Chapter 210

Episode 210 Observation (2)

Slice.

A sharp No. 10 scalpel split the patient's right flank.

It was a site that had already been operated on once. Following directly along the red, raised scar, the epidermis and dermis parted to both sides.

"Bovie (*electrocautery)."

Professor Han Lee-hyun briefly extended his hand. Without an instant of delay, the scrub nurse placed the pen-type electrocautery into his hand.

Sssssssss.

White smoke rose along with the smell of burning flesh.

"Suction."

"Yes!"

As if drawing a picture, Professor Han Lee-hyun maintained a perfectly comfortable posture as he burned through the subcutaneous tissue and controlled the bleeding, continuing the incision. Inside the operating room, only the rhythmic sounds of the machines and the burning flesh echoed.

It was then.

"Dr. Han."

While keeping his eyes fixed on the surgical field, Professor Han Lee-hyun spoke nonchalantly.

"Yes, Professor," I replied tensely.

"What would you say is the biggest variable that could occur during this incision process? With the Bovie power at 30."

"It's 30."

Even while directing the setting, Professor Han Lee-hyun took the liberty of throwing a question my way. His hands were moving without rest, splitting the yellow layer of fat.

He’s so damn casual.

Usually, reoperations make surgeons highly sensitive because adhesions limit the field of view, but this gentleman was as peaceful as a person out for a stroll. I quickly wracked my brain.

"I think it would be related to whether or not there is bleeding."

"Bleeding? Specifically?"

"Rather than a typical pattern of bleeding..."

I glanced out of the corner of my eye at the void to my right.

Korean Slave 1 (Male): What's the variable during the incision? Just bleeding?

Mes of the God (Male): It’s not just normal bleeding. If the structural integrity of the chest wall muscle layer is lost and the adhesions are completely clumped up due to the previous surgery, you won't be able to distinguish what's muscle and what's pleura.

Operating Room Ghost 3 (Male): I’m not in Thoracic Surgery, but adding a word from a General Surgery perspective, neovascularization occurs around scar tissue, so the capillaries are heavily developed. If you touch this, it’s hard to stop the bleeding.

Thoracic Surgery Fossil: Don't forget that the course of the intercostal artery might be distorted.

I synthesized the ghosts' tutoring and output it through my mouth.

"Um... there is a high probability that the normal anatomical structure of the chest wall muscle layer has been lost due to the previous surgery. In particular, as adhesions progressed around the scar tissue, severe capillary development in the chest wall may have occurred."

Professor Han Lee-hyun's hands slowed down for a moment. It was a sign that he was listening closely.

"Therefore, during the dissection of the subcutaneous tissue and muscle layer, I think there could be massive bleeding from touching a blood vessel in an unexpected position or from the adhered tissue. The possibility that the course of the intercostal artery is distorted cannot be ruled out either."

"Oho."

Professor Han Lee-hyun raised his head and looked at me.

"That's not the kind of detail that usually comes out of an Emergency Medicine resident's mouth."

He turned his gaze back to the surgical site and searched for the bleeding point with the Bovie tip.

Zzzzt.

Tap.

"In that case, what is the solution you envision, Dr. Han? What will you do if the blood starts gushing?"

"Instead of the cutting mode, the Bovie should be used primarily in the coagulation mode, and if necessary, the level should be increased to proceed with hemostasis and incision at the same time. When the field of view cannot be secured, rather than forcing entry, the dissection range should be widened to catch the blood vessels first."

"Good. That's the correct answer."

Professor Han Lee-hyun spoke toward the nurse.

"Switch to Bovie coagulation mode, and set the power to 40."

"Changed to coag mode and increased to 40."

Sssssssss—!

Just as I said, he increased the output of the coagulation mode and boldly seared the muscle layer where blood was seeping out. The blood that had been rising red instantly burned black and stopped.

"You studied hard," Professor Han Lee-hyun asked with a chuckle. "Did you buy a new textbook?"

"That... no. I used the one I already had. I just happened to remember seeing it before..."

"Really? The content is quite substantial for an old book."

He focused on the surgery again.

"Let's apply the retractors."

"Yes."

Hong Seon-ho hooked the instruments onto both sides of the incision and pulled with force.

Rrrrripp.

The hardened scar tissue parted, revealing the intercostal muscles between the ribs. Looking at that sight, I smiled bitterly to myself.

In a way, the forum behind me is also...

A place where hundreds of years of experience and knowledge had accumulated. A database more vivid than any latest textbook and more practical than any thesis. I glanced up slightly at the blue window floating in the void.

It's a textbook.

Even if the authors are dead people, their tone is a bit harsh, and they have ruined personalities.

"Kelly."

When Professor Han Lee-hyun reached out, the nurse handed over the curved forceps.

"The adhesions here are severe. The muscle and pleura are completely stuck together."

Professor Han Lee-hyun attempted to enter by carefully prying open the tissue with the Kelly forceps.

"Metzenbaum."

