Liu Zhengliang furrowed his brow and asked further, "Do you often experience stomachaches normally?"
Not really. I usually participate in all kinds of activities like skipping rope, running, and playing badminton. I'm lively and energetic, and I've never had any pain.
Liu Zhengliang asked Che Mingming to write the medical record. He pondered over it but didn't think it was particularly important. He had already performed an abdominal compression examination on the child, and the child showed no pain, so it couldn't be acute peritonitis.
At this moment, Teacher Wang comforted the child, saying, "Don't worry, this is your senior, my student. He's a doctor from Heping Hospital, and his skills are quite impressive—he's a Ph.D. from Peking Union Medical College."
While Liu Zhengliang's mind was racing, Che Mingming chuckled at this remark. Meanwhile, Li Qingcheng was taken aback. How could this seemingly dull emergency department doctor be a Ph.D. from Peking Union Medical College? Was the teacher out of his mind? A Peking Union Medical College Ph.D. working here, and in the emergency department at that?
Liu Zhengliang seemed to be speaking to himself, or perhaps to Che Mingming and Li Qingcheng: "Abdominal pain and vomiting should indicate acute gastroenteritis, but he shows no other symptoms. Let's do this: first, run a series of tests for appendicitis, pancreatitis, cholecystitis, intestinal obstruction, gastrointestinal perforation, and kidney stones."
Just then, the child's parents arrived and stood nearby.
Che Mingming voiced his doubts to Liu Zhengliang: "There's no tenderness at McBurney's point, so it shouldn't be appendicitis. Appendicitis typically starts with pain in the upper abdomen, then moves to the navel, and finally settles in the lower right abdomen. No matter where it hurts, if it's due to inflammation spreading, McBurney's point will definitely be painful. But this child isn't in pain. I tapped the liver and gallbladder area for a while and didn't see any reaction from the child. I doubt it's gallstones or anything like that. The child shows no signs of jaundice; his face is rosy, so his liver should be fine too. There's no pain when percussing the kidney area in the lower back, so it's probably not kidney stones or ureteral stones either. The child ate very little this morning and had dinner at school last night, so the likelihood of pancreatitis is also low."
Che Mingming said to the parents, "We'll do blood tests, an X-ray, and an abdominal ultrasound. If everything looks fine, I'll fill out the forms, and you can go pay directly."
The parents hesitated. The couple, wearing sleeves and blue-gray work uniforms, stood timidly at the door. Che Mingming understood the situation and said, "It won't cost much—at most three hundred yuan." Only then did the couple go to pay.
During the break, Wang Bao asked Liu Zhengliang, "Why did you come to the Second Hospital? Weren't you working as a doctor at Heping Hospital?"
Liu Zhengliang then told his teacher about being fired.
After hearing this, Teacher Wang remarked, "Without the cold of winter, one cannot know the pine and cypress; without difficulty, one cannot know a gentleman."
The parents returned with the child, and the three doctors examined the scans and test results. The pancreas showed no edema or lesions; the liver had no signs of inflammation; the kidneys and ureters contained nothing but urine, with no stones at all; the gallbladder was clean. Liu Zhengliang then looked at the complete blood count and found elevated white blood cells, indicating inflammation, but it was unclear exactly where the inflammation was.
Li Qingcheng said to Liu Zhengliang, "Dr. Liu, could it be chronic enteritis?"Liu Zhengliang wasn't unaware that the symptoms resembled chronic enteritis, but chronic enteritis should at least involve diarrhea. However, since the cause remained unclear, he decided to prescribe medication accordingly. The child's abdominal pain might be due to intestinal spasm caused by vigorous exercise after eating, so he administered an antispasmodic—Atropine sulfate injection—to soothe the gastrointestinal tract and provide pain relief.
Teacher Wang Bao told the child's parents, "I don't have any classes this afternoon. I'll stay at the hospital with the child. You two should go back and not delay your business. We'll observe him after he takes the medicine, and if everything seems fine, then you can leave. This doctor is my former student, so rest assured—we're all like family here and will do our very best."
The parents expressed profuse thanks before leaving.
Liu Zhengliang brought the child and teacher to the observation room, had the child lie down to rest, and prescribed some anti-inflammatory medication. After the Atropine sulfate injection, the child's energy noticeably improved almost immediately. As the anti-inflammatory IV drip started, Wang Bao said to the child, "You should aim for a Ph.D. in the future too. This is my favorite student, Liu Zhengliang, the one I talk about every day."
By the afternoon, the emergency department had quieted down significantly, so Liu Zhengliang came over to chat with the child and teacher. He asked about the child's parents' occupations. Wang Bao explained that they sold pickled vegetables at the farmers' market—a hardworking couple supporting their son's education by selling garlic preserved in sweet vinegar, pound after pound of potherb mustard, and head after head of kohlrabi. The child was determined and ranked in the top ten of his grade, even coming in second last time. Wang Bao added, "He's our class's future Tsinghua University candidate."
Hearing his homeroom teacher mention that his parents sold pickled vegetables, the child lowered his head in slight shame. Liu Zhengliang held the child's hand and said, "Don't be embarrassed about your parents' work. My own parents were laid-off workers. After my father lost his job, he worked as a manual laborer at the Fakujie Market near our school's west gate. My mother has silicosis and stays at home. Every day after school, I could see my father there, especially in winter, wearing padded shoes and stamping his feet to keep warm while waiting for work—earning twenty-five yuan a day carrying sandbags and loading trucks."
Teacher Wang said, "You two are quite alike. Last week during midterms, this child had a fever for three or four days, hitting 40 degrees Celsius. I told him to go home and rest since it wasn't a crucial exam, but he refused. He insisted on getting a good score to show his parents."
