Chapter 398 - 258: Calm Freak
The doctors in the hospital room were all stunned.
Harlequin syndrome?
What a niche term.
Even Director Liu Jianbang was baffled. He quickly searched his brain for relevant information, but damn it all, he came up with nothing.
Director Li from the Respiratory Research Institute, however, had heard of the term and looked at Jiang He with some surprise.
’I can’t believe Jiang He even knows about this. Incredible.’
In truth, you couldn’t blame the directors for their ignorance.
The main issue was that in 2008, ECMO was still an exceptionally rare piece of equipment—something you’d almost never see.
Even at Affiliated Hospital No. 1, there was only one machine in the entire hospital.
It was used very infrequently, and mostly in rare cases of cardiopulmonary failure where the family was extremely well-off...
The moment you turned that thing on, the cost was calculated by the second. To be honest, very few people could afford it.
Lacking practical experience, the vast majority of ICU doctors, including Liu Jianbang, only understood ECMO at the most basic level:
That is, it could replace the function of the heart and lungs, drawing out dark blood and pumping in red blood.
As for Harlequin syndrome?
It was an extremely rare complication.
Only Director Li from the Respiratory Research Institute, being at the forefront of critical respiratory care in the country, had ever come across the term’s abbreviation in a few foreign medical journals, but he still had no practical experience in handling it.
Therefore, Liu Jianbang instinctively wanted to object. He said:
"Jiang He, her blood oxygen saturation is 98%, heart rate is 85 beats per minute, and mean arterial pressure is stable above 65mmHg. Her vital signs are already stable! Why do we still need to perform an internal jugular vein puncture? And why modify the ECMO circuit? Isn’t that too risky?"
Director Li, who was standing nearby, also spoke up. "Director Jiang, I must remind you, this machine is currently running a V-A configuration. If you want to add a Y-connector, it means we have to cut the aortic return cannula. During this process, even the slightest mistake could lead to a massive air embolism!"
Yang Xu stood to the side, frowning without a word.
Everyone’s attitude was the same: they didn’t understand, and they were even resistant.
The main thing was, in everyone’s eyes, they had already succeeded. Why gild the lily?
If massive bleeding or an air embolism occurred while modifying the circuit and the patient died on the table, what then?
Jiang He was well aware of this.
If this had been half a month ago, when he was just a team leader.
Faced with the joint opposition of a senior ICU director and an expert from the Respiratory Research Institute, he most likely wouldn’t have been able to push his decision through.
When you’re a person of low status, your words carry little weight. There’s nothing you can do.
But thanks to Miller, since returning from Baltimore, his status had undergone a massive change.
He was in charge of a major project under the national 863 Program, was a core member of the national targeted drug R&D center, and was cloaked in the aura of being on the national list of protected scientific research talents.
Most importantly, the provincial department and the hospital’s Party committee had just made an exception and granted him independent surgical privileges at the Deputy Chief Physician level, with the full backing of the entire hospital.
He was now, in name and in reality, a Deputy Chief Physician at Affiliated Hospital No. 1.
The reinforcement of his status added weight to his words.
However, before taking action, he still had to persuade the directors. He had to have their cooperation.
Jiang He said quickly, "Director Liu, Director Li, if we stop now, she will suffer irreversible brain damage within ten minutes at most."
Liu Jianbang’s brow furrowed. "The pulse oximeter probe is clipped to her toe. Is that 98% reading fake?"
Jiang He: "Yes."
It was time to let the facts speak for themselves.
Jiang He took the pulse oximeter probe off the girl’s toe.
He reattached it to the girl’s [right hand] index finger.
At such a critical juncture, Jiang He was still calm enough to consider such a detail.
The oxygen-rich blood flowing retrograde from the ECMO might have just met the deoxygenated blood at the aortic arch, forming a mixing cloud. Because of this, the oxygen level in the left hand might not drop immediately. However, the right hand and the right side of the brain would definitely be the first and most severely affected by hypoxia.
That’s why it had to be the girl’s right hand!
’What a fucking calm monster.’
He said, "Take another look at the monitor."
Everyone’s eyes snapped to it.
"BEEP—"
"BEEP—"
A high-pitched red alarm blared!
98% had suddenly become 65%!
Liu Jianbang was stunned. He rushed forward. "How is that possible?!"
Director Li immediately went to check the oximeter probe’s connection. "Is the probe broken? Or is the peripheral circulation in her finger too poor? No, that’s not right. Her blood pressure hasn’t dropped, so the periphery shouldn’t be this bad!"
Jiang He immediately said, "The probe isn’t broken. This is the Harlequin syndrome I was talking about. If you look closely at her skin tone, you’ll see that the lower half of her body, her legs and abdomen, are rosy. But the upper half of her body, including her face, neck, and both arms, is gradually becoming cyanotic and turning purple."
Liu Jianbang whipped his head around to look at the patient.
