Chapter 121: Intense Training in the OR

I still wonder how yesterday’s patient was managed?

In the end, the patient wasn’t even moved back to the original bed. My gut tells me the situation was more serious than it appeared.

“Today, three of you were actually scheduled to assist in another operating room. There are two important surgeries there that require teaching, so I’ll be instructing you all day. My surname is Shan. I can independently lead Level 1 and 2 orthopedic surgeries, have assisted in multiple Level 3 operations, and even handled the most complex parts.”

Successful doctors seem to share one common trait.

They’re all great at boasting.

These days, you simply can’t avoid it. Patients only trust you if they hear you’re skilled and have handled numerous complex surgeries, so they feel safe letting you operate.

“My principle is merit above all. The capable rise while the mediocre sink. If you prove yourself and seize every chance to practice, I’ll give you top marks. Let me be clear: only those with sufficient skill can operate on patients. If you perform terribly, I won’t give you another chance.”

Dr. Shan began by explaining the competitive rules to the six of them.

It all sounded fair and square.

“Now, everyone, take a look at the X-ray of our first surgical patient of the day. I’ll give you five minutes to study it, and then I want your diagnostic opinions and treatment plans. Learning to read these images is the first step in your training. Feel free to answer out of turn.”

The moment her words faded, her assistant activated the light projector.

A light screen appeared on the wall.

It displayed four X-ray images.

They clearly showed the patient’s right foot bones.

Taken from various angles.

The patient’s big toe phalanx was noticeably deformed.

Zhou Can marveled at the state-of-the-art facilities in the Orthopedics suite while carefully scrutinizing the foot X-rays.

The severe inward twist of the big toe phalanx seemed either congenital or due to some unusual secondary cause.

There were no signs of fracture healing lines.

It could almost certainly be identified as a congenital deformity.

Thus, the treatment likely wasn’t to be performed here.

Zhou Can continued his careful inspection.

By then, someone had already started to answer.

“These four X-rays are of the patient’s right foot. You can clearly see a severe deformity in the big toe phalanx, which would affect the patient’s ability to walk. I believe surgery is needed to correct it.”

The person answering wore an expression of sheer excitement.

They thought they’d clinched the top spot.

However, after speaking, Dr. Shan showed no reaction.

Yesterday, Zhou Can received extensive guidance from Dr. He, and his ability to read X-rays had improved considerably.

He noticed a slight fracture at the junction of the first metatarsal and the navicular bone on the patient’s right foot.

“It appears to be…”

“I think…”

Zhou Can and another trainee began speaking almost simultaneously.

In the end, Zhou Can graciously motioned, “You go ahead first!” The other trainee, not one to hold back, agreed.

After all, the next three months of orthopedic training—and even staying in the OR—depended on it.

This would greatly affect their future careers.

“I believe it’s a mild fracture of the first metatarsal. No surgery is needed—just a plaster cast and about 42 days of rest.”

If the fracture isn’t severe, it can heal on its own.

The younger you are, the faster it heals.

Children’s bones heal the quickest and are most stable afterwards, while the elderly heal very slowly.

Judging by the images, this was an adult’s foot.

A 42-day plaster treatment sounded very reasonable.

“Zhou Can, you may speak now.”

Dr. Shan had actually remembered his name.

And she treated him fairly without any suppression.

This came as a slight surprise to Zhou Can.

Many women tend to be petty; despite offending her yesterday, she didn’t hold a grudge.

“The previous suggestion and his opinion are identical, including the treatment plan. However, allow me to add that the big toe phalanx deformity is congenital. Since the patient is an adult, their willingness for corrective surgery would be low. Moreover, the patient has likely adapted to the deformity while walking. I do not recommend surgical correction.”

Zhou Can’s suggestion was clearly more comprehensive than his counterpart’s.

It was not only more thorough but also more considerate of the patient’s perspective.

“Alright, both of your answers are correct. Zhou Can’s response is more complete and considerate; that’s commendable.”

Dr. Shan clearly didn’t wish to lavish praise on him.

But his performance was outstanding—she couldn’t help but praise him.

“Who here can apply a plaster cast to this patient?”

“I can!”

“I can!”

All six of them could.