Upon hearing about the prolonged fever, Liu Zhengliang felt the child's forehead and quickly took his temperature with a thermometer. He still had a low-grade fever of 37 degrees. A fever lasting several days wasn't typical for a common cold.
Liu Zhengliang asked, "Are you still feeling unwell?"
The child replied, "My stomach doesn't hurt anymore, but my chest feels a bit tight, and I'm still somewhat nauseous."
Liu Zhengliang's expression grew tense. He took out his stethoscope and placed it over the child's heart. Earlier, when the child complained of stomach pain, his focus had been entirely on the abdomen, and he hadn't considered cardiac issues. Now, observing the child's condition—slightly rapid breathing and a frighteningly pale complexion—he grew concerned.
Liu Zhengliang asked again, "Do you have any energy?"
The child said he didn't.
Liu Zhengliang immediately called for Li Qingcheng to draw blood for lab tests. Since the white blood cell count was already elevated, there was no need for a routine blood test; he specifically requested cardiac troponin and creatine kinase-MB levels. Not daring to waste time, as soon as Li Qingcheng finished drawing blood, Liu Zhengliang performed an ECG on the child. The results showed an ST segment injury pattern, premature atrial contraction, third-degree atrioventricular block, and tachycardia.Liu Zhengliang touched the child's hand again. Although Mingming's forehead felt feverish, his hands were somewhat cold. After checking his blood pressure, it was found to be extremely low.
Liu Zhengliang murmured softly, "It might be fulminant myocarditis."
Li Qingcheng remained skeptical, "Third-degree atrioventricular block along with tachycardia—shouldn't that rule out myocarditis?"
Liu Zhengliang immediately responded, "It could be due to atropine sulfate."
About ten minutes later, the test results came in. Both cardiac troponin and creatine kinase-MB levels were exceptionally high, almost confirming significant myocardial cell death.
Liu Zhengliang finally understood why the child's condition had slightly improved after administering atropine. Besides treating intestinal spasms and relieving pain, the drug also stimulates the heart to some extent, partially masking the fact that the child had already been in heart failure. Atropine was originally intended for gastrointestinal issues. Liu Zhengliang had initially assumed the child had a stomach problem, and the temporary symptom relief made him believe his diagnosis was correct. In reality, however, the drug had stimulated the already slowed heart rate, making it appear closer to normal and obscuring the underlying heart failure.
The realization filled Liu Zhengliang with anguish. Visions of misdiagnoses flashed through his mind, along with scenes of countless people questioning him.
He said to Che Mingming and Li Qingcheng, "This child had a fever last week and still hasn't recovered—I just found out through conversation. I felt his hands, and they're cold. Considering all the symptoms and data, it's certain: this is fulminant myocarditis. The child is in critical condition and could go into cardiogenic shock or even sudden death at any moment. Our hospital doesn't even have PCPS, let alone ECMO. If his heart stops suddenly, what do we do then?"
Li Qingcheng reminded him, "The downtown hospital has IABP. We could use that."
Liu Zhengliang replied immediately, "A 2018 study from Tokyo University involving 633 patients showed that combining IABP with ECMO increases survival rates by 20% for those with cardiogenic shock and myocarditis. Moreover, IABP is just an auxiliary blood pump. If the child's breathing can't keep up and blood oxygen drops, even a short period could cause insufficient cerebral blood flow. Even if we save him, his brain might not recover. ECMO, on the other hand, acts as an artificial heart and lung—it supplies oxygen. Most importantly, IABP still relies on the heart being somewhat functional, while ECMO allows the heart to rest. It's great if the heart can work, but if it fails, ECMO can take over. Every organ in the body can rest except the heart. If cardiac arrest occurs, maintaining blood oxygen can still save a life. This child has organic lesions and is at constant risk. We need to find a way to transfer him—not to the downtown hospital, but directly to Shenyang Shengjing General Hospital. They have ECMO, and it's only a half-hour drive."
Li Qingcheng said, "Don't be impulsive. You're thinking of worst-case scenarios—how likely is that? IABP can generally handle cardiogenic shock. If we transfer him to Shenyang and something happens on the way, who takes responsibility? Besides, his condition doesn't meet the criteria for transfer!"Liu Zhengliang said, "If we go to the central hospital and find the IABP ineffective halfway through, it'll be too late. A child this young has strong vitality—there's a high probability they can pull through with the right equipment. Without it, they could be gone in an instant."
Before Liu Zhengliang could finish speaking, Teacher Wang Bao from the observation room rushed over and said the child had suddenly felt dizzy and was gradually losing consciousness.
Che Mingming, afraid that Liu Zhengliang might act impulsively again, grabbed him and said, "Hold on. Going to Shengjing Hospital for ECMO—how much would that cost? Have you considered whether their family can afford it? Let's stick with conservative treatment here: arrange for Antiviral drugs and cardiac nutrients. If the child doesn't make it, you won't be held responsible. But if something goes wrong on the way, I'm telling you, you might not even have a place to eat. Think again—are there any alternatives? Let's hold on here for a while; maybe we can pull through. Don't panic."
When faced with problems, they always tried to "hold on" or "make do." Liu Zhengliang could make do with bone fragments for an artificial skull, or use a Throat swab as a makeshift endoscope and Zebra Guidewire. But what could he use to make do for this child's heart? There was no making do. If you're hungry at night and say you can't afford braised pork hock, could you make do with stinky tofu mixed with rice? That might work. But if the heart stops beating, what can you substitute? In the end, all those clever shortcuts in medical services are useless. Only solid financial resources and genuine technical expertise can truly save a life.
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