Chapter 51 The Pressure Of Silence

Li Xiuying had changed and was now dressed in a set of green scrubs. Her hair was tied back and she had a disposable green surgical cap and surgical mask on.

She completed her surgical hand scrub, put on her surgical gown and sterile gloves and entered the theater with her arms crossed.

Li Xiuying made her way to the surgical table where Dr. Liu was currently operating: "Dr. Liu"

Dr. Liu looked to his right: "Dr. Li thank you for coming. This patient is a 55 year old female with chronic alcoholic pancreatitis. She has not responded to medical management and is suffering from intractable pain. Imaging has indicated presence of bile obstruction and duodenal obstruction. The patient reported loss of appetite, postprandial pain, nausea, vomiting and right upper quadrant pain. I wanted your opinion on whether I should carry out a Frey's or a Whipple."

Li Xiuying nodded. She then walked over to the screen that displayed the CT abdomen.

Li Xiuying turned to a theater nurse. "Cholangiogram? Ultrasound? Bloods?"

The nurse brought up the images one by one then the blood test results.

Li Xiuying: "Her last CT abdomen?"

The nurse clicked open the image: "The Last scan was in 2008."

Li Xiuying: "Thank you."

Li Xiuying walked back to the surgical table. "Lower the table please."

The table was lowered and Li Xiuying looked into the abdominal cavity. She used her right hand to feel the anatomical structures and to move structures out of the way to better visualize all the patient's anatomy.

Li Xiuying mumbled to herself: "Dilated bile duct, severely enlarged stomach, dilatation of veins and arteries. Also presence of anatomical variation of the arterial and venous supply. "

Li Xiuying: "I would carry out a pylorus preserving Whipple's procedure, the disease is predominantly located in the pancreatic head and there is significant biliary and small bowel involvement. Also, the patient has clear symptoms of bowel obstruction.I would also recommend putting in an NG tube alongside the NJ tube to aspirate the stomach content."

Dr. Liu: "I was leaning towards a Whipple's myself. Thank you."

Li Xiuying nodded and proceeded to leave the theater.

....

Emergency Room

Hu Yín Tao was nervously waiting at a computer in the emergency department. She hadn't expected Dr. Li to page her today. She still hadn't covered all the topics she had planned to. Hu Yín Tao thought that she still had two more days to prepare for her session with Dr. Li.

Hu Yín Tao took out her phone and quickly started reading a pocket guide on Emergency medicine.

She had just finished reading about angina when she felt impending doom approaching.

She looked up from her phone screen and spotted Dr. Li in the distance. Li Xiuying was now wearing black scrubs with white doctors' coat on top. Hu Yín Tao swallowed her saliva.

Hu Yín Tao started slowing walking towards Dr. Li.

Hu Yín Tao nervously spoke: "Good morning Dr. Li."

Li Xiuying nodded. She walked to the doctor's station and checked the patient list on a computer.

The next patient on the list was a 35 year old man with loin to groin pain. Li Xiuying marked the patient as being seen.

Li Xiuying: "Loin to groin pain, differentials?"

Hu Yín Tao mind went completely blank, she had read up on this over the weekend but when faced with Dr. Li expressionless face and indifferent tone her ability to think and speak had fled.

Hu Yín Tao: "Erm I erm its err erm I, I. "

Li Xiuying: "Words."

Hu Yín Tao's voice became quieter as she spoke each word: "Erm I think erm kidney stones?"

Li Xiuying frowned slightly at Hu Yín Tao's hesitation: "And?"

Hu Yín Tao: "Cancer?"

Li Xiuying: "Type?"

Hu Yín Tao: "Erm I, Erm"

Li Xiuying: "Go and see Mr. Mao Ting bed 10. Take a history and do an examination. Then come back and present. You have 15 minutes."

Hu Yín Tao walked dejectedly to the patient.

I made myself look so stupid! Dr. Li must think I'm and absolute idiot now.

When the patient was within Hu Yín Tao sights, she composed herself.

Hu Yín Tao: "Hello Mr. Mao Ting. I'm Dr. Hu."

Mao Ting was sitting on the edge of the bed: "Hello Dr. Hu."

Hu Yín Tao: "I'll be asking you a few questions and then do an examination. I'll then go and report to my senior and she'll come to review you."

Mao ting: "Sure."

Hu Yín Tao: "Tell me what's happened to bring you in today."

.....

Li Xiuying was sitting at the desk waiting for Hu Yín Tao to return. It had been 17 minutes since Hu Yín Tao had gone to assess the patient.

Li Xiuying leaned on the desk and put her head in her hand. She strummed the fingers of her other hand on the desk. Li Xiuying took her phone out of her pocket and sent a message to Ren Daiyu and Xǔ Junjie: 'I'll finish work at 2:30.' She returned her phone to her pocket.

Hu Yín Tao appeared after 25 minutes.

Li Xiuying: "25 minutes. Present."

Hu Yín Tao forced herself to sound confident: "I'll be quicker next time. I saw Mr. Mao Ting a 35 year old male who has presented with loin to grain pain. The pain started 2 weeks ago. It feels sharp, and doesn't radiate anywhere else.He doesn't have any urinary or bowel symptoms.It's a constant pain. It's worse on movement, and he scaled it at 8/10.

He has no other medical conditions. No surgical history. He is not taking any medication and is allergic to penicillin. He does not have a family history of any diseases.He works as a taxi driver, smokes cigarettes 20 a day and is a social drinker.

On examination: He did not have any peripheral signs of any disease. His abdomen was soft and non-tender. No signs of organomegaly. His inguinal lymph nodes were not enlarged."

Li Xiuying: "Management?"

Hu Yín Tao: "I would like to get a set of obs, urine dipstick and a set of bloods.I think the patient may need a CT KUB."

Li Xiuying: "Differentials?"

Hu Yín Tao: "UTI, Kidney stones, kidney cancer; transitional being the most common or squamous cell carcinoma, bladder cancer."

Li Xiuying: "Aorta?"

Hu Yín Tao confusedly asked: "Aorta?"

Li Xiuying: "Important differential to exclude for loin to groin pain is aortic dissection."

Li Xiuying: "Check his aorta and then order all the investigations you listed. Pain relief?"

Hu Yín Tao nodded: "I'll prescribe PRN paracetamol."

Li Xiuying looked at the computer screen and clicked on a name: "Your next patient is a 85 year old female patient with left lower abdominal pain. Bed 6. I'm going to see the patient in Bed 2. You have 17 minutes."

Hu Yín Tao: "Yes." She quickly walked back towards Mao Ting.

...

Li Xiuying and Hu Yín Tao continued seeing patients non-stop until 2:30.

Hu Yín Tao felt both physically and mentally exhausted; her brain was filled to the brim with new medical knowledge.Hu Yín Tao had never felt so under pressure. Dr. Li was the type of doctor who would wait for you to give an answer no matter how long it would take.

Dr. Li's gaze had made Hu Yín Tao feel like all her inner thoughts were being seen through, analysed and rejected. The more silence there was the more pressure Hu Yín Tao felt, the more nonsense she spouted and the more of an idiot she felt.

Hu Yín Tao counted that Dr. Li had frowned at her a total of 67 times.