Plastering is simple and easy to learn. Even if one hadn’t mastered it before joining Orthopedics, spending a day in the Orthopedics ward yesterday would have taught them the basics.

However, with only one day, they only learned the most basic technique.

They can only perform simple operations.

“You were the first to answer correctly, so you get to operate. Dr. He, please accompany him and ensure everything goes smoothly.”

Dr. Shan addressed one of her assistant doctors.

This Dr. He was known to Zhou Can.

He was the same doctor who, yesterday in the office, taught all eighteen of them how to fill in the registration forms.

“Now, let’s review the data of our second patient!”

No sooner had Dr. Shan finished speaking than the trainee assigned to plastering had his smile freeze.

He knew that while he was out plastering the patient, he’d surely lose many opportunities.

Sure enough, as Dr. Shan said, every opportunity is equal.

A new light screen displayed two new images.

This time, they weren’t X-rays but an ultrasound scan.

Judging by the appearance, it seemed to be of the knee.

Reviewing the ultrasound images, Zhou Can recalled the intensive training he received in the Emergency Department under the tutelage of experts like Dr. Xu.

Clearly, as a protégé of such a skilled physician, he wasn’t lacking in talent.

He immediately identified the issue.

“The patient appears to have significant effusion in the right knee joint. I recommend aspirating the fluid, followed by an injection of medication. Hyaluronic acid, such as sodium hyaluronate, should be our first choice.”

At that moment, Zhou Can finally understood what true preparation leading to breakthrough looked like.

His practical experience in the Emergency Department, combined with the medical knowledge he’d studied, gave him an edge over the other trainees.

The other four trainees were left dumbfounded.

“Damn! Is this really a trainee?

How is it that his image-reading ability seems superior even to that of an attending physician?”

This group was truly unfortunate to have such a ‘phenom’ among them.

In today’s competitive OR selection, it was almost certain they’d be crushed by Zhou Can.

“Correct.”

When Dr. Shan looked at Zhou Can, the surprise in her eyes couldn’t be hidden even by her dark-framed glasses.

This Emergency Department trainee truly lived up to his reputation.

She now somewhat understood why Chief Resident Shen had reacted so when he heard Zhou Can’s name.

Chief Resident Shen obviously knew Zhou Can’s capabilities.

“This patient’s treatment is a bit special; it requires intraosseous puncture—a procedure so challenging that even I must be extremely cautious when performing it. Just watch and learn the steps carefully.”

The patient was quickly wheeled into the room.

An elderly lady with white hair whose left knee was swollen nearly to the size of a thigh.

Her appearance was quite frightening.

She cried out in pain continuously as she was pushed in.

Such joint pain is incredibly tormenting.

It doesn’t kill instantly but, like a dull knife slowly cutting through flesh, it gradually wears down one’s will.

“Grandma, we’re about to treat you. Please sit still and maintain this position.”

For knee joint puncture, it’s best for the patient to sit, as it makes selecting the puncture site easier.

This position facilitates choosing the correct puncture point.

“Now, look here. We select the puncture site at this location.”

Dr. Shan drew the puncture point with a pen.

“This isn’t the only possible puncture site. Depending on the patient’s condition, you might choose the medial or lateral side just below the patella. If puncturing laterally, this is the point you’d use.”

She explained every detail meticulously.

The First Assistant, who looked about twenty-eight or nine years old and appeared to be an intern, had clearly mastered knee joint puncture long ago. He simply watched from a distance.

He didn’t come close.

“Once you locate the puncture site, insert a 5ml syringe into the joint cavity until you feel a breakthrough. Yes, only when you feel that breakthrough can you be sure the puncture is successful.”

Her expression momentarily stiffened as the syringe encountered resistance during the puncture.

“Ouch… miss, go easy…”

The patient cried out in agony.

Dr. Shan couldn’t help but flush with embarrassment.

Why did misfortune have to strike now—right in the middle of her training session?

Was it on purpose to make her look bad?

The intern seemed to notice Dr. Shan’s predicament and rushed forward to help.

“Dr. Shan, we men are stronger. Let me give it a try!”

He said this clearly to save her face and help her out.

He stepped in to defuse the situation.

“Knee joint puncture isn’t easily done—it’s a Level 2 procedure. Be careful and don’t rush it.”

