Chapter 45

Yang Ping was resting in the on-call room. Regardless of how noisy it was, he could still fall asleep, a skill that allowed him to recharge anytime, anywhere.

When he woke up, there were many fruits by his bed, left by his colleagues and washed clean. Yang Ping ate an apple and washed his face, recalling the case discussion scheduled for three o’clock in the afternoon.

At two forty, Yang Ping arrived at the teaching room, where many people were already waiting. Little Five, Zhang Lin, and Fang Yan all greeted him, pointing to an available seat and signaling him to sit quickly.

The teaching room also served as the department’s meeting room, where case discussions were conducted. Except for those involved in emergency surgeries, everyone was required to participate, discussing complex and fatal cases encountered during the week.

For young doctors, this was a valuable learning process, while for senior doctors, it was an opportunity to showcase their talents. How the surgery went was clear on the table, and theoretical knowledge was tested during case discussions. During these discussions, everyone closed the doors, engaged in heated debates and banged tables, all of which were regarded as legal.

Song Zimo came in and sat next to Yang Ping. He whispered, “Regarding the preterm baby last time, its blood vessels were too fragile. I practiced on a newborn mouse, used drugs to make its blood vessels fragile, and practiced for many days. Now I can barely manage to do suturing. Can you advise when you have time?”

Yang Ping said in surprise, “You didn’t take a nap at noon and practiced operations under the microscope?”

Song Zimo said, “Yes, you are not an elder brother for nothing, you must teach me when you have time. Let me do it for the next baby’s operation, with you as backup?”

“Your ‘elder brother’ carries a great deal of weight,” said Yang Ping.

But Song Zimo had enough talent and diligence, and a broad-minded. He had pride but he could face the gap. Having such a colleague was a blessing. Now, whenever he had spare time, Song Zimo would actively step up to assist during Yang Ping’s surgeries.

“Alright, next time I’ll arrange the operation for you,” Yang Ping said.

Song Zimo put his arm around Yang’s shoulder and asked, “How is it going with the surgical nurse? Any progress?”

Yang Ping shrugged his shoulder and took his hand off, “Why are you so nosy? Can’t you tell the occasion?”

Song Zimo said, “I am a human being too, as your elder brother, I should also pass on life experiences, don’t hide your methods.”

Yang Ping sneered, “Forget it, who doesn’t know about you, Song Zimo, a single smile from you when walking down the street can cause people to have heart palpitations.”

People started coming in one after another. Once Director Han came in, Song Zimo stood up, stretched, and sat next to Director Han. He was the secretary of the department, responsible for record-keeping.

People gathered in groups in the teaching room, packing it so tightly that there was almost no room to move. Several senior directors sat in the first row, a bottle of mineral water in front of each. The doctors’ office had a projector, but here a high-definition screen was used.

“Everyone, be quiet, this week we didn’t have any fatal cases, but there were a few difficult ones. Let’s discuss them, starting with Director Ouyang’s team –”

The resident physician in Director Ouyang’s group started reporting the case.

“XXX, male, 14 years old, recurrent pain and swelling in the limbs for 3 years. Three years ago, without any trauma or obvious triggering factors, left wrist joint pain and swelling occurred, gradually progressed to bilateral shoulder joints, elbow joints, right wrist joint, bilateral hip joints, knee joints, ankle joints. Treated in several hospitals– Past history: 4 years ago, due to an old fracture of the left carpal scaphoid, he underwent open reduction, bone grafting, and internal fixation. After the fracture healed, no functional impairment remained. Physical examination: swelling and tenderness in the limbs– Auxiliary examination: MRI of bilateral shoulder joints, elbow joints, wrist joints, hip joints, knee joints, ankle joints showing synovial swelling and joint effusion–”

After the resident doctor ended the case report, Dr. Jin, a senior doctor in Director Ouyang’s team, added, “This child comes from a relatively good family and has traveled to many places. Renowned hospitals and professors across the country have treated him, as well as traditional Chinese medicine, Western medicine, internal medicine, and surgery departments. However, the pain and swelling persisted, and even normal walking became difficult. He has consulted many hospitals, but the problem has not been resolved. Everyone, let’s discuss and see how to make a clear diagnosis and treatment.”

Dr. Jin had been a senior doctor for a long time. He was over forty and only a few years younger than Director Ouyang. According to his years of service, he should have been a chief physician. However, he was rigid and never indulged in falsehood. To this day, he hadn’t published any papers or obtained any research topics, so he hadn’t progressed to an associate chief physician. But in terms of actual skills, he was already at the level of a chief physician.

After Dr. Jin supplemented, several young doctors began to scratch their heads. This kind of atypical case was the most troubling and tested a doctor’s diagnostic abilities, which just happened to be a weak point of surgeons.

