Chapter 493: Race Against Time: Tracking the Hidden Source

“Not only is Dr. Zhou incredibly skilled, but he also knows just what to say! Let’s hurry up and discuss the patient’s condition. The longer we drag this out, the higher the risk!”

Director Shang was never the patient type.

After a brief greeting, he urged Zhou Can to join the consultation.

Even with Director Shang and his two graduate students now involved, the patient’s exact cause of illness remained a mystery.

In the past, he’d always called Zhou Can ‘Little Zhou.’ But after not seeing him for a while, his tone had grown more formal.

“Director Shang makes a good point. After administering medication, the patient’s temperature dropped a bit, but they’re still running a fever. What worries me even more is the likely presence of a significant internal bleeding source. Right now, our top priority is figuring out exactly where the bleeding is coming from.”

Deputy Director Han was a man of action too.

These older doctors had a level of dedication to their patients and medicine that was truly admirable.

The phrase ‘a doctor’s heart is like that of a parent’ often revealed itself in the smallest details.

“After the discussion, do you both have any conclusions?”

Zhou Can asked humbly.

“We still can’t pinpoint the exact illness. However, I think the symptoms mimic upper gastrointestinal bleeding. You had Dr. Ai extract and monitor the patient’s gastric fluid—that was a smart call, which we’ve already put into action. Also, I heard that during your rectal exam, you found dark red blood on your glove. In cases of genuine upper GI bleeding, it’s rare to see dark red blood in a rectal exam.”

Director Shang had clearly familiarized himself with the previous diagnosis and treatment plans.

“There’s a test used abroad to distinguish between upper and lower GI bleeding. Clinical studies show that an elevated plasma urea concentration is a sign of GI bleeding, and the degree of elevation correlates with the amount of blood lost. By comparing the plasma urea nitrogen level to the plasma creatinine level, you can infer whether it’s upper or lower GI bleeding.”

Chief physicians really do know their stuff.

Zhou Can had read about this diagnostic method in journals too.

But he wasn’t clear on how to apply it in clinical settings.

Mainly, all those lab values were tough to remember.

Besides, the method wasn’t foolproof—about 95% accurate, but not perfect.

“If the ratio is above 100, upper GI bleeding is more likely. Below 100, and lower GI bleeding becomes more probable.”

Director Shang’s method was well worth trying.

It only took two simple lab tests to run the numbers and distinguish between upper and lower GI bleeding.

Simple, effective, and cost-efficient.

“By calculation, the probability of lower GI bleeding is much higher.”

Director Shang was impressive, no wonder he headed the Gastroenterology Department. His personal involvement in this case brought major prestige to the Emergency Department.

“For a patient like this—with lower GI bleeding and fever—we should keep inflammation and tumors high on our list. Since the onset was sudden, intestinal tuberculosis causing GI bleeding is unlikely. Inflammatory issues are most likely here.”

The two graduate students immediately whipped out their notebooks, scribbling down notes.

Back when Zhou Can learned from Director Shang, he often jotted things down in his own notebook.

“It’s been a while since you left Gastroenterology, Dr. Zhou. Do you still remember the key points of intestinal inflammation?” Director Shang, for reasons unknown, seemed to want to test Zhou Can.

“Honestly, I always found your old nickname for me, ‘Little Zhou,’ kind of endearing.”

Zhou Can also understood that Director Shang never really saw him as just a student.

When he was in Gastroenterology, Director Shang gave him tons of guidance and opportunities.

It was Director Shang who sent Zhou Can and Deputy Director Shi to participate in consultations at Xinxiang Maternity and Child Hospital. That chance got Zhou Can selected for Tuyu’s reserve team of top doctors.

“Haha, not a problem! I was just worried that, since your status has changed, calling you ‘Little Zhou’ might put you in an awkward spot!’ Director Shang laughed.

“In your eyes, I’ll always be that ‘Little Zhou.'”

That one line from Zhou Can made Director Shang beam with pride.

Every doctor appreciated loyalty and gratitude. Director Shang had put a lot of effort into mentoring Zhou Can over the years.

Even after three years, Zhou Can still admired and felt deeply grateful to him, which made Director Shang feel truly gratified.

“I still remember a lot of the things you taught me. Inflammatory bowel diseases can be divided into specific and non-specific types. Inflammatory bowel disease generally refers to the non-specific chronic conditions like ulcerative colitis and Crohn’s disease. They usually show up as abdominal pain, diarrhea, and weight loss.”

