Chapter 129: A Critical Surgical Dilemma

Zhou Can’s plastering skills are now almost as good as Dr. He’s.

If he spends another year in Orthopedics, his plastering prowess could easily rival that of most attending physicians.

His proficiency in Bone Fixation Technique has also grown impressively, now matching the level of a junior resident.

After all, in Orthopedics there’s an abundance of opportunities to fix broken bones.

In just over two months, while shadowing Dr. Dan and Chief Resident Shen, Zhou Can took part in 117 bone fixation procedures.

He could clearly feel his skills improving.

In the past, he mostly performed finger fixations, as senior doctors only let him handle these low-risk, simpler cases.

Now, having attained a resident’s level in bone fixation, he can also manage fixes on bones such as the humerus and tibia.

Although his results don’t come out as perfectly as those of Dr. Dan or Dr. Chi.

His progress in the three orthopedic techniques has been commendable—except for Bone Setting, which has remained at an intern’s inadequate level despite lessons.

The primary issue is the lack of opportunities to practice.

Most patients needing bone setting are treated immediately in the Manual Reduction Room and never make it to the Operating Room.

Occasionally, a case with complex dislocation or misaligned joints defies manual methods and must be reset through invasive surgery.

Such operations are usually handled by the Orthopedic Trauma Team, a group that has never performed them before.

Without the chance to practice Bone Setting, Zhou Can was left with no alternative.

He could only hope to find further training opportunities later.

The main goal of standardized resident training is to master basic diagnostic and treatment procedures.

It’s not necessary to perfect every single technique.

No one can master all the required skills within just three years.

They simply learn the basics when they join and then polish their skills gradually as they work as residents.

During his two-plus months in Orthopedics, besides advancing in his bone skills, he also significantly improved in suturing, ligature, hemostasis, debridement, and tissue separation.

His hemostasis technique is now approaching the intermediate level of an attending.

With frequent opportunities, his skills in suturing and ligature have improved rapidly, already nearing outstanding attending level.

As early as last month, he had reached an outstanding attending level—almost at the associate chief physician standard.

He was especially excited about this.

What would it feel like to perform at a chief level?

That day, Zhou Can arrived early at the Orthopedics department as usual.

He made sure to get to his team’s doctors’ office at least thirty minutes early, all to review the surgical cases. Knowing the details of the patients scheduled for surgery helped him prepare mentally.

He also kept track of post-operative patient conditions and surgical plans, ensuring he understood the outcomes thoroughly.

This accumulated experience would serve him well in his future practice.

When he came across an X-ray of a calcaneus fracture scheduled for surgery today, Zhou Can scrutinized the patient’s various reports and images, but his mind drifted back to the patient’s case during rounds.

The patient’s X-ray clearly showed a severe calcaneus fracture.

Surgery required an incision near the ankle to reposition the fractured calcaneus and then drill holes to insert screws for internal fixation.

Although the operation site is just one of the limbs and may seem straightforward, this procedure is classified as Level 4.

Even associate chiefs wouldn’t be allowed to lead it.

Only a chief physician could personally perform the operation.

The surgical classification follows strict criteria, rating the procedure based on difficulty and risk.

A Level 4 operation is never an easy task.

Chief Resident Shen would personally lead this operation at 9 a.m. today.

By now, he had surely reviewed all the reports and images, and might either handle the pre-op consultation himself or delegate it to an attending.

Zhou Can repeatedly enlarged the patient’s X-ray, examining it meticulously.

The left foot of this patient showed significant swelling and overall brightness on the X-ray. The patient had been hospitalized for two days, and the surgical plan had only been finalized yesterday.

“What are you looking at, Dr. Zhou?”

Dr. He walked into the office and, noticing Zhou Can was the first to arrive, greeted him with a smile.

“I’m just reviewing our team’s patient files. Can you help me check this X-ray for any issues?”

Zhou Can’s instincts were sharper than most people’s sixth sense.

Whenever he reviewed patient files, he always felt that something was off.

Dr. Hezhang approached and examined the X-ray carefully.

“It looks fine to me—a clear severe calcaneus fracture.”

After his review, he found nothing wrong.

“Maybe I’m just overthinking it! I’ll go check on the patient in the ward.”

Zhou Can got up and headed to the ward.

The ward was lined with rows of open beds.

Because large hospitals get so many patients, they often use open ward arrangements to cut management costs and save space.

Along the way, various family members and patients greeted him.

The savvy ones knew well that Zhou Can held a high-ranking position here.

During morning rounds, even though Zhou Can was the fourth in line, when it came to critical cases, even Dr. Dan made a point of discussing them with him.

This was a treatment neither Dr. Tang nor Dr. He could claim.

The reason was simple.

Zhou Can’s skills in Pathology Diagnosis were impressive, and his vast medical knowledge often provided very constructive insights.

He frequently identified issues that others overlooked.

That reliability and trust made him indispensable.