She was very grateful for the intern’s intervention.

Taking advantage of the moment, she stepped back.

The intern took the syringe, replaced the needle, and attempted the puncture anew.

“Hmm…”

His veins stood out as he exerted considerable force. The elderly lady screamed in pain, her tone shifting with every jab.

“It hurts, it hurts…”

She patted the armrest of her wheelchair repeatedly.

It must have really hurt.

If the needle misses the joint and hits the periosteum, the pain is excruciating—a pain that sears to the bone, unbearable by anyone.

“Dr. Tang, you take a break. Let me handle this!”

Dr. Shan couldn’t bear to let the intern continue.

She glanced at the patient’s images and, with a slight flush of embarrassment, said, “The severity of the joint degeneration has drastically increased the difficulty of the puncture. But don’t worry, switching to a lateral puncture under the patella will work just as well.”

Replacing the needle, she soothed the patient while identifying the proper puncture site on the lateral side and executed the puncture.

“Ugh…”

Judging by her expression, she was silently cursing the stubborn blockage.

Zhou Can stood by, watching intently.

He had also reviewed the patient’s images; however, the ultrasound couldn’t clearly display the knee’s bony structure.

As Dr. Shan mentioned, the patient’s severe joint degeneration had rendered the usual puncture site ineffective.

After two more attempts, her face turned red and sweat began to drip.

During a teaching session, one mistake was enough to embarrass her.

Who would have thought that even switching to a lateral approach would fail?

This was only the initial puncture.

It was mortifying.

“Dr. Shan, I’ve practiced puncture techniques as well. How about letting me try?”

Zhou Can’s injection technique was rated at Level 4—an above-average level among attending physicians.

He used to think that injection techniques were hardly useful.

Now he understood their value.

Beyond just injections, they’re essential for punctures.

Lumbar punctures, thoracic punctures, spinal taps… any procedure that involves puncturing is a skill every OR trainee must master.

Back in school, teachers used to inspire students by saying if you master the physical techniques, you can conquer the world.

Now, Zhou Can wanted every doctor to know: perfect your injection technique and every puncture will be just a single, precise shot.

Those who require two, three, or even more attempts clearly haven’t mastered the art.

At this point, Dr. Shan was at a loss for how to gracefully step down.

Having already failed several times, forcing another puncture might succeed—but it would more likely end in further failure and greater embarrassment.

She considered calling someone over for help.

Zhou Can volunteered. Even though she wasn’t very hopeful, having someone to back her up was always a good thing.

Otherwise, if the first patient’s surgery ruined her reputation, how could she possibly teach these trainees afterwards?

They wouldn’t dare laugh in her presence, and worse, they might gossip behind her back.

“Operate carefully. When I call a stop, you must immediately cease.”

She reminded him with a hint of anxiety.

“Alright!”

Zhou Can took the syringe, replaced the needle with a new one.

It must be noted that if a needle fails to puncture successfully, it’s best to use a new one.

This is primarily to prevent bacteria from contaminating the previously sterile joint cavity. An infection here would have severe consequences.

A needle isn’t expensive, anyway—it’s just part of the consumables.

Zhou Can gently palpated the patient’s joint area before confidently inserting the needle.

“Swish!”

The needle first encountered resistance in the dermis, then swiftly broke through.

In one smooth motion, the puncture was a success.

“Did it work? Was that a successful puncture?”

The room fell silent—trainees, nurses, and even Dr. Tang held their breath, waiting for the outcome.

Dr. Shan’s eyes widened until she confirmed that the needle had indeed penetrated deeply into the skin. With effortless ease, Zhou Can had completed the knee joint puncture.

“Incredible!”

Someone quietly marveled.

The other trainees felt hopeless—how could they possibly compete against such a prodigy?

At least there were six available spots in the OR.

They secretly hoped that among the eighteen trainees, only Zhou Can turned out to be this exceptional.

“Hold still; let me check!”

Dr. Shan crouched down and, after a meticulous inspection, her expression shifted to one of disbelief.

Remarkably, the needle was perfectly in place—it was indeed a successful puncture.

“Well done. Once the needle is in the knee joint, we must first aspirate the joint fluid.”

She demonstrated the procedure herself.

“After aspiration, inject about 10ml of 0.25% lidocaine.”

