Chapter 399 - 259: Fifteen Seconds
The nurse quickly handed him the puncture needle.
As he took it.
The tip of the needle trembled.
Jiang He’s hand paused.
’From a professional standpoint, my current condition is: heightened sympathetic nervous system activity combined with static muscle fatigue, causing minute spastic impulses at the motor end plate.’
’In layman’s terms: I’m tired, and my hand is shaking a little.’
Yang Xu noticed this keenly and said, "Should I take over?"
Jiang He was silent.
’This procedure is extremely difficult.’
’If the puncture is off by even a fraction...’
’The patient will die within minutes.’
’Besides, my teacher has no experience performing a blind puncture while a patient is on V-A ECMO.’
’I can’t let him do it.’
Jiang He said, "It’s fine. I’ve got this."
He first placed his hand on the area to get a feel for it.
The situation was worse than he had imagined.
He couldn’t feel the carotid pulse at all.
The reason was that the suppressive force from the ECMO’s high-pressure retrograde flow was too strong, and the amount of blood the heart was pumping on its own was minuscule...
Director Li observed Jiang He’s expression and tentatively suggested, "Can’t you feel the arterial pulse? Should we try reducing the ECMO flow a little to let the heart pump out more blood on its own?"
Liu Jianbang immediately shot him down. "No! Her blood pressure right now is being completely propped up by the machine!"
This was a classic dilemma.
At a time like this.
Perhaps the only thing Jiang He could rely on was his own years of experience.
He closed his eyes.
Breathed.
Steadied his muscles.
He placed his index and middle fingers lightly on the right side of the girl’s neck.
Feeling.
Searching...
’The experience from so many surgeries in my past life won’t betray me.’
The apex of the sternocleidomastoid triangle.
’Found it!’
He opened his eyes.
Found the right angle.
A 30-degree angle to the skin.
Needle in!
Steady, precise, and decisive!
Everyone in the room held their breath.
Dark red blood was seen drawing back into the syringe.
He’d found it!
And this was a blind puncture!
There was nothing anyone could do to help now.
They could only applaud wildly in their hearts.
’Incredible!’
The guidewire slid deep into the blood vessel.
He withdrew the puncture needle.
Jiang He held out his hand. "Dilator."
The dilator was twisted into the skin.
As it spread the wall of the internal jugular vein...
The terrifying aspect of heparinization became apparent.
To keep the ECMO running, the girl had just been injected with a large dose of heparin sodium, and her blood had almost completely lost its ability to clot.
At the incision held open by the dilator, dark red blood continuously overflowed from the gap between the guidewire and the dilator!
In just a few seconds, a large section of the sterile drape was stained red.
"There’s a lot of bleeding!" a nurse at his side reminded him nervously.
"Don’t panic. This is normal," Jiang He said, his tone calm.
He withdrew the dilator.
Applied pressure to the bleeding point.
Picked up the venous cannula.
Slid it in along the guidewire.
All the way to the entrance of the right atrium.
Withdrew the guidewire.
Clamped the end of the cannula.
He created a pressure dressing around the puncture site with gauze.
The overflow of blood was finally, barely, under control.
"Internal jugular vein access established. Director Li, prepare to clamp."
Next came the most dangerous part: modifying the circuit.
Ninety-nine percent of people would fail at this step.
Director Li walked over to the main ECMO console.
He said nervously:
"Director Jiang, the pressure in the tubing is extremely high. The centrifugal pump is operating at four thousand RPM."
"If we clamp it for too long, the high-speed idling inside the pump head will generate extreme heat and shear stress, causing instantaneous, severe hemolysis!"
"How much time do we have?" Jiang He asked.
"Less than fifteen seconds. Within fifteen seconds, you have to cut the tube, connect the Y-connector, purge all the air from the connection, and then immediately release the clamps to restore flow. Can you really do it?"
"Yes."
Jiang He’s reply was simple.
But everyone around him was so tense they felt like they were about to explode.
He picked up a pair of surgical scissors and stood by the tubing.
Another Perfusionist, holding the Y-connector, stood close by Jiang He’s side.
The two exchanged a look and nodded.
