Even if the diagnosis is clear, there are many young doctors in our provincial hospital, and the autopsy will help them better grasp the human anatomy.""
If only that's the case.I heard that the anatomy class is still used by the general teacher ten years ago, so I can only watch but not do it.Then you might as well give a model. ”"That's it.It's not like we were back then, when every student had a hands-on opportunity. ”"Xiao Li, did you do human anatomy when you were in school?""
Nope.We had anatomy classes, and we were all looking at ready-made specimens.Seven or eight people are around a dissecting table, but they can't see or touch it. ”"I heard that you were scared last time you saw the autopsy, do you dare to go again?""
I definitely don't dare this year."
Li Min generously answered Director Wang's question.There's a small one in my belly.Don't dare to give those ghosts who have just died and are unwilling to die leave any chance to covet them.Li Min was led to the point of no return by those superstitious sayings.※※※※※※※※※※※※※※※※※※※※ end of science is metaphysics () a little far away