"I just said it was weird." After hearing Zhou Cheng's advice, Ningling suddenly realized that some of the mysteries he had considered before suddenly became clear.
Although Ningling understood it, others did not fully understand.
Among them, Chen Xuehua and Xue Guoqing are the two who performed quite outstandingly.
Chen Xuehua and Xue Guoqing, however, did not show any obvious expression because of their dignity. Li Neng squinted his eyes and thought for a while before asking: "Professor Ning, how can we explain this?"
Li Neng simplified the problem and stated exactly how to explain the patient's symptoms.
Ningling pointed at the physical examination section on the medical record in front of Zhou Cheng and said, "Professor Li, I personally did the physical examination of this patient. When I did the physical examination, I actually pointed to it, not the central nervous system."
Neural inhibition.”
"If the central nervous system actively suppresses it, then the muscle tension, that is, the muscle tension controlled by peripheral nerves, will increase."
"And if it is a natural blockade of peripheral nerves, then the muscle tension will relax! Professor Li, this is the characteristic of paralysis. Spastic paralysis or flaccid paralysis!"
In spastic paralysis, because the cortical motor area and descending pyramidal tracts control muscle groups more intensively, the lesion often leads to paralysis of the entire limb. Paralysis of one limb and bilateral lesions can cause paralysis of both lower limbs or quadriplegia.
Such paralyzed limbs have increased muscle tension, hyperactive tendon reflexes, weakened or disappeared superficial reflexes, and pathological reflexes without muscle atrophy or fasciculations. However, disuse muscle atrophy can be seen after long-term paralysis. Electromyography shows normal nerve conduction velocity.
, no denervation potential.
Flaccid paralysis is caused by lesions of the anterior horn cells of the spinal cord or the motor nucleus of the brainstem and the nerve fibers they emit. It is the last common pathway for receiving various impulses from the pyramidal tract, extrapyramidal system and cerebellar system, the premenstrual root,
Peripheral nerves transmit to the motor end plates of skeletal muscles.
Fasciculations can be seen without pathological reflexes. Electromyography shows reduced nerve conduction velocity and denervation potential. Often only a certain muscle group is affected.
After Ningling gave everyone some time to react, he concluded: "We found that the patient's muscle paralysis was not paralysis of all muscles, and the electromyogram showed no reduction in nerve transmission speed or denervation potential.
"
"This kind of performance combines the characteristics of two kinds of paralysis, but does not even show one of them. It is very strange and is not in our cognitive reserve."
"Furthermore, we found no lesions in the brain or spinal canal, and no special space-occupying extrusion lesions were found in the nerve deformation segments. This can be explained clearly."
Ningling's explanation left a lot of blanks, but others with more clinical experience understood it.
This is an uncommon but typical clinical manifestation of paralysis.
Especially Chen Xuehua and others have a profound understanding.
"Professor Ning, now that the diagnosis is clear, the follow-up treatment will be arranged by Professor Ning and Professor Li. It's getting late, so I'll leave first!" Zhou Cheng did not dare to express his opinions any more.
.
According to what he has learned so far, this patient's paralysis is largely iatrogenic, which will involve the hospital where the old man underwent hemorrhoid surgery.
This is not an issue that Zhou Cheng wants to argue about. Whether or not he wants to make it clear depends on the attitudes and opinions of Ningling and Li Neng.
This problem is not difficult, and it is easy to solve, but if you can't find it, you won't be able to start.
After hearing this, Ningling looked at the time on his watch and found that it was already past four o'clock, close to five o'clock.
Then he said: "Dr. Zhou, this patient is still fasting. Now that the diagnosis is clear, surgery will be arranged today."
"How about this, Director Xue, you go and complete the preliminary surgery first, and I'll send Doctor Zhou to you first."
Li Neng also stood up after hearing this: "Professor Ning, let's send Doctor Zhou off together. Today is indeed too troublesome for Doctor Zhou."
The two professors said this, and Chen Xuehua, Xue Guoqing and others also proposed to send him off, but Zhou Cheng refused.
In the end, under Zhou Cheng's insistence, only Ningling accompanied Zhou Chengyi to the outside of the department. Li Neng and others were responsible for arranging the surgery.
This case is very special, but by finding out the key points of muscle paralysis, it can be made into a special case, which will have guiding significance for future treatment.
Although the bone was difficult to chew, after chewing it off, the improvement was huge. Therefore, Li Neng did not refuse and stayed to continue discussing the surgery plan with several other directors!