Jiang He took a deep breath and said in a low voice, "I’ll count to three. Director Li, on my command, reduce the RPM!"
Director Li responded nervously, "Understood!"
"One."
"Two."
"Three!"
"Reduce RPM!"
Director Li yanked the knob down, and the roar of the ECMO console dropped suddenly.
The centrifugal pump’s speed was instantly brought down to the safe line.
At almost the same instant, two heavy-duty tube clamps came down!
"Cut!"
Jiang He’s hand moved like a flash.
The tubing was cut.
A little blood spattered out.
But he didn’t even blink.
"Connector!"
The Perfusionist inserted the two ends of the Y-connector into the severed main tubing.
The third end was quickly connected to the cannula just placed in the internal jugular vein.
"Purge the air!"
Just then.
The unexpected happened.
A tiny air bubble was stuck in a dead corner inside the Y-connector.
Air is lethal.
Everyone has seen a nurse purge the air from a syringe before giving a shot.
Let alone in a situation like this.
If the bubble were to enter the arterial system with the blood flow, it would cause a severe arterial gas embolism.
If it entered the venous system, it would trigger a fatal pulmonary embolism.
The Perfusionist immediately said, "There’s a bubble!"
Director Li: "Hurry! We can’t extend the downtime any longer!"
In a flash.
Jiang He grabbed a syringe.
He plunged the needle diagonally into the wall of the PVC tube!
And aspirated!
The tiny bubble was instantly sucked into the syringe.
"Bubble purged! Connection complete!"
Jiang He pulled out the syringe. Due to the positive pressure in the tube, a bead of blood instantly seeped from the puncture hole.
With lightning-fast reflexes, he quickly clamped the puncture site and shouted:
"Release the clamps! Restore RPM!"
Director Li released the tube clamps and pushed the speed control knob back to its original position.
"WHIRRR—"
The ECMO’s centrifugal pump roared to life again, its speed shooting back up to four thousand RPM!
The high-pressure blood flow instantly broke through the obstruction.
The oxygenated blood split at the Y-connector. One part continued to surge toward the femoral artery, while the other part flowed through the newly established internal jugular vein access, directly into the girl’s right atrium.
A fifteen-second race against death.
—Successfully won!
Everyone in the room let out a long, involuntary sigh of relief.
But Jiang He’s gaze hadn’t relaxed in the slightest.
He whipped his head around and stared at the bedside monitor.
This was the final moment of truth, to see if the V-A-V configuration was truly working.
On the monitor.
The reading from the pulse oximeter clipped to the girl’s right index finger began to fluctuate wildly.
This represented the oxygen content of the blood that had passed through the right heart, through the pulmonary circulation, and was finally being pumped to the brain by the left ventricle.
65%...
85%...
98%...
100%!
The blood oxygen shot straight to max!
The signs of severe hypoxia on the girl’s face quickly faded!
But before anyone could cheer, Liu Jianbang’s face changed drastically. "Something’s wrong! The arterial pressure is plummeting! The mean arterial pressure has dropped to 45! The lower body is losing its blood supply!"
Director Li was aghast. "What’s happening? The circuit is open, and the total ECMO flow hasn’t changed!"
Jiang He’s heart sank.
’What was bound to happen, has happened.’
’Fluid dynamics...’
The internal jugular vein connects to the right atrium, which is part of the low-pressure venous system; the femoral artery is part of the high-pressure arterial system.
Blood always follows the path of least resistance.
After the Y-connector split the flow, because the resistance on the venous side was far lower than on the arterial side, the vast majority of the oxygenated blood created a shunt effect, surging into the low-resistance internal jugular vein!
The volume of blood entering the right heart was instantly overloaded, causing the upper body’s blood oxygen to skyrocket, while the femoral artery line, with its higher resistance, lost its proper blood supply, leading to a systemic blood pressure crash.
’I have to redistribute the flow!’
Jiang He held out his hand. "Give me a flow clamp!"
The scrub nurse immediately handed it to him.
Jiang He took the flow clamp and placed it on the new tubing leading to the internal jugular vein.
He began to slowly turn the screw on the clamp.
Manually.
