First administer the sedative Propofol. Intubation through the trachea is uncomfortable. If the patient remains conscious, they may struggle and move around, making the procedure difficult for the doctor. One injection induces sleep, making it easier for everyone. Intubation requires swift action.
Lift the patient’s head about ten centimeters.
Use a tongue depressor to check for loose teeth, ensuring no teeth are accidentally pushed into the trachea during intubation.
Check the intubation tube’s cuff by squeezing it to confirm it’s airtight, then inflate the cuff.
Insert a guidewire and slightly bend the endotracheal tube to make it easier to enter the trachea.
Liu Zhengliang mentally rehearsed these training protocols, running through each step like a film in his mind.
Assume a horse stance at the head of the patient, support the right forearm on the side of the patient’s head, and use the right thumb and index finger to control the mouth and nose, applying force to align the mouth, throat, and airway into a straight line. Hold the laryngoscope with the left hand and exert force to reflect the blade to the epiglottis. Insert the tube through the vocal cords, have an assistant connect the manual resuscitation bag, use a suction device to clear secretions from the tube, confirm proper placement, secure the tube, and connect it to the ventilator.
After completing this procedure, the blood oxygen saturation immediately rose, reaching over 95%.
However, Old Li had just experienced difficulty breathing, which Liu Zhengliang hadn’t noticed earlier. He was still running a fever of 38.5°C. It seemed like a simple case of pneumonia, and antibiotics had been administered systemically for nearly a month. The white blood cell count was neither too high nor too low, and the C-reactive protein level was slightly elevated. This didn’t make sense to Liu Zhengliang. With several antibiotics used in combination, no pathogen should withstand such an assault. Even chronic bacterial prostatitis would be completely resolved after a month of antibiotics—the prostatic ducts are narrow, and if blocked, inflammation would still clear up, let alone in the alveoli. Moreover, as an elderly farmer from the Northeast who engaged in heavy physical labor daily, his blood flow was fast, making pulmonary embolism unlikely.
Che Mingming said, "Generally, pulmonary embolism has some underlying cause, such as prolonged bed rest leading to sediment in the blood vessels, lower limb edema causing vascular debris, or blood disorders. Old Li has none of these."
Liu Zhengliang replied, "His fever hasn’t subsided all day."
Che Mingming asked, "Could it be tuberculosis?"
Liu Zhengliang shook his head. "Impossible. We did a smear test and antibody detection upon admission, both were clear. Should we run a T-SPOT test?"
They decided to proceed with another test. Whether at Heping Hospital or a secondary Grade C hospital, doctors encounter all sorts of unusual cases. The only difference lies in their psychological expectations. Patients coming to this hospital, if not in critical condition, don’t necessarily demand a solution but have limited patience—solve the problem quickly, or admit defeat and arrange a transfer without delay. No one cares about your credentials; if you were truly exceptional, you wouldn’t be working here. So Liu Zhengliang didn’t dare delay and ordered an additional test to check if the patient’s T-cells had immune memory of Mycobacterium tuberculosis infection.
They drew a tube of blood late at night, and the result came back negative.In the ICU of a small hospital in a small city, rules were lax. While family visits were supposed to be scheduled, respectable people wouldn’t choose such a place for intensive care. When spending heavily to save a life, everyone rushed to big, reputable hospitals. So, the ward housed only Old Li and his family, and with the doctor’s tacit approval, his son stayed to care for him.
Old Li lay on the bed, breathing unconsciously with the ventilator. A normal person would show clear chest expansion and contraction, but not him—it felt like pumping air into a leaky bicycle tire. His daughter-in-law, exhausted from the night vigil, had gone home, leaving his son sitting by the bed, silently shedding tears. One moment he held his father’s hand, the next he wiped the old man’s arms and face.
The bond between father and son ran deep. Usually, the son was as stubborn as a mule, retorting a hundred times for every word said to him. But now, fear had set in. With parents around, even at seventy, you remain a child, sheltered from death by their presence. If a father passes, the heart grows restless—the one who showered you with warmth is gone. Put nicely, you become the family’s pillar; put bluntly, that pillar must bear the weight, unrepairable and unyielding, and you just have to endure it.
Little Li kept murmuring, "Dad, the hazelnuts on the mountain haven’t been harvested yet. You still need to tend the garden. I’ll be delivering goods south in winter, and my wife will come to care for you, but who’ll watch the kids? Dad, you have to get better." Then he resumed crying.
Those without direction often believe they’re brimming with courage and skill, only held back by their father. It’s in moments like these they realize their own inadequacy.
Che Mingming thought Liu Zhengliang’s judgment was off this time, though Liu had his reasons. The internist on night duty was also uncertain. Che Mingming said to Liu Zhengliang, "I think it’s tuberculosis. Think about it—how long has the old man been self-treating at home? Does his son know? With such prolonged, high-dose antibiotics, isn’t it possible the bacteria outside the lesion were killed, leading to negative tests?"
Liu Zhengliang replied, "Impossible. Regular antibiotics can’t eliminate them."
The internist said, "Our facilities are limited. We should either transfer him to the central hospital or send him to Shenyang. Don’t delay here and risk complications."
For a moment, Liu Zhengliang hesitated again.
Che Mingming added, "I suspect the old man has had this illness for a long time. Why don’t I collect more sputum samples? If antibodies aren’t detected, it’s likely due to low concentration. Anyway, it’s the middle of the night—transfer isn’t practical. Even at the central hospital, he’d just go to the ER, similar to our situation. If we confirm mycobacteria, they can transfer with the results and save time."