Sure enough, just as Jiang He had said, the girl’s face was a dusky, cyanotic color.
"This... What on earth is happening?"
"AIC just published a paper on the related pathophysiological model this year. I happened to have read it."
Jiang He first found a theoretical basis to back him up, then quickly explained:
"Director Li, we’re currently using a V-A configuration. Venous blood is drawn from the femoral vein, oxygenated by the membrane lung, turned into bright red, oxygen-rich blood, and then pumped back through the femoral artery, correct?"
Director Li nodded quickly. "Correct."
"And what about the direction of blood flow? The blood that the ECMO pumps into the femoral artery flows retrograde, up the aorta."
"That’s right. Retrograde flow to supply the whole body."
"Okay. Her heart, after CPR and ECMO support, has had its coronary arteries perfused with oxygen-rich blood and has resumed spontaneous beating. But her lungs are still white-out lungs from severe ARDS, with absolutely no gas exchange capability!"
Liu Jianbang’s pupils contracted sharply. He had vaguely grasped something, but his mind wasn’t turning fast enough.
Jiang He’s speech quickened. "Her right heart is pumping the dark, deoxygenated blood from the systemic circulation back into her lungs. The lungs are on strike, so the dark blood doesn’t change at all. It flows directly back to the left heart, and then, the heart pumps this dark blood directly from the left ventricle into the ascending aorta!"
Director Li understood instantly.
As an expert in extracorporeal circulation, if he still didn’t understand after Jiang He had explained this much, he might as well take off his white coat and resign on the spot.
𝑓𝘳𝑒𝑒𝓌𝘦𝘣𝘯ℴ𝑣𝘦𝑙.𝘤𝑜𝑚
Seeing the expression on Director Li’s face, Jiang He breathed a sigh of relief. At least the man wasn’t an idiot.
’Thank god you can understand what I’m saying.’
He immediately made his final summary: "The lower body is oxygen-rich, the upper body is hypoxic. This is Harlequin syndrome."
"The 98% oxygen saturation at the toe is because it’s full of the blood pumped back by the ECMO."
"The 65% oxygen saturation at the finger is because that area is only getting the blood pumped out by her own heart. Understand?"
Everyone present was utterly shocked.
Their entire perspective had been overturned once again.
’There’s such a thing?’
Director Li finally understood why Jiang He was so highly valued by the country and why he could be promoted outside the usual career path.
’The man really has the goods!’
’Seeing is believing!’
No.
In the middle of a high-pressure emergency rescue, how the fuck could he recall a paper he’d read before?
And then, based on his own on-the-spot deductions, predict a rare complication in a critically ill patient, and then come up with a solution right then and there?
No.
Is he fucking human?!
Director Li was thoroughly convinced. He obediently asked Jiang He, "Director Jiang, what should we do now?"
Jiang He was frantic inside, and his words came faster and faster:
"This is why I need to make an incision in her neck and create a V-A-V configuration! Since her heart is only pumping out the dark blood that flows through her right heart, then we’ll just have to artificially create red blood for it!"
"We cut the cannula returning to the femoral artery, attach a Y-connector, and divert a portion of the oxygen-rich red blood to be infused directly into her right atrium via the right internal jugular vein!"
"The red blood enters the right atrium, flows into the right ventricle, and the right ventricle then ejects this red blood into that pair of on-strike white lungs. Since the blood itself is already oxygen-rich, it doesn’t need gas exchange from the lungs. It passes directly through the pulmonary circulation and returns to the left atrium and left ventricle."
"This way, the blood ejected by the left ventricle into the aortic arch and flowing to the brain will be the red blood oxygenated by the ECMO!"
"Does everyone understand?!"
Only one word remained in Director Li’s mind: Genius...
But it was Yang Xu who reacted the fastest. He made a snap decision and roared, "Prepare for a right internal jugular vein puncture! Bed one, lower the head of the bed to expose the right side of the neck!"
A wave of relief washed over Jiang He.
’That’s my mentor for you!’
When a life was on the line, there wasn’t a single second to waste!
Jiang He said to Yang Xu, "Professor, her cerebral hypoxia has already lasted for three minutes. We need to be fast."
"Right. Get the Y-connector, flow-limiting clamps, and heparin-saline flush for the circuit. Calculate the shunt ratio. Quick, quick, quick!"
Yang Xu rapidly pushed all the preparations forward.
Jiang He, meanwhile, put on a new pair of gloves.
Standing at the right side of the patient’s head, he used povidone-iodine to quickly and widely disinfect the girl’s right neck.
The risk was very high.
The others had no idea how to do it, nor would they dare.
So he had to do it himself.
But the long period of CPR just now...
...had made his hands a little weak...
Jiang He closed his eyes. Inhale. Exhale.
He did this three times.
Calming his emotions.
Focus...
Focus...
Focus.
Jiang He opened his eyes.
He held out his hand.
And said with absolute composure, "Open the puncture kit. Prepare for insertion."