Adding resistance to the venous return line.
"Director Jiang, you..."
Director Li was at a loss for words.
He was keenly aware of the risk of this action!
Manually controlling the resistance, seeking a dynamic equilibrium between two life-or-death pathways.
’How can he do this?’
’The slightest deviation...’
’...and instead of fixing one problem, he’d create two.’
Finding the right balance depended entirely on the doctor’s on-the-spot judgment!
He tightened the flow clamp by a millimeter.
Jiang He’s eyes were glued to the monitor.
The arterial pressure slowly rose: 50 mmHg.
The blood oxygen saturation dipped slightly: 98%.
He gritted his teeth.
And tightened it another millimeter.
"Jiang He, take it slow," Yang Xu reminded him in a low voice from behind.
"Understood."
His entire focus was concentrated on the screw in his hand.
Another millimeter.
Arterial pressure: 58 mmHg.
Blood oxygen: 94%.
"It’s not enough. The blood pressure still isn’t high enough," Liu Jianbang couldn’t help but mutter aloud.
The forced blood began to flow more toward the femoral artery, but the oxygen being supplied to the brain was decreasing!
Jiang He held his breath, performing an extreme micro-adjustment, and turned it again.
Half a millimeter.
Another half millimeter.
Blood oxygen: 96%... 95%... 96%...
Mean arterial pressure: 62... 68... 70 mmHg!
Finally.
The blood oxygen stabilized at 96%, and the mean arterial pressure stabilized at 70 mmHg.
The flow in the two vessels had reached equilibrium!
Everyone was secretly stunned.
’—Holy shit, that actually worked? Fucking amazing.’
On the hospital bed.
An adequate amount of oxygenated blood flowed to the brain, while perfusion to the lower body was also fully guaranteed.
The flower was blooming; she was getting better.
Harlequin syndrome.
Had been completely defeated by Jiang He’s unreasonably precise micro-adjustments!
’Time for that line from Dynasty Warriors.’
’—"The enemy is shamed; I go to strip his clothes!"’
He continued to observe the patient.
All her vitals were back above the critical line.
Jiang He released his grip on the flow clamp.
Only then did he feel that his hand had gone numb.
He looked up, scanned the faces of his colleagues, who could barely conceal their excitement, and said seriously:
"V-A-V configuration, circulation successfully established, hemodynamics balanced, cerebral perfusion restored."
"Director Liu, please recheck her ACT every two hours. Maintain a target value between 180 and 200 seconds. Adjust the heparin sodium micro-pump as needed based on the ACT results."
"Leave the ventilator parameters as they are. Continue to maintain the extreme lung-protective ventilation strategy. Keep the tidal volume at 4 mL per kilogram, PEEP at 12, and continue with the permissive hypercapnia strategy."
"For pain management and sedation, propofol combined with midazolam, with a muscle relaxant if necessary."
"Also, we need to escalate her antibiotics. The current drugs aren’t cutting it. Put her directly on Tienam—imipenem/cilastatin sodium—combined with vancomycin. Add an antifungal agent if necessary."
His orders were clear, logical, and covered every detail.
Liu Jianbang nodded repeatedly.
’—As expected of our hospital’s associate chief physician. He’s really something else~’
After giving all the instructions, Jiang He turned to Yang Xu. "Teacher, I’ll leave the follow-up observation to you and Director Liu. If her parameters fluctuate, call me anytime."
Yang Xu said reassuringly, "Alright. You’ve worked hard."
In his heart, Yang Xu was actually well aware.
’Today’s emergency rescue was another one that could rewrite the medical guidelines.’
’This was different from the posterior approach.’
’He could still understand the posterior approach, but this was on a level that was completely beyond his comprehension.’
’Jiang He was just too good.’
’As Jiang He’s teacher, he had just been coasting along and somehow became a vice president, coasted some more and became a Yangtze River Scholar.’
’It’s actually quite embarrassing.’
’And here Jiang He was, constantly producing new, incredible feats.’
’Is this really right?’
Ah, Yang Xu. His thoughts at this moment could be summed up in one sentence:
’—My disciple, Jiang He, has the makings of a great emperor!’