Downstairs in the inpatient building of Shashi Third People's Hospital, Zhou Cheng said: "Professor Ning, please go back first, there is still work to do."
"It's hot outside, so I'll be sweating by then."
When Ningling heard this, he smiled and said, "Xiao Zhou, you and I don't need to see each other. I don't treat you as an outsider, so I called you here. You are blaming me for wasting my life at this age."
"I'll take you to your destination. The surgery here requires some distance from nerve exploration and suturing."
Zhou Chenglian said he didn't dare, but he definitely didn't mean it.
Ningling directly put his hand on Zhou Cheng's back and walked toward the parking lot.
Then he explained: "Dr. Zhou, the truth is, the patient who called you today was the one we were planning to go on stage with. Then before the operation, there was a problem with the last indicator of the review results."
"Director Zheng of the anesthesiology department was originally worried that the patient's condition had changed and he did not want to undergo surgery, so he stopped the operation midway."
"But I felt that this patient could still expect a better quality of life after the operation, so I decided with Professor Li to invite a hospital-wide consultation."
"Of course, before the operation started, I didn't know the cause of the patient's muscle paralysis, so I just wanted to see it while doing it."
When Zhou Cheng heard this, his face was slightly embarrassed.
Ningling still insists on having surgery when there is no guarantee that he will be able to get off stage?
Isn’t this Ningling’s style?
Did the wave blow?
Zhou Cheng's face and emotions were complicated: "Professor Ning, if that's the case? Why not just refuse the surgery?"
Ningling looked at his phone and said, "Of course I have to try it."
"Dr. Zhou, although you are young, your technical and knowledge reserves are actually deeper than mine. I always try hard to do things that are beyond my own ability circle but within my ability threshold, otherwise I will not be able to grow.
"
"Unlike Dr. Zhou, you have solid basic skills and a deep foundation. You don't need to go into unknown waters to be able to do it with ease!"
Ningling's tone of voice, eyes and expressions were all full of envy, and his eyes were sincere, not like he was being deliberately sinister.
"Professor Ning is too flattering and too humble." Zhou Cheng smiled back.
When Ningling was about to speak, the car had already arrived. He originally planned to open the door for Zhou Cheng, but Zhou Cheng beat him to it.
Ninglingcai said: "Dr. Zhou, it's okay. In fact, I have wanted to chat with you, Dr. Zhou, but I have never had such an opportunity before. I just want to ask for advice."
"Don't dare, Professor Ning." Zhou Cheng replied quickly. Ningling's performance today was indeed slightly different from before. Is it because she refused to do nerve suturing with him?
Or it was simply too much pressure on him.
Ningling got into the driver's seat and said, "Xiao Zhou, you are too nervous. Where did I just talk? Oh, there is no need to try the depth of the sea."
"Actually, Dr. Zhou, you should know that we doctors are like the iceberg theory when we work. What we show is just the tip of the iceberg, but in fact, the knowledge reserve that needs to be hidden inside is huge."
"There are countless mountains above the sea. If you want to go to another mountain from where we are, you have to trek across the sea. If you have a sufficient foundation, the road you pass will be all beaches, just like taking a leisurely stroll."
"If the foundation is not enough, then if you take one step further, you will fall into the abyss of the sea! What do you think, Dr. Zhou?"
Zhou Cheng was thoughtful after hearing this.
Professor Ningling's analogy is very novel, and he naturally has deep thoughts to make such an analogy.
Clinically, seemingly common diseases actually have a lot of pitfalls, and some people still try them, and even if there is a precedent, people will still try them again.
If you don't step on it, you may pass; if you step on it, you may be subverted and obliterated.
"Professor Ning, this is the first time I have heard such a statement, but it makes sense. You need to walk on thin ice at all times in clinical practice." Zhou Cheng sighed with emotion.
Even Zhou Cheng was sometimes helpless, such as the current situation of Lu Qianzhou's wife Yue Xin. He didn't know how to intervene directly, so he had to give her a rehabilitation plan.
While driving, Ningling said cautiously: "Doctor Zhou, let's regard this iceberg that emerged by ourselves as our own circle of competence. I know these places, and I will definitely be able to walk there."
"But in other places under the iceberg, we can only proceed with caution."
"Based on the experience of some seniors, we roughly know how big the beach we hide under the water is, and whether we can make progress towards each mountain."
"This is our cognitive domain, and whether we can go through it is the threshold of our ability."
"If we can swim and the weather is good, maybe we can get over."