The internist remarked to Che Mingming, "I’ve noticed you emergency folks have been quite competitive lately."
Che Mingming laughed and said, "Well, we’ve got a top student here now. If we don’t put in extra effort, we’re afraid of being left behind. With a PhD working in emergency, what can a bachelor like me do if I don’t step up?"Liu Zhengliang thought Che Mingming made sense and immediately had the nurse collect sputum samples. They needed to collect samples hourly to test for tuberculosis bacteria DNA. Their hospital didn't have a genetics department, so they had to send it to the Mining Bureau Hospital. The internal medicine doctor said, "I'm familiar with that place - we were all classmates. I'll drive it over right now."
The first test came back negative.
Old Li's son was crying beside his father. The old man's trachea sounded like a leaky bellows from a rural stove. When the nurse came to suction sputum, the phlegm was thick, yellow, and even slightly green. Che Mingming happened to arrive to prepare for the second test. Seeing this situation, he quickly said, "Don't move! This sputum sample is perfect - it's freshly brought up from the lungs, still warm, and probably concentrated enough." He directly took the suction tube to the Mining Bureau Hospital for testing.
In less than three hours, the DNA results came back positive for Mycobacterium, confirming pulmonary tuberculosis.
Little Li asked Che Mingming, "Does my father still need to transfer to the central hospital?"
Che Mingming raised his eyebrows: "It's already confirmed. Your father has an infectious disease. The old man was probably trying to save money and delayed treatment at home for too long, only coming to the hospital when he was critically ill. You need to tell your father not to always think about saving money on illness. Saving dozens of dollars on treatment now will cost you thousands later to buy back your life. Just look at your ICU stay - though you didn't need other equipment, it still cost over twenty thousand, and you'll have to pay over ten thousand even after reimbursement. We'll transfer him to the infectious disease hospital in a few days when he's more stable, but he can't move now - it's too dangerous."
Liu Zhengliang added, "With Isoniazid, Rifampicin, Ethambutol, and Pyrazinamide - these anti-tuberculosis drugs - the old man should improve within days. If money is tight, you can leave the ICU today and just get a regular hospital room with oxygen. After he improves, he can go to the infectious disease hospital. This disease requires six to nine months of treatment."
When the daughter-in-law came to deliver food in the morning and heard about this long list of medications, she started worrying about money again: "Why so many drugs? Are you squeezing us dry like wringing water out of a toad?"
Che Mingming said, "If you can treat it yourself, then do it at home. What do you mean 'wringing water'? Do you even understand what these medications do? We've studied for over twenty years - don't you think we know better than you? Isoniazid starves the Mycobacterium by making them malnourished. Rifampicin is like castrating the bacteria, preventing them from reproducing and dividing. Ethambutol chemically castrates adolescent tuberculosis bacteria. Pyrazinamide suffocates the bacteria by depriving them of oxygen. Do you know how difficult tuberculosis is to treat? We must use combination drug therapy to make it impossible for them to survive from all angles, to wipe them out completely, even killing the tuberculosis bacteria absorbed by T cells. Besides, look at how much these drugs cost - they're all twenty or thirty yuan each. These are required to be low-cost drugs in the national pharmacopoeia. The full course won't exceed one hundred yuan - how is that 'wringing water'?"
The daughter-in-law still wasn't convinced: "The ICU and various tests have already cost so much, and now we need nine months of treatment - how much will that cost?"Che Mingming first had Little Li go pay for the medication and administer it immediately. After finishing the prescription, she looked up and said to her daughter-in-law, "We're not practitioners of traditional Chinese medicine who can diagnose just by observation, listening, questioning, and pulse-taking. We have to rule out each possible pathogen causing the infection. Without proper diagnosis, haphazard medication is useless—you've seen how long your father-in-law has been self-medicating. Has it helped?"
Within three hours of administering the medication, Old Li's fever subsided. When it was time for another CT scan, the daughter-in-law started complaining about the cost again, but after Little Li scolded her with "Stop talking, you wasteful woman," she quietly kept her mouth shut.
Looking at the scan results, Liu Zhengliang felt much more relieved. There was improvement in lung absorption, and blood oxygen levels had increased significantly. Liu Zhengliang said, "Based on this, we can observe a bit longer and then consider removing the ventilator."
During lunch, Liu Zhengliang asked Che Mingming, "How were you able to diagnose it as tuberculosis?"
Che Mingming replied, "Don't bring up that patient with me. I can still vividly recall that sticky phlegm. This morning on my way to work, I bought some KFC chicken nuggets, and when I opened the sauce packet, it immediately reminded me of that image. I completely lost my appetite."
Che Mingming continued, "In this poor area, when people get sick, they don't come to the hospital first. They act as their own doctors and treat antibiotics like daily meals. The old man waited until his condition deteriorated to this point before coming to the hospital—he even developed pulmonary embolism. He must have been bedridden at home for quite some time. If his son hadn't returned home and noticed the problem, the old man would have continued suffering in silence. When dealing with poor families, you have to analyze their behavior patterns. Just seeing how stingy his daughter-in-law is, I could tell that even if the old man fell ill, he'd just quietly take some medication and tough it out. If it were some other viral pneumonia, wouldn't both of them have been infected after all this time? They'd definitely be showing symptoms. Seeing that both of them were still energetic, I ruled out highly contagious diseases, which left tuberculosis as the most likely cause."
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