Injecting the anesthetic helps facilitate the subsequent treatment.

“This solution also contains about 5mg of triamcinolone, aimed at targeting the patient’s pain points. Then, help the patient move the knee joint to fully activate the medication.”

Dr. Shan closely observed the patient’s reaction.

Once the medication took effect, the patient ceased wincing in pain.

“Grandma, you’ll need five treatment sessions. Come back in a week for your second session.”

She reassured the elderly lady.

Now that the pain in her knee had subsided, the patient appeared genuinely pleased.

“Thank you, thank you so much!”

The elderly lady repeatedly expressed her gratitude to Dr. Shan and Zhou Can.

Even at her age, she could clearly tell who had cured her.

“Miss, my memory isn’t what it used to be. Please remind my son later, will you?”

“Alright! We’ll be sure to tell him later!”

After her treatment, the patient was wheeled out of the OR.

Dr. Shan glanced at Zhou Can, then her gaze swept over the other trainees.

“This treatment is typically administered over five sessions. The first two involve injecting the earlier-mentioned solution; from the third session onward, we use sodium hyaluronate, as Dr. Zhou Can recommended. The main challenge lies in the joint puncture—so I want you to observe, contemplate, and practice as much as possible.”

Recalling the earlier puncture mishap, she still felt a tinge of embarrassment.

Even now, she couldn’t understand why her punctures kept failing.

Such issues rarely happened.

She’d be too embarrassed to directly ask Zhou Can about it.

But nothing could stump a clever woman like her.

“Dr. Zhou, please share your experience on achieving that successful puncture.”

“Alright!”

Zhou Can gave Dr. Shan a knowing look.

He was well aware of her little ploy and inwardly admired her skill in handling the situation.

Chief Resident Shen’s praise yesterday for her leadership and teaching style certainly had its effect.

“My success in puncturing was largely due to luck. Additionally, as Dr. Shan mentioned, the patient’s joint degeneration altered the bone structure considerably. I felt along the joint and discovered the cavity was indeed narrowed. Therefore, I deliberately chose a point slightly above the midline on the medial side.”

Zhou Can then rolled up his pant legs to demonstrate.

Dr. Shan immediately understood.

So that explained why previous attempts on patients with severe joint degeneration were failing.

Each patient’s joint deformation is unique.

This elderly lady’s condition was one of the rarer variants.

Zhou Can modestly credited his success to luck, yet she knew it was a subtle nod to her earlier guidance.

Her respect for Zhou Can grew noticeably.

“Excellent! Thank you, Dr. Zhou, for sharing your insights. Now, let’s review the third patient’s exam report.”

The screen now displayed two images—the patient had undergone both an MRI of the hand’s bony structure and an X-ray.

Generally, MRIs aren’t cheap and any ethical doctor would only order one when the diagnosis is uncertain or further investigation is necessary.

The decision is always made in consultation with the patient.

The report showed that for at least four to five minutes no one had volunteered an answer.

This patient’s condition was extremely complex.

After two rounds of competing answers, everyone understood that it wasn’t about answering quickly—it was about answering correctly.

“Is there no one who can interpret these findings?”

Dr. Shan seemed genuinely pleased.

Finally, she had the chance to reestablish her authority and lead the operation.

Since the trainees couldn’t decipher the images on their own, her explanation would further underscore her expertise.

After that recent puncture mishap, she was eager to restore her reputation.

“I only noticed that the patient’s extensor tendon for the index finger is ruptured, and it appears the joint might also be affected by rheumatoid arthritis?”

Zhou Can felt uncertain.

This involved knowledge from Internal Medicine, making it quite challenging for a trainee like him.

“I also suspect that the rupture is due to rheumatoid arthritis.”

Another trainee echoed Zhou Can’s opinion.

He too seemed as uncertain as Zhou Can.

Rheumatoid arthritis in the hand is extremely damaging—it can easily lead to rupture of the extensor tendon.

Many patients, even without heavy lifting or sudden movements, might just hear a ‘rip’ sound as if cloth were tearing.

Then they experience excruciating pain in the hand and lose their grip.

That pain is akin to taking a giant misstep and tearing something, a continuous, unbearable agony.

In such cases, it is usually a tendon rupture.