"But the safest thing is for us to lay the foundation of our mountain until it can become the widest circumference, and then reach directly. After all, we humans are animals that walk on two lower limbs. It is safest to walk all over the land."
"But if these fail, we can only test the depth of the sea water, take one step and explore one step!"
"Take today's case as an example. I generally know what the problem is, and I also know where not to go. It's an abyss."
"However, until I don't have a clear and accurate path forward, I don't know which direction to go, which direction to turn back, and which direction to go. Then I won't be able to turn back..."
As Ningling continued to speak, Zhou Cheng's expression continued to grow serious.
To be honest, this was the first time Zhou Cheng got serious and got to know other seniors in the same industry.
Although Ningling is only an associate professor, he is also known as professor.
Ningling really changed Zhou Cheng's view of the word professor. Not all professors are good, but at least most professors, even associate professors, have knowledge that is beyond the reach of ordinary people.
Circle of competence, cognitive domain, ability threshold, iceberg, sea surface.
These analogies not only explained to him why Ningling insisted on the operation, but also analyzed Ningling's mentality when facing cases that he could not control.
He wants to make progress and make progress.
But if you want to make progress steadily, you must make all preparations.
For example, in the cognitive domain, it must be the degree of understanding of a disease, such as rare diseases, cutting-edge research on treatment, etc. If I can do it without overturning the wheel, at least I know where to go.
As far as this medical record is concerned, Ningling knows that the biggest consequence is to return without success, which will not lead to amputation or other negative consequences for the patient!
Then there is the ability threshold. Ningling himself said that his own ability threshold is the techniques of nerve incision, nerve exploration, and nerve suturing. This is what he is best at, so as long as he can find the problem, you can basically solve it.
However, the real circle of competence is actually in the apparent neurological damage. You can see where the damage is, so you can fix it in one go.
This is telling Zhou Cheng that as long as you point out where the damage is, I can solve the problem and you don't have to worry anymore.
However, the cognitive domain, in fact, in addition to the potential cognitive domain, there is also a real cognitive domain, which is the real diagnosis, including the qualitative and positioning of the diagnosis.
As for Zhou Cheng, what he can do is the true cognitive domain. He knows where the damage is and points it out. Ningling can do it.
What Ningling was able to do before the operation was the potential cognitive domain. I knew that it was not a nerve space-occupying lesion. It must be on this nerve in the lower limbs and not elsewhere. I had to look for it.
one time!
After Ningling talked for a while, he said: "So Xiao Zhou, I really hope and look forward to you being able to come up with your theory of levels and learning as soon as possible."
"Because if you can thoroughly divide the corresponding disease types and skill levels, we can more clearly figure out our own strength, whether we can handle the corresponding disease types, whether there will be any discrepancies, and reduce our
The panic in my heart gives me a clearer and objective understanding of my own strength."
"When my teacher talked about this matter with me, I thought so. This is not only an important guide for young doctors, but also a clearer self-understanding for middle-aged doctors like us.
Know how to challenge and which direction to challenge."
"Actually, I'm not afraid of your jokes. The position I'm in now is what scares and panics me the most."
"There are no teachers above to consult, but there are students below who need to learn everything, teach, have some theoretical reserves, and have some technical reserves, but they are relatively limited. They are not as profound as the teachers. In the eyes of others, I will eventually become a big man with a big face."
Flag figure.”
"But I know in my heart that I have inherited only 40% to 50% of what my teacher has learned. There is still a big gap. Then, when I encounter a disease in clinical practice, I don't know how to judge it or whether I should fight for it.
"
"When do I make the wrong choice and when do I make the right choice? I am even more worried!"
"It's just like last time!" Ningling told Zhou Cheng almost heartily.
Zhou Cheng doesn't have any of these pressures, because Zhou Cheng doesn't lead the team like him now, so he definitely doesn't have the pressure he does. Zhou Cheng doesn't like him now, and needs to take over the mantle of the teacher.
"Professor Ning, you are already good enough."
"If you are willing, we can have a corresponding communication in private in advance, because I still don't know my teaching level theory, good or bad, right or wrong, so I dare not comment on Professor Ning's learning and skills.
depth."
"There may be some areas that need to be improved by Professor Ning in the future." Zhou Cheng said formally.
Indeed, Zhou Cheng felt that if he directly objectified the corresponding standards, he might hurt some people. After all, different people have different ideas. If there were absolute standards, it would be a bit silly.
But how to re-establish standards is really a question that needs to be discussed.