Chapter 490: A Night in the Emergency Room

Usually, if you’re over forty-five and still haven’t made deputy chief physician, it’s because you’ve hit a wall with your academic work. Nine out of ten times, that’s the reason.

These days, with credentials mattering more than ever, even nurses need a bachelor’s degree just to get started.

The top nurses? Most of them have a master’s under their belt.

Even now, a lot of people look down on nurses, thinking all they do is give shots, change bandages and look after patients. That’s because they’re stuck with old stereotypes from when nurses mostly graduated from technical schools.

But so what?

Driven nurses already leveled up with further study, earned graduate degrees and stand out above the rest. Those who weren’t motivated have retired or switched careers by now.

These days, at major hospitals, the quality of nurses is top-notch.

Dr. Ai Li is something of an outlier at Tuyu Hospital.

The hospital always planned to build a comprehensive department, but it’s never really gotten off the ground.

Because of that, there are very few general practitioners at Tuyu Hospital.

Only two generalists in the whole Emergency Department have made it to attending physician or above: Dr. Ai Li and Director Lou.

Director Lou is already a deputy chief and runs the Emergency Department. Compared to Ai Li, you could call him a total success.

Rumor has it, Director Lou faced the same awkward situation as Ai Li back in the day.

Trying to do too much, you end up mastering nothing!

Being a generalist sounds impressive, but in practice, it just means knowing a little about everything.

Really, just a little.

Reaching peak medical skill that way is nearly impossible.

Director Lou realized that traveling the generalist path, he’d never make deputy chief in his lifetime. He got bumped from one of the key departments and ended up in Emergency, and he wasn’t in great shape to begin with.

He was much sharper and more forward-thinking than Ai Li, though.

After eleven years on the job, he went back and got his master’s. Then, to get that coveted promotion, he specialized in pulmonary medicine—the one field where it’s easier to stand out.

Emergency work means dealing with severe and urgent cases, so ensuring patients can breathe is absolutely essential.

So specializing in pulmonary medicine fits his work perfectly.

The rest is history. He made deputy chief, then the department head position opened up and he shot to the top like a dark horse.

Back then, there were two serious contenders for Emergency Department head: Deputy Director Han and another now-retired deputy.

No one expected Lou, the plain-looking underdog, to swoop in and steal the prize.

After Lou became department head, that Deputy He fell ill not long after. Probably from sheer frustration.

Deputy Director Han held on longer, but he was definitely hostile toward Lou.

How Lou managed to turn that enmity into a close partnership is anyone’s guess.

Lou isn’t much to look at, but he’s ruthless and sharp, with vision and big ambitions. Having him lead the Emergency Department has actually been a blessing.

If Han Changqing had gotten the job, the department wouldn’t be anywhere near what it is today.

Sometimes, fate really does hinge on a single choice.

Ai Li just didn’t have Lou’s guts or foresight. She made it to fifty and still hasn’t moved past attending physician.

Most likely, she’ll retire at fifty-five at her current level.

When it comes to clinical experience, though, Dr. Ai Li has plenty.

So what kind of patient could have her stumped?

Zhou Can hurried after the nurse toward the emergency hall.

From across the room, he could see a woman breaking down in tears at the patient’s bedside, while the rest of the family stood nearby, all anxious and grieving.

Dr. Ai Li was busy running a series of checks on the patient.

They clearly hadn’t figured out what caused the shock, so no one’s taken any major emergency measures yet.

In the ER, you can break down a patient’s decline into three stages: serious illness, shock and death.

Severe, shock, then death.

Most doctors panic when a patient goes into shock, but for someone like Dr. Ai Li, this is just routine. Sometimes she sees multiple cases like this in a single shift.

Tuyu’s ER volume is staggering—even if only one percent of patients go into shock, there are still plenty every day.

“Dr. Ai, what’s going on with this patient?”

Zhou Can squeezed past the family crowded around the mobile emergency bed. As he greeted Dr. Ai Li, his eyes were already scanning the patient.

