I Am Diagnosed as a Medical Titan

[Physical Exam: Impaired consciousness, pale complexion, cold and clammy all over. BP 75/45 mmHg, HR 135 bpm, RR 28 bpm. Abdomen distended, with obvious tenderness and rebound tenderness on palpation, shifting dullness (+). Severe swelling of both lower limbs, dark purple in color, with loss of sensory and motor function.]

[Catheterization: Drained approx. 20ml of dark, soy sauce-colored urine.]

[Urgent Blood Chemistry: Serum potassium 7.4 mmol/L, Creatine Kinase (CK) > 15,000 U/L.]

[Past Medical History: 10-year history of rheumatic heart disease, long-term use of oral digoxin.]

Lin Han was delighted.

’Crush syndrome. This was the topic I took a wild guess on, and it actually came up!’

But his joy was quickly followed by a rapid mental assessment.

The lower limbs had been crushed for eight hours, causing extensive muscle necrosis and releasing large amounts of myoglobin and potassium ions.

The dark, soy sauce-colored urine and the off-the-charts CK levels were ironclad proof.

With a serum potassium level of 7.4, the patient could go into cardiac arrest at any moment.

Next, he considered the patient’s abdominal signs.

’Abdominal distention, positive shifting dullness, blood pressure of 75/45...’

Lin Han continued his analysis:

’Traumatic hemorrhagic shock, with a high suspicion of massive intra-abdominal hemorrhage from a splenic or hepatic rupture.’

According to textbook logic,

For crush syndrome complicated by hemorrhagic shock, the absolute first step in resuscitation is to establish IV access.

This is followed by rapid, large-volume fluid resuscitation.

The goal is to expand volume to combat shock while alkalinizing the urine to protect the kidneys.

Lin Han’s pen was already touching the answer sheet, ready to write down "Rapid volume expansion, intravenous sodium bicarbonate."

But then, he stopped.

His eyes were fixed on the last line of the case file.

[Past Medical History: 10-year history of rheumatic heart disease, long-term use of oral digoxin.]

’Digoxin...’

Suddenly, what Jiang He had told him by the flowerbeds that morning flashed through Lin Han’s mind.

"If you have an elderly patient with a history of heart failure who is on long-term digitalis medication, remember that calcium ions and digitalis have a synergistic effect on the myocardium. In that situation, if you rapidly push a standard dose of calcium, you can easily induce ventricular fibrillation..."

Lin Han broke out in a cold sweat.

That was a close call.

The standard emergency treatment for hyperkalemia is to administer calcium gluconate to counteract the cardiotoxicity.

’If I’d written that down, I would’ve lost a ton of points!’

’Thank goodness I went to see Jiang He this morning! It’s all thanks to his warning!’

’One good turn deserves another, I guess?’

But the problem wasn’t that simple.

According to the case description, the patient also had rheumatic heart disease and extremely poor cardiac function.

This meant the heart couldn’t handle a rapid, large-volume fluid infusion.

Without fluids, the patient would die from hemorrhagic shock and acute renal failure.

But if he forced fluid resuscitation, the patient’s fragile heart would instantly fail, leading to acute left-sided heart failure. The patient would suffocate.

Fluids meant death; no fluids also meant death.

Without using calcium for the hyperkalemia, the process of lowering the potassium level would be significantly compromised.

Lin Han listed the resuscitation steps on his scratch paper.

Step one: Volume expansion.

But as soon as he wrote "rapid fluid infusion," bold text from an internal medicine textbook flashed in his mind: "Rapid, large-volume fluid infusion is contraindicated in patients with severe rheumatic heart disease; it can easily induce acute pulmonary edema."

He crossed the words out.

’Time for another approach. Vasopressors!’

He wrote on the paper: Dopamine, norepinephrine.

But immediately, a warning from his Surgery textbook surfaced: "Without restoring blood volume first, solely using vasoconstrictors will only worsen tissue ischemia and accelerate acute renal failure."

Crap!

Fluids meant death, no fluids meant death; using the drugs was wrong, and not using them was also wrong!

How was this fair?

Tiny beads of sweat formed on Lin Han’s forehead.

He was certain that even in a real clinical setting, a case this diabolically difficult was rare.

’This was deliberately designed to be impossible! It’s not a question for an undergraduate student!’

...

Meanwhile, in Exam Room 9, next door to Lin Han’s.

Jiang He pulled the case file from its folder and his eyes swept over it.

Crush syndrome, signs of peritonitis, hemorrhagic shock, rheumatic heart disease, digoxin.

Ten seconds.

All the key information automatically reorganized and categorized itself in his mind, forming a clear chain of logic for the resuscitation.

Jiang He had even figured out why the examiners chose this specific scenario.

Simply put, back in ’08, many doctors were still stuck in a mindset that separated "conservative medical management" from "surgical intervention."

When faced with complex trauma like this, they tended to fall back on the dogma of "stabilize vitals first, then consider surgery."

But not Jiang He.

He knew the truth was simple:

When a water tank has a giant hole in the bottom, the only solution is to jump inside and plug the hole directly.

All that talk about not giving large fluid volumes to a patient with rheumatic heart disease, or not using calcium for hyperkalemia, had to take a backseat to the core problem: bleeding.

Jiang He picked up his pen.

[Primary Diagnosis: Traumatic splenic/hepatic rupture with hemorrhagic shock; Crush syndrome with hyperkalemia.]

[Emergency Management: Immediately administer 50ml of 50% glucose solution + 10U of regular insulin via slow IV push to lower serum potassium.]

[Abandon CVP-guided stepwise fluid resuscitation.]

[Immediately initiate Damage Control Surgery (DCS) protocol.]

[Activate Massive Transfusion Protocol (MTP), request packed red blood cells and plasma for 1:1 transfusion.]

[Immediately notify the operating room. Do not wait for blood pressure to recover; proceed directly to exploratory laparotomy in the emergency OR to prioritize controlling the source of the hemorrhage.]

After writing the last line, Jiang He didn’t even need to check his work.

He simply put down his pen and walked out.

Only two minutes and forty seconds had passed since he first walked into the exam room.

Jiang He pushed open the door at the back of the exam room.