Zhou Can had long since mastered these knowledge points.

“Excellent!”

Director Shang nodded repeatedly in satisfaction.

“Based on the patient’s history, symptoms, and labs, we can rule out bacillary and amoebic dysentery. I suggest testing the Widal reaction. Right now, it’s about the fifth week of illness—perfect timing for it.”

“Are you thinking it might be intestinal typhoid fever, Director Shang?”

Zhou Can’s eyes lit up.

The chief physician’s thought process was on another level.

Compared to Director Shang, Zhou Can could clearly sense the gap between them.

Right now, his skills in pathology diagnosis were at the associate chief physician level. To reach the chief level, he still needed more time.

Especially since he’d been spending more time preparing for his medical exams, reducing his clinic hours, and slowing the pace of gaining hands-on diagnostic experience.

Luckily, Cardiothoracic Surgery had seen a surge in cases lately, with lots of complex patients, giving him the chance to rack up valuable pathology experience.

Zhou Can did suspect the patient might have malignant histiocytosis of the intestines—he’d at least started to grasp the fringes of it.

He even considered ordering a bone marrow test.

If it is intestinal typhoid, a bone marrow culture should reveal it.

As for blood culture, now that the illness was already four weeks along and the bacteremia peak had passed, it would likely come back negative.

“At this stage, typhoid is still just a preliminary suspicion. With these tricky digestive diseases that have long, unclear courses, you’re left with only about a dozen rare, hard-to-treat options once you rule out malignancies. Things like Crohn’s or ulcerative colitis. Most cases develop slowly and may come with bowel obstruction or abdominal masses. This patient clearly doesn’t match in several ways.”

“Acute onset does occur in ulcerative colitis too, and some severe cases cause high fevers and bloody stools. That matches up with this patient. But since he’s only just been admitted, even if we want to do an emergency colonoscopy, his gut needs to be prepped—including clearing out all the retained blood—or the exam won’t be reliable.” Director Shang was being extremely careful with his diagnosis.

From his reasoning, it was already clear the patient most likely had intestinal typhoid, possibly combined with lower GI bleeding.

This wasn’t Zhou Can’s first time witnessing diagnostic thinking at the chief level, and he greatly admired such skill.

Over the next two days, they ordered additional tests for the patient.

This included monitoring the gastric fluid.

The patient’s temperature stayed between 37.7 and 38.9 degrees—a persistent fever that just wouldn’t break.

On the first day, the gastric fluid was pale yellow and cloudy, with a few streaks of old blood.

By the second day, the fluid had turned clear.

At this point, major upper GI bleeding was all but ruled out.

Yesterday, the patient’s stool was still black, indicating the bleeding continued.

With no upper GI bleeding but ongoing dark stools, the most likely culprit was continuing bleeding from the lower GI tract.

After passing black stool, the patient had two more episodes of dark red bloody stool this morning.

That matched what Zhou Can found in his initial rectal exam.

Back then, he’d already noticed dark red blood on his glove.

As expected, the blood culture result came back negative.

Testing for bacteria after the bacteremia peak always gave results like that.

The bone marrow routine also came back—no abnormal immature cells or histiocytes found, but this was only the standard result. The diagnosis still depended on the bone marrow culture.

By this morning, the patient’s blood pressure had plummeted to 60/42 mmHg. His pulse was thready and the heart rate hovered around 120 beats per minute.

That was a terrible sign.

It meant the bleeding still hadn’t been controlled. The patient was still losing blood.

If they didn’t identify and stop the source immediately, saving him might be impossible.

Coincidentally, today was Zhou Can’s shift in the Emergency Department. After the patient went into shock again, the staff in the resuscitation room, worried things would go south, called for Zhou Can.

As soon as Zhou Can arrived, he performed a peripheral vein catheterization and checked central venous pressure—just 0.78 kPa.

He hadn’t expected the condition to deteriorate so fast.

In just two days, despite transfusing a thousand milliliters of blood and multiple treatments, the patient still went into shock, with a dangerously low blood pressure.

At this point, they still didn’t know the bleeding source or have an effective way to stop it. Using vasopressors would just make the haemorrhage worse.

Zhou Can quickly ordered the nurses and doctors to expand fluid volume and transfuse blood to fight the shock. Three bags of blood later, they’d finally raised the blood pressure again.

“Dr. Zhou, this patient is definitely still bleeding. Please, you have to think of something! Internal medicine just isn’t working. We might have to use surgery to stop the bleeding.”