“According to the family, the patient had black stools for nearly a month. This morning, while having breakfast, his nose suddenly started bleeding. Then he became confused and collapsed. They worried that an ambulance would take too long, so they drove him straight here themselves.”

Dr. Ai Li gave a quick rundown of the patient’s history.

Black stool means a gastrointestinal bleed.

A nosebleed at breakfast—could it be an upper GI bleed?

Zhou Can quietly checked the patient’s appearance. His face and lips were ghostly pale. Not much color, though he was still conscious, grimacing in pain. No rashes or bruises on the neck or arms. The sclera weren’t yellow.

He felt for swollen lymph nodes in the neck—none.

Thyroid seemed normal too.

He pressed on the chest—no pain.

“Patient’s temperature is 36.7°C, pulse 100 per minute, respiration 21 per minute, blood pressure 90 over 70.”

Dr. Ai Li finished checking vitals and reported them to Zhou Can.

Being older doesn’t automatically make you better at medicine.

Now that Zhou Can was here, Dr. Ai Li clearly looked to him as the lead.

“His blood pressure is definitely low. Do we have labs yet? Once we know his blood type, the blood bank needs to get plasma ready. I’m sure we’ll need a transfusion and fluids,” Zhou Can said, still giving the patient a physical.

A doctor’s skill often shows in the details.

Some just run through a physical like they’re checking boxes.

But skilled doctors assess everything—skin color, alertness, build, chest percussion, the works—to make a real diagnosis.

Normal blood pressure’s around 120 over 80.

This patient’s systolic is down to 90. That’s dangerous.

With the blood test, Zhou Can could probably estimate the blood loss from the hemoglobin alone.

Right now, the top priority is finding the source of the bleed and stopping it.

If you can’t stop the bleeding, transfusions won’t do any good.

“Blood’s already sent off for tests!”

Dr. Ai Li was steady—much calmer than the younger Dr. Xie in these situations.

Zhou Can nodded and started pressing on the patient’s abdomen.

If there’s a GI bleed, the abdomen is what you have to check.

Most of the intestines and the stomach are in the abdominal cavity, after all.

The patient’s abdomen was soft. No reaction when pressed.

No obvious masses on palpation.

Bowel sounds were there and pretty active.

But when Zhou Can pressed below the xiphoid process, the patient let out a grunt of pain.

“Mr. Lou, hand me a disposable glove for a rectal exam.”

At the same time, Zhou Can took the patient’s hands and gave them a careful once-over.

“Dr. Zhou, what are you checking for on his hands?” The young woman beside Dr. Ai Li—she looked about twenty-three or four—asked him boldly.

She was a new intern in the Emergency Department.

Since interns rotate departments so much, Zhou Can rarely bothered to remember their names.

But this one was gutsy, asking questions at a time like this.

“Mainly I’m looking for palmar erythema, spider nevi, and clubbing. Also redness or swelling around the finger and wrist joints. If you’re not sure about the significance of these, read up after work and memorize them well, because there’s no time to check the books in emergencies.”

Zhou Can’s tone was gentle as he gave a quick explanation about why he checked the patient’s hands.

There was no time for detailed teaching with such a critical patient waiting.

Some things, rookie doctors just have to study and memorize.

There’s so much to learn in medical school. The more you cram in while young, the better you’ll remember it. Once you start practicing, it sinks in through experience.

A nurse handed Zhou Can a thin glove for the rectal exam.

He pulled it on, pulled down the patient’s pants and started the exam right there.

If the patient was a woman, they might’ve considered privacy and found a private spot. But male patients rarely get that kind of treatment.

When it’s life and death, propriety goes out the window.

Doctors only do what they must to save a life.

On exam, Zhou Can found the sphincter tense. No signs of hemorrhoids. The glove came away with a little dark red blood.

So, rectal bleeding can mostly be ruled out.

If it was, the blood would be bright red.

“Dr. Ai, should we get an urgent chest X-ray and abdominal ultrasound?”

“Great idea!”

In front of the family, Dr. Ai Li always worked in perfect sync with Zhou Can.