Dr. Dan felt reassured having him as a consultant.

Both patients and their families were very astute.

They knew Zhou Can’s status in Orthopedics was high and vied for his favor, hoping to gain extra attention during their treatment and hospitalization.

Zhou Can proceeded directly to Bed 77.

“Mr. Zhao, we’re planning your surgery today, alright?”

“The nurse notified me last night and had me stop eating and drinking,” the patient replied warmly.

As Zhou Can’s understated reputation in Orthopedics grew, he was rarely met with indifference when checking on patients.

Now, when he personally inquired about Mr. Zhao’s condition, both the patient and his family were pleasantly surprised.

“How many days has it been since your injury?” Zhou Can asked.

Mr. Zhao’s eyes flickered as he hesitated before answering, “I think it’s been three days.”

The accompanying family member, likely his father who was there to assist with admission, seemed unaware of the full details of the injury.

Hospitals typically impose an unspoken requirement during admissions—no caregiver, no admission.

Once a patient is admitted, the hospital is responsible for all aspects of their care, from mobility to pre-op and post-op support.

Hospitals can’t assign a nurse solely to tend to one patient.

Many assume that since they’re paying hundreds or even thousands per day, having a nurse exclusively attend them is a given.

Heh, such folks are just too ‘young’ in their expectations.

A nurse’s job is to change dressings, set up IVs, administer injections, and monitor blood pressure—not to cater to every personal need.

Some overly confident male patients might even fantasize about a nurse’s charming smile and gentle manner, hoping for a romantic encounter through the opportunity.

Patients with superior backgrounds—rich second-generation, children of officials, young corporate executives—might actually succeed.

But for ordinary folk, it’s best to stay in line.

They needn’t overthink things and get worked up.

Zhou Can examined Mr. Zhao’s left foot closely—his ankle and the top of his foot were all swollen.

However, the skin appeared a bit ashen with subtle wrinkles emerging.

Raising his tone slightly, Zhou Can asked, “Are you sure your injury was only three days ago?”

Doctors nowadays really have it tough.

A slightly harsh tone could instantly spark hostility or even a complaint from a patient.

Zhou Can suspected the patient was not being entirely truthful, yet he couldn’t openly accuse him.

So he resorted to a cautious, reminder tone and asked again.

Some patients lie for various reasons.

It’s quite exasperating.

Some lies are told to cover up embarrassment—for example, when Zhou Can in the Emergency Department treated a patient with a foreign object stuck in his anus, the patient claimed it had accidentally slipped in when he sat down.

Would you really chase him for more details?

That kind of lie has little impact on treatment; a doctor knows what’s really going on and doesn’t press the issue.

But some lies can lead to misdiagnosis, with dire consequences.

If something goes wrong, it’s not only the patient who suffers—the doctor bears the blame too.

After Zhou Can’s second round of questioning, Mr. Zhao’s eyes still darted nervously.

“If your injury time is off by just a few hours, it’s not a big deal. But if it’s off by several days or more, it could seriously compromise your surgery,” Zhou Can explained, his tone firm.

He wasn’t bluffing—this surgery was inherently high-risk.

A significant discrepancy in the pre-op details could dramatically increase the odds of complications.

“It should be three days—I was drinking and can’t remember clearly,” Mr. Zhao insisted.

Such blatant dishonesty was puzzling.

Normally, there would be no reason to lie about an injury time.

So why was this patient deliberately concealing the truth?

Seeing no further way to get an answer, Zhou Can re-entered the doctors’ office after a careful look at his foot.

Just then, Dr. Dan arrived.

“Dr. Dan, there’s a peculiar case on our team,” Zhou Can began.

He generally preferred not to meddle in such matters, but with the safety of the operation at stake, he had to speak up.

“Which patient are you referring to?”

Dr. Dan, now well acquainted with him, replied in an easygoing tone.

“Mr. Zhao in Bed 77.”

“Chief Resident Shen is scheduled to operate on him at 9 a.m. this morning. What’s the matter?”

Dr. Dan knew Zhou Can never wasted words, and she always valued his insights.

She immediately sought to understand the issue.

“When I reviewed the patient files this morning, something seemed off, though I couldn’t pinpoint why. So I went down to check his actual condition. Judging by the blood stasis and ashen, creased skin on his foot, I suspect his injury might be older than three days.”

Zhou Can said seriously.

“Sometimes a patient’s memory isn’t precise—a few hours’ discrepancy is fine, especially since it’s not a limb reattachment surgery,” Dr. Dan responded dismissively.

“But I’ve asked him twice, and he insists his injury time is correct. Yet, his eyes clearly betray a lie. I’m baffled—why would he deliberately misstate his injury time?”

Zhou Can pressed on.

Dr. Dan mused, almost aloud, “Maybe, like in that forensic TV series I’ve been watching, he’s hiding criminal evidence?” She laughed at her own remark, a rare nod to her unusual taste for forensic dramas.