Many orthopedic surgeons, once the X-ray film was hung on the viewing light: Surgery! Very straight forward. Why bother diagnosing? Isn’t everything clear on the film? Diagnosis was the field of internal medicine doctors.

“It’s very necessary to discuss this case. Usually, for those with joint pain and some atypical cases, if we can’t find the cause, we just let it go. I always say that a surgeon not only needs to be good at surgery, but also needs to have good clinical thinking ability. Now, let’s discuss how to make a diagnosis and treatment for this patient,” said Director Han.

There are many diseases in medicine that can’t be traced to a specific cause. Diagnosis is like solving a detective case, following certain logical thought processes based on medical history, physical examination, and auxiliary examination to pinpoint the illness. There are unsolvable cases and undiagnosable diseases.

Usually, in case discussions, the doctors with less experience start off, gradually moving on to the seniors. In today’s case, the less experienced doctors are at a loss for words.

“We have run a battery of tests including endocrine, metabolism, nutrition, blood, rheumatism, etc. We did all the imaginable tests—X-rays, surface ultrasound, CT, and MRI scans. We have done dozens of MRIs.”

“A variety of diagnoses have been considered: synovitis, rheumatoid arthritis, autoimmune arthritis, reactive arthritis. Someone even bluntly made a diagnosis: a difficult and complicated disease?” Noticing the silence, Dr. Jin chimed in to avoid an awkward pause.

His knowledge is more profound, like an old draft cow that endures hardship without complaint. Director Ouyang has relied on him for many years, and as a result, he hasn’t performed an emergency operation in a long time. Each time, it’s Dr. Jin who takes care of the major emergencies.

“Reactive arthritis is more like a catch-all phrase; when the disease can’t be traced, it’s called reactive arthritis. This disease, however, has no medical history related to urogenital or intestinal infections.” Director Ouyang said.

“Many transient synovitis cases found in clinical practice have no obvious causes. This diagnosis is indeed challenging. Otherwise, someone wouldn’t have gotten frustrated and labeled it as a difficult and complicated disease.” Director Bai said.

“Was a synovial biopsy performed?” Director Tian asked.

Dr. Jin responded: “Yes, it was done in a Beijing hospital. The pathological examination indicated the inflammation of the synovial tissue.”

Yang Ping half-closed his eyes, leaning on the chair while Song Zimo told him, “Why don’t you say something? Aren’t you always full of surprising solutions?”

Hearing this, Yang said, it doesn’t take any time to access the system. In real life, it only takes an instant. Now he is emotionally ready to switch to the system at any time and any place.

Upon opening the window, he found the newly added library function. After accessing the system, he began an exhaustive search of textbooks, journals, and papers about synovitis, especially rare cases, and even individual case reports.

Synovitis is merely a symptomatic diagnosis, not an etiological one. Like fever, many diseases can cause it, but you have to find the cause of the fever to treat it effectively.

Yang Ping thought to himself, “The system is indeed a torture device. Providing such a large library, it would have been easier to just help with the diagnosis, and then I would be able to show off without any effort.”

But it requires so much effort to find relevant information. Fortunately, the search function of the system’s library is quite potent. He finally found many papers, one of which caught Yang Ping’s attention.

Five years ago, an Austrian doctor wrote a paper which was published on an inconspicuous medical school journal, written in German. The system, being very considerate, actually had a translation function.

The paper mentioned–metal ion reactive synovitis, which usually happens internally with implants, such as steel plates, artificial joint replacement, and even metal dentures could cause it. This happens because the synovial joints are sensitive to metal ions, thereby causing an inflammatory reaction. This is a very rare disease. After searching, Yang Ping found that apart from this Austrian doctor, nobody else had reported it.

That’s interesting. Yang Ping studied the paper in detail. This kid had surgery on his left scaphoid four years ago as shown on the X-ray with residual metal screw. Could this metal screw be releasing metal ions into his bloodstream and then causing synovitis after being deposited in the synovial joints?

The kid’s symptoms seem similar to those mentioned in the paper, but it’s just a hypothesis and there’s no concrete evidence. After a lot of searching, this is the most plausible diagnosis he could find. After looking up more information but not finding anything more suitable, Yang Ping exited the system.

“Yang Ping, Song Zimo, what are you two doing hiding there, say something!” Seeing everyone remaining quiet, Director Han called out their names directly.

Now that Director Han has called them out, it wouldn’t be appropriate to remain silent.

Song Zimo nudged Yang Ping, “Big brother, it’s your turn!”

Yang Ping cursed him silently. At this time, he called him ‘big brother’ more sweetly than anyone else.

Pushed into acting swift, Yang Ping sat upright. He couldn’t lose face in front of his colleagues, so he maintained a thoughtful expression, “Hmm, this, after listening carefully to the medical history, I think it may be metal ion reactive synovitis, a very rare disease with few reported cases.”

Metal Ion Reactive Synovitis, what? They had never heard of this disease. Is it even a real illness? