Seeing Liu Zhengliang preparing to take charge again, Che Mingming quickly asked, "Dr. Liu, aren't you sending this patient to Neurosurgery?"
Chen Junnan chimed in, "Old Li from Neurosurgery is ancient—he can handle outpatient consultations, but he's definitely not up for surgery anymore. The rest are just kids who graduated two or three years ago; they wouldn't dare make an incision even if you handed them the scalpel. Let's just go ahead—have the nurse call the director, and we'll handle it in Emergency. Liu Zhengliang's itching for it again; too much book learning has made him reckless. He gets restless without a scalpel in his hand."
Chen Junnan understood Liu Zhengliang. The months away from Heping Hospital had left him feeling disillusioned with life. As a doctor, if he couldn't treat patients, he lost his sense of purpose. Now, in this small hospital with its uneven departments, where talent had drained away and specialists were either too old or too inexperienced, Liu Zhengliang—an interventional neurosurgeon—saw a chance to stretch his skills. It wasn't about showing off; it was purely for the thrill.
Liu Zhengliang instructed Che Mingming and Chen Junnan to wheel the patient to CT while he prepared for surgery.
Noticing the patient was still somewhat conscious, Che Mingming asked as they pushed the gurney, "How did you get this injury?"
The thirty-three-year-old woman replied, "My husband hit me with a stick."
Hearing this, Che Mingming grew furious. Scanning the hallway and seeing only the woman's parents, she said to Chen Junnan, "Damn it, if he dares show up, I'll teach him a lesson."
Chen Junnan agreed, "Yeah, how could anyone be so brutal?"
Che Mingming's eyes widened. "Brutal or not, you just don't hit your wife, period."
Liu Zhengliang stepped out and told the woman's parents, "Your daughter's injury is very serious. The CT shows a depressed skull fracture at the crown of her head, with over two centimeters of depression. Surgery is absolutely necessary. Go pay and get her admitted right away."
The family asked, "Doctor, is our daughter in life-threatening danger? Does she really need surgery? Could she die?"
Liu Zhengliang said, "Without surgery, she will definitely die."
They pressed, "What about side effects after the surgery?"
Che Mingming cut in, "That depends on the extent of the trauma. Some patients develop epilepsy after surgery—brain cell damage causes seizures. Stop asking so many questions and go pay up so we can operate."
The family asked, "How much do we need to pay?"
Liu Zhengliang replied, "Around thirty thousand yuan."
The husband muttered to his wife, "Why so much? Once you're in the hospital, you're just waiting to be fleeced."
Che Mingming snapped impatiently, "The surgery fee is three thousand yuan—that goes to the hospital, which then pays a few hundred to us doctors and nurses as a service fee. But you'll need to cover medications, surgical supplies, possibly cerebrospinal fluid drainage and monitoring systems for at least twenty thousand, and maybe an artificial skull for tens of thousands more. Look, our doctor's work is only worth three thousand; the rest isn't going into our pockets—it's all for supplies and equipment. Hurry up and go pay for the admission; don't waste time."
Chen Junnan grumbled beside her, "They're just asking a few questions—no need to be so rude. Why are you flying off the handle?"Che Mingming replied, "I just can't stand it. The way he asked, 'Does it really require surgery?' Clearly doesn't care about his own daughter. Found himself a scumbag son-in-law, and now he's worried about money, even accusing us of ripping him off. If we really wanted to rip him off, we wouldn't treat her at all—we'd just hand her over to Ai San's daughter. That business brings in tens of thousands per case. Spending money to buy joss paper—what business could be better than that?"
After the elderly couple paid the first installment of thirty thousand yuan for the surgery, Liu Zhengliang's operation began. Several young doctors from Neurosurgery gathered around, observing from the side after sterilization. Ever since Liu Zhengliang had saved a deeply comatose girl with Brain Herniation, the Neurosurgery department at Second Hospital had started viewing him in a new light. Previously, they thought he was just someone placed there by some official to idle away his days, or a bookworm who couldn't make it in Beijing. Now, through actual cases, they had come to reassess Liu Zhengliang.
Liu Zhengliang examined the CT images and said to Chen Junnan and all the other doctors present, "Although it was caused by a single blow, with visible trauma on one side, the patient briefly lost consciousness after falling and hit the other side of her head on the ground. Currently, there's a depressed fracture in the left temporal region, midline shift, and a Subdural hematoma on the opposite side. Let's not overcomplicate it—debride unilaterally and perform a large bone flap decompression."
Chen Junnan irrigated the wound with gentamicin solution and hydrogen peroxide to disinfect it. As he worked, he remarked, "Such a large depression—we'll need to remove at least a 13-centimeter bone flap. Did he hit his wife with a baseball bat? Is he even human?"
Liu Zhengliang continuously rinsed the wound Chen Junnan had cleaned with saline using an irrigation tube and said, "Focus on your work. Don't let emotions interfere."
Che Mingming, standing nearby, asked, "If there's an epidural hematoma on the opposite side, we'll need to perform a large bone flap decompression there too, right?"
Without pausing his work, Liu Zhengliang replied, "Yes."
Che Mingming said, "With such a large part of her skull missing, how will this girl live her life? Maybe we could make the incision smaller and use intracranial pressure monitoring. As long as the pressure isn't high, let's try to remove as little bone flap as possible. Otherwise, it'll look terrible. Look how pretty this girl is—if a big chunk of her skull is gone, how will she face people? How will she go on living?"
Liu Zhengliang asked, "Is that your call to make?"