Zhou Can considered this possibility.

Otherwise, why would the patient lie?

“Should we report his file to the local police station for a check?” he asked.

He explained that hospitals are obligated to report cases involving drug abuse, gunshot, stab, or assault injuries, to help law enforcement maintain public safety.

Some criminals, fearing detection, avoid major hospitals and opt for small clinics instead.

“It never hurts to have the police check things. You can call them directly—here’s the number for the local precinct,” Dr. Dan said, pointing to a business card hidden on a corner of the office desk.

Zhou Can immediately dialed the number to report the patient’s details, leaving the rest for the police to investigate.

He then refocused on the surgical plan.

As he reviewed the date on the X-ray, his eyes lit up.

It turned out the image was taken two days ago.

Had two days passed, would the bone condition have altered?

“Dr. Dan, do you think we need another X-ray before the operation?” he asked.

“Considering the treatment costs, hospitals usually only do one X-ray upon admission and don’t repeat it within three days. A follow-up is only done post-surgery, at discharge, to assess bone healing,” she replied while reviewing today’s surgical patient files and reports.

Zhou Can rechecked the X-ray from two days ago.

As he studied it, a thought struck him suddenly.

He quickly pulled up an X-ray of a femoral head necrosis case for comparison.

The contrast revealed a slight abnormality.

It appeared that Mr. Zhao’s calcaneus was already showing early signs of avascular necrosis.

Without a detailed comparison with other necrotic bone images, this subtle anomaly would have been easy to miss.

There are several contraindications for calcaneus fracture internal fixation—if any one is present, the surgery shouldn’t proceed.

First, poor local skin conditions; second, malunited old fractures; third, established avascular necrosis of the calcaneus; fourth, severely comminuted fractures.

Zhou Can strongly suspected that the calcaneus was beginning to develop avascular necrosis.

This was a major finding that needed immediate reporting.

Pre-operative detection and post-operative discovery are entirely different matters.

“Dr. Dan, please check: does Mr. Zhao’s calcaneus show signs of avascular necrosis?”

Although Zhou Can was just a trainee, he was expected to report such concerns to Dr. Tang or Dr. He.

But given his special standing and proven ability, and with Dr. Dan present, he went ahead and reported it up the chain.

After all, this wasn’t the first time he’d done so.

“No way, right? Both my mentor and I have examined the X-rays, and even Dr. Chi saw nothing abnormal,” Dr. Dan said with some disbelief as she stepped to Zhou Can’s computer to review the images carefully.

“My expertise is limited—I can’t see it. However, this issue is too important to ignore. I’ll call Chief Resident Shen,” she continued.

Without delay, she phoned Chief Resident Shen.

“Teacher, this is Dr. Dan. I’m sorry to bother you, but our team’s Dr. Zhou has raised concerns that the patient scheduled for calcaneus internal fixation this morning might already have avascular necrosis. I’ve reviewed the X-ray, but I can’t be sure and need your opinion.”

After hanging up, it wasn’t long before Chief Resident Shen arrived at the hospital and walked straight into the office.

“Little Zhou has some sharp eyes—none of us caught this issue, yet he spotted it. Regardless of the outcome, his attention to detail is commendable,” he said with a smile as he praised him.

Then, he examined the patient’s X-rays more intently.

A few minutes later, his expression turned grave.

“There are indeed signs of avascular necrosis, though very mild. Let’s get another urgent X-ray to reassess before finalizing our decision,” he stated.

After all, the patient was scheduled to enter the Operating Room at 9 a.m.

Emergency tests had to be expedited.

Chief Resident Shen personally submitted an urgent request for the new X-ray, which the Radiology Department promptly executed.

Soon, the new X-ray was available.

It clearly revealed more pronounced signs of avascular necrosis.

“Oh my goodness, it really is avascular necrosis. It’s a good thing we caught this in time—if we had proceeded with surgery, it would have been a failure,” Chief Resident Shen said, breaking into a cold sweat.

“Little Zhou, you did very well,” he added, offering him praise before outlining the management plan.

“First, we must inform the patient and his family to mentally prepare them. Given the current condition, the necrosis is in its very early stages; during surgery, we’ll tailor the approach based on the actual findings. In some cases, post-op management might just involve external fixation with plaster. In more severe cases, a bone marrow stem cell transplant might be needed.”

As he spoke, he frowned in confusion.

“Strange, logically, a three-day-old injury shouldn’t lead to necrosis so quickly!”

Dr. Dan chimed in with a laugh, “Dr. Zhou was right this morning—I suspected the patient was hiding his true injury time. Perhaps he’s trying to cover up a criminal incident.”

Chief Resident Shen suddenly understood and patted his forehead.

“No wonder—if the injury was really under three days old, necrosis wouldn’t develop so fast. Doctors these days not only have to treat illnesses, but apparently also play detective. Who would have thought a trivial lie could occur?”

His remark drew chuckles from everyone present.