“I’m guessing the bleed’s in the upper digestive tract. Let’s clear the chest and abdomen first—then consider an emergency gastroscopy. Even though he’s nearly in shock, his signs point to the bleeding slowing down. If plasma’s ready, we should be safe enough.”

Zhou Can never gives any guarantees.

His Hemostasis skill was now at level six, which made diagnosing patients like this much easier.

By reading all the patient’s signs, he could get a real sense of how much bleeding was happening inside.

All those checks he’d just done were to roughly identify the bleeding’s location and severity. Not a precise measurement, but close enough.

The patient was soon wheeled off for tests.

The intern who spoke up earlier went along.

When someone’s in shock, you don’t have them wait their turn—you skip the line. Critical patients get top priority for every test and procedure.

That’s what the Emergency Department is for: saving lives.

Dr. Ai Li pulled Zhou Can aside and whispered, “Dr. Zhou, I’m really out of my depth here. Once the patient is stable, you can go to the OR, okay?”

She knew that once Zhou Can went to surgery, he might not return until after noon.

Sometimes, if things got busy, he might spend the entire day in the OR.

“Alright.”

Zhou Can nodded and agreed without hesitation.

When a senior asks, it’s not the time to refuse.

The bloodwork came back quickly.

Hemoglobin was only 56 g/L. White count 7.3 × 10^9/L. Neutrophils 0.87, lymphocytes 0.15, platelets 132 × 10^9/L.

Stool occult blood test: positive with triple plus. White cells: positive. No ova, amoebic trophozoites or similar findings.

Urine test: negative.

Looks like the bleeding’s pretty severe—his hemoglobin’s really low.

But, since he’s had black stools for over a month, maybe this latest bleed wasn’t as big as it seems.

How to put it?

This latest bleed was like the straw that broke the camel’s back.

Keep losing blood steadily like that, and even the healthiest body can’t keep up.

“Doctor, is my son going to be alright?”

The patient’s mother, in her forties, was still crying—her face full of fear and anxiety.

This time it was the patient’s father asking.

Their clothes and style were about what you’d expect from local city residents.

Probably not rich, but not desperately poor either.

“Frankly, he’s already lost quite a lot of blood. Why did you wait so long to bring him in? It’s been over a month—you’ve got some nerve.”

There was a hint of rebuke in Zhou Can’s voice.

But he almost never scolded family members directly.

“He never told us anything! Once these kids grow up, they barely talk to us anymore. Since winter break started, he just hides in his room playing games or out with friends.”

The father shook his head and sighed.

At twenty, he could have been using his break to earn some cash and help out. Instead,

the lazy ones spend day after day glued to games with their friends.

Maybe the patient noticed something was wrong but couldn’t be bothered to share.

A lot of people don’t even look at their stool’s color—just flush and move on.

And even if they spot black stools, unless they know medicine, they probably dismiss it.

“Of course you’re blaming me! You’re always yelling at him—how can he talk to us about anything? Even now, when he’s in this state, you’re still scolding him…”

The mother broke down, sobbing.

That put an end to the father’s complaints.

Soon, the chest X-ray result came back.

Nothing besides the ordinary.

Meaning the heart and lungs—those crucial organs—are at least functioning.

Next was the abdominal ultrasound.

It showed a slightly enlarged spleen, but the liver, gallbladder and pancreas looked fine.

Just like Zhou Can suspected—the bleeding’s probably in the upper GI tract.

With his Hemostasis skill at level six, he really could assist with diagnoses like this.

As he gains more clinical experience, he’ll be able to diagnose as well as the top experts.

With a glance at the patient and a quick review of the history, he can already get pretty close to the truth.

He used to think surgical skills only applied in the OR, but now at chief level, he’s delighted to find they work in diagnosis too—when combined with pathology.

He couldn’t help but marvel: this Medical Experience System is incredible.

Without it, he’d never rise so quickly.

And there’s no way the chief physicians would recognize his talents like this.

“Let’s do an emergency gastroscopy. The bleed’s definitely in the upper GI tract.”

Zhou Can said to Dr. Ai.