As he spoke, Liu Zhengliang looked up at Che Mingming standing in the operating room. Che Mingming neither agreed nor nodded.
Liu Zhengliang called out, "Scalp clips."
Che Mingming immediately handed over the scalp clips. Liu Zhengliang had already incised the patient's scalp with a scalpel and used the clips to secure it tightly, preventing bleeding—much like a stapler pinning the incised scalp together.
Liu Zhengliang continued, "Deep irrigation. Use gentamicin for meticulous layered cleaning."After peeling back the periosteum to finally expose the skull, Liu Zhengliang showed Che Mingming and the other doctors: "With this degree of comminution, we must perform a large bone flap removal. An Italian doctor conducted a study three years ago - the size of the bone flap removal should correspond to the degree of midline shift. If the preoperative CT shows a midline shift greater than 5mm, we must expand the bone flap removal area. Back when I was at Heping Hospital, I didn't believe it, thinking this must be another crackpot European theory with small sample sizes and no scientific validity - probably just neurosurgeons making excuses for surgical convenience. My mentor told me that we neurosurgeons are like house renovators - we work around the brain, afraid to touch anything since every area is risky. We just install skylights, repair pipes, and replace tiles. So our reference standards are simple - we just look at the midline position on CT scans, and our solutions are limited to cerebrospinal fluid drainage for decompression, or bone flap removal for decompression and hematoma evacuation. With today's case, we shouldn't consider the patient's future quality of life - our priority is significantly reducing her mortality rate. When there are no better options, this choice becomes the best choice."
Chen Junnan nodded, helping to stabilize the patient's head as Liu Zhengliang picked up the cranial drill to begin boring.
After removing the bone flap, Chen Junnan took charge of cleaning the subdural hematoma and prepared to place the intracranial pressure monitoring probe. Liu Zhengliang asked Chen Junnan: "The patient's midline shift is nearly 10mm - are you confident?"
Chen Junnan replied: "If I'm not confident, are you?"
Liu Zhengliang said: "I'm not either."
Chen Junnan said: "See? You have your limitations too. Don't worry, I'm experienced with this. Small local hospitals have their advantages - I've long mastered these assisting procedures."
Liu Zhengliang had already prepared drill holes for the probe and instructed Chen Junnan to insert it using the puncture needle.
Only then did Chen Junnan realize: "Couldn't we just do a lumbar puncture? Wouldn't measuring cerebrospinal fluid pressure through lumbar puncture work the same?"
Liu Zhengliang explained: "With this patient's condition, intracranial pressure measurements from lumbar puncture wouldn't be accurate. Moreover, lumbar puncture can cause cerebrospinal fluid leakage. With existing intracranial hypertension, if you directly drain cerebrospinal fluid through lumbar puncture, the sudden pressure differential could force brain tissue out, causing immediate brain herniation."
Chen Junnan shook his head, pointing at the CT scan: "Look how displaced the midline is - this girl's brain has more partitions than a subdivided apartment, it's like a crowded rental unit. Where am I supposed to find the ventricles?"
Liu Zhengliang said: "You'll still have to do it. You're the only one here who's performed ventricular punctures. I've only seen my mentor do it, never performed one myself. Consider this learning on the job - you're the only one here with experience, so it has to be you."
After zeroing the probe, the intracranial pressure monitor ICP displayed zero, and the puncture needle was mounted on the cannula.Chen Junnan was trembling with fear. One centimeter, two centimeters, three centimeters... Chen Junnan felt the puncture needle encounter resistance. With a slight push, it pierced through the ventricular wall, and the resistance suddenly decreased. The needle had been inserted six centimeters deep—normally, five centimeters would have been sufficient to reach the target. Chen Junnan was drenched in sweat, and time seemed to stand still. In that moment, he doubted everything he had learned over the years, all the time he had spent observing in the operating room, and all the surgeries he had performed himself. It felt as though he knew everything, yet nothing at all. He had never gambled with his career like this before. At the start of the insertion, he had been hesitant, unsure about the angle of the needle. But by the final centimeter, he was both resolute and doubtful. It wasn’t until Liu Zhengliang said, "You can suture now, the cerebrospinal fluid is flowing," that Chen Junnan finally let out a deep breath.
Liu Zhengliang reminded him from the side: "Secure it with the butterfly suture device, connect the adapter, and install the protective cap."
Chen Junnan was somewhat rusty with these finishing steps. After all, having spent so many years in the hospital, his main role had long shifted to facilitating connections for Flying Scalpel doctors from higher-tier hospitals. It had been years since he last set foot in an operating room, so his lack of practice was understandable. Seeing his hesitation, Liu Zhengliang immediately stepped in to take over.
The intracranial pressure monitoring data could now be measured.
Che Mingming patted Chen Junnan on the shoulder and said, "Not bad—succeeding on the first puncture attempt."
Chen Junnan smiled wryly and replied, "This was like a bride getting into her wedding sedan for the first time—I’ve never encountered such a complex situation before. Just look at the CT scan; it’s terrifying. If I had been even slightly off, I’d be facing a lawsuit."
Liu Zhengliang checked the monitoring data and confirmed that the intracranial pressure was still dangerously high. It seemed that bilateral large bone flap removal was now inevitable. There was no longer any need to debate whether to preserve the patient’s appearance—saving their life was the priority.
Liu Zhengliang had been managing the hematoma all along. He personally handled the removal of both large bone flaps. Once the hematoma was cleared, the surgery concluded. The puncture needle inserted by Chen Junnan would remain in place for postoperative medication and monitoring.
OpenNovel