"Metzenbaum."

Snip.

As the tangled tissue was cut away with scissors, the pleura finally began to appear.

"Alright, entering now. Be careful not to damage the lung. Please pause the vent for a moment."

At the direction toward anesthesia, the machine sound cut off abruptly. The moment the lung's movement stopped, Professor Han Lee-hyun opened the pleura.

Pshhhhh.

Trapped air and a bit of blood sprayed out, and the patient's internal thoracic cavity was finally exposed nakedly. A chaos of chaos, where 15-year-old adhesions and the traces of yesterday's surgery were mixed.

"Yankauer."

Along with Professor Han Lee-hyun's voice, the nurse handed over the blunt-tipped plastic suction tip.

"Suction."

"Suction."

Slurrrrrp—

The Yankauer tip began to suck up the dark red blood pooled in the thoracic cavity and the acute clots that had hardened like jelly.

Gurgle gurgle—

While pouring in warmed normal saline to wash away the blood clots obscuring his view, Professor Han Lee-hyun continued his onslaught of questions directed at me without rest.

"You know what to do after irrigation because you heard it during the conference earlier, right?"

Please stop asking questions.

I screamed internally.

We're in the middle of a surgery right now. We're busy enough wiping up blood, do you really have to give me a quiz to feel satisfied?

And more than anything, what was unfair was:

I don't even understand half of it when I listen to a Thoracic Surgery conference, you gentleman.

That conference earlier at 7:00 AM. In that place where pre- and post-operative pictures and all sorts of abbreviations flew around, the only thing I, a resident from another department, could do was nod my head perceptively and grasp just the general context.

I don't know the details, you gentleman!

I spat out the information I vaguely knew.

"I heard you will first check the transected surface of the right lower pulmonary vein and the pulmonary artery branch that were ligated during the primary surgery."

"Oh, you remembered. Exactly."

Professor Han Lee-hyun nodded in satisfaction and moved his gaze toward the cross-section of the lung that was exposed white, located deep within the thoracic cavity. And then.

"Then, Dr. Han."

Here it comes again. The pattern I predicted. One hundred percent, he's going to ask about a variable.

"Right now, in this situation, what is the thing I should be most careful about when approaching to check that stump?"

I looked at the void to my right very naturally.

I'm really cheating a whole lot today, seriously...

But what could I do? I had to survive first. I had already brought up the window, you see.

Korean Slave 1 (Male): What's the variable when checking the pulmonary vein and pulmonary artery branch after irrigation? What do I need to be careful of??

Mes of the God (Male): Does this kid really think the operating room is a quiz show?

Korean Slave 1 (Male): No, I don't know Thoracic Surgery!!

Thoracic Surgery Fossil: Correct answer! While suctioning, you accidentally nudge it and active bleeding bursts! If you touch where the scab settled there, a blood fountain will spray.

Korean Slave 1 (Male): Thx thx

Latte is Mine: Is there no prize?

I lightly ignored Latte's words and turned my gaze back toward Professor Han.

"While suctioning... um... in the process of removing blood clots or securing the field of view, active bleeding could burst due to unskillful instrument manipulation."

"Where?"

Professor Han Lee-hyun's eyes gleamed. I scanned the ghosts' comments again.

Korean Slave 1 (Male): Shiiiiit, emergency. Where does the bleeding burst from?

Thoracic Surgery Fossil: Look at the base of the pulmonary artery. Granulation tissue will be tangled up around where it was tied with thread.

"At the base of the previously tied pulmonary artery or in the fragile granulation tissue formed around it. Because that area will have become very weak after the adhesion dissection."

"Wow."

Professor Han Lee-hyun's hands stopped. He looked at me as if truly impressed.

"What are you, really? How much studying did you do?"

"You flatter me."

I bowed my head humbly, but internally, I was sweating a whole bucket.

This is driving me crazy.

Even though I received one-on-one Spartan tutoring from the ghosts all weekend without sleeping, in practice, I was barely answering by receiving their advice. Just how deep did the knowledge of Thoracic Surgery go? It was only a matter of time before my lack of actual knowledge was exposed.

Professor Han Lee-hyun focused on the surgery again and moved the Yankauer.

"Yeah, good answer... HEY!!!!"

A sudden shout. The air in the peaceful operating room froze instantly.

"Yes?"

I flinched reflexively and answered. Did I say something wrong? Was it not granulation tissue? But the place Professor Han Lee-hyun's gaze was directed toward was not me.

"Yes!"

Hong Seon-ho answered, startled. Professor Han Lee-hyun's gaze turned fierce.

"Are you really going to place the tip like this? Do you want to rupture the patient's artery?"

"No, sir. Sorry."

Hong Seon-ho turned pale and adjusted the position of the suction tip.

"Focus. You're not losing your mind, are you?"

"Sorry. I will secure the field of view."

"Yeah."

Professor Han Lee-hyun returned to a peaceful voice as if nothing had happened and proceeded with the surgery.