Dr. Ai Li looked exhausted after worrying about the patient for days.

She’d poured her heart and soul into this case.

No doctor liked dealing with nightmare patients, especially tough cases of GI bleeding. As an ordinary attending physician, she was out of her depth.

Seeing the patient go into shock again, she was so anxious, she couldn’t help but stamp her feet—even at fifty years old.

“Don’t panic, we’ve basically narrowed it down to lower GI bleeding. The color of the stool looks like blood from the ileocolon. The thing is, the patient’s condition won’t permit a barium enema or colonoscopy, and even exploratory surgery would need the bleeding site pinpointed to be effective.” Zhou Can had plenty of experience handling difficult cases like this.

“But if we can’t do any exams, and we don’t know where they’re bleeding from while it just keeps getting worse, what are we supposed to do?” Dr. Ai Li looked desperate.

Most ordinary doctors just couldn’t handle this kind of patient.

“Abdominal arteriography might be our best bet. Interventional radiology does have some risks, but for mysterious GI bleeding, it’s excellent for locating the source. Sometimes you have to take some risks to save a life. But timing is critical; we have to do it while the patient’s actively bleeding.”

Zhou Can proposed a solid solution.

The timing of abdominal arteriography was crucial.

If they did it while the bleeding paused, the site might not show up.

Here’s where Zhou Can’s Level 6 Hemostasis skill could shine.

Just by looking at the patient’s skin, complexion, face, and state, he could generally tell if the bleeding was active.

Plus, with two recent bouts of liquid bloody stool, there was no doubt major bleeding was underway.

Opportunities like this didn’t come twice.

Without hesitation, Zhou Can told Dr. Ai Li to report to Deputy Director Han and arrange an emergency selective abdominal arteriography.

The doctors in the intervention room took one look at the patient’s state and, worried he might die right there during the procedure, insisted Zhou Can be present.

Zhou Can had built quite a reputation—lots of doctors at Tuyu Hospital knew he was skilled at both endoscopic and interventional procedures.

He often got called to lend a hand.

This time, the invitation was less about help and more about sharing responsibility if things went wrong.

Zhou Can didn’t call them out on it. He just went along.

After all, he was the one who suggested this test in the first place.

At the end of the day, someone had to shoulder responsibility for saving the patient.

Of course, the patient’s family had to sign all the paperwork first.

Zhou Can was always ready to fight for his patients, but he wasn’t about to shoulder all the risk himself.

If the family wanted the doctors to take all the risks while refusing responsibility, that was never going to fly. Zhou Can was no martyr—when he needed to be tough, he was tough.

Luckily, the patient’s parents were reasonable and signed everything quickly.

In the intervention room, Zhou Can suited up in heavy lead aprons and carefully threaded the angiography catheter into the femoral artery, then into the abdominal aorta, and onward to major branches like the celiac trunk, superior mesenteric artery, and inferior mesenteric artery.

He was hyper-focused throughout the entire procedure.

Fluoroscopy showed no abnormalities in the branches of the celiac trunk or inferior mesenteric artery.

His heart sank.

Had they just picked the wrong moment for this test?

On screen, he could see the superior mesenteric artery was noticeably narrowed, and at the end of its branch to the ileocolon, he spotted contrast leaking out.

A surge of excitement hit Zhou Can.

At last, he’d found the bleeding source.

“There! Right there!”

Zhou Can signaled the team to confirm the exact spot.

It was clear on the display: at the end of the colic artery branch, a concentrated ball of contrast had pooled up.

Once the site was identified, 20 units of vasopressin were slowly injected through the catheter, then it was removed.

So it was active bleeding of the ileocolic artery—no wonder it was so severe.

Almost any significant arterial bleed was terrifying.

And they almost never stopped on their own.

Now he finally understood why even using two hemostatic medications together hadn’t worked.

“This patient needs surgical hemostasis immediately. Let’s move him back first. I’ll consult Dr. Xu and see if we can do this surgery in the ER right away.”

Zhou Can already had a surgical plan taking shape in his mind.

But he still needed to discuss things with Dr. Xu first.

After all, Zhou Can would operate, but Dr. Xu bore the main legal responsibility.

After talking it out, Dr. Xu watched the angiography replay and agreed to handle the surgery.

For Zhou Can, this was a fantastic learning opportunity.

Jiangbian Yuweng reminds you: Don’t forget to bookmark after reading.