"Alright, let's dissect here. Metzenbaum."

I swallowed hard.

He seemed to have a really good personality.

As expected, a surgeon is a surgeon. Even if they laugh like a nice person, they ruthlessly draw their blade the moment it directly concerns the patient's life. That must be the appearance of a true professional, though.

I should keep a low profile.

Tense as could be, I decided to stay quietly glued to the side of the operating table while staring at the ghosts' window until my eyes felt like popping out.

Snip.

Snip.

Professor Han Lee-hyun's hand movements were unrealistically fast. Usually, if it's a reoperation, common sense dictates that it takes a good few hours just to detach the adhesions clumped together from the previous surgery one by one. Because if you touch the wrong thing, blood bursts and organs tear.

However, his scalpel and scissors dug between the tissues without hesitation. Looking down at the surgical field, I couldn't help but be astonished internally.

Is this speed even possible?

Are all the thoracic surgery professors at this hospital like this? Or are the director and this gentleman unique? I glanced slightly at the window floating in the void to the right and left a comment.

Korean Slave 1 (Male): He finished all the dissection and opened up the pleura.

Mes of the God (Male): ?? What kind of bullshit is that. It took him 50 minutes to open the thorax and crush those clumped-up adhesions?

Korean Slave 1 (Male): Yeah, it's real.

Thoracic Surgery Fossil: His hands are a machine. How does he do adhesion dissection like he's cutting tofu?

Mes of the God (Male): No, that's kind of amazing. That's talent.

During that short period of time, Professor Han Lee-hyun cleanly organized the adhesions between the chest wall and the lung pericardium.

"Professor Son?"

Anesthesiologist Professor Son Myeong-jin replied, "Ah, yes. Professor Han."

"Yes. Now we need to go in and check. You can turn on the vent."

"Yes. I will set the pressure to 20. Shall I apply PEEP?"

"Yes, please apply it."

Whoosh— clack.

Whoosh— clack.

The ventilator that had been stopped operated again, making a rhythmic mechanical sound. As air was injected into the patient's collapsed lung, the lung began to inflate inside the thoracic cavity. Professor Han Lee-hyun turned his head and looked at me.

"Dr. Han Hyeonjae."

"Yes, Professor."

"By any chance, what is the reason for taking the risk to apply positive pressure ventilation again right now during surgery?"

Here it came again. A surprise question. But this time, there was no need for any help from the ghosts. Because this was a completely fundamental question.

I know this.

I let out a sigh of relief internally. What do you have to do to find a puncture in a tire? You can submerge it in water and put air in. The place where bubbles go gurgle-gurgle rise up is precisely the hole.

"It would be to confirm the leak point. It's to find the place where air bubbles rise by inflating the lung while it's filled with normal saline."

"Right. Correct answer."

Professor Han Lee-hyun grinned, then clicked his tongue.

"Anyway, your brain is perfect... but it's a waste that you can't use it in the operating room. Tsk. It's a pity."

He sighed as if truly regretful. It wasn't that my brain was good, but that the ghosts living off my body were smart. Well, letting him misunderstand was more beneficial to my personal safety.

Professor Han Lee-hyun poured warm normal saline until the thoracic cavity was full. The inflated lung was submerged in the sloshing water. And a moment later.

Bubble bubble—

Small air bubbles began to rise above the clear water.

"Found it."

Professor Han Lee-hyun's eyes flashed.

"The air leak is here. As expected, between the interlobar fissures like I said earlier."

He pointed to the exact spot with his finger. In a deep valley where the lungs near yesterday's surgical site met each other, air bubbles were rising up.

"Suction."

"Suction."

As Hong Seon-ho sucked up the water, the field of view was secured.

"Hrmmm... I found the pericardial rupture site too..."

Professor Han Lee-hyun picked up a small torn tear on the side of the pericardium surrounding the heart with forceps. The hole where air came out and the hole where air went in were facing each other miraculously.

"We're lucky. Because the field of view comes out right away without having to irrigate a few times. Usually, you wander around for a while looking for bubbles."

"Yes. It's truly a relief."

I chimed in. Rather than luck, it was probably thanks to the good field of view because he had done the dissection so cleanly.

"Dr. Hyeonjae."

"Yes, Professor."

"As a resident, seeing a CS surgery from this close feels different, doesn't it? Compared to looking over someone's shoulder during PK or intern days."

"Uh... yes. Definitely."

I nodded honestly.

"It seems very different. Because now I can see that every single one of those is a process directly connected to the patient's life. The weight is different."

"Right? The weight is different."

Professor Han Lee-hyun smiled broadly as he cut the thread.

"So, how is it?"

"Pardon? What do you mean?"

I blinked at the random question.

"That your surgical skills are amazing?"

"Not that."

Keeping his focus on the surgical field, Professor Han Lee-hyun continued speaking.

"How do you feel about Thoracic Surgery? I was wondering if you had any thoughts of trying a surgical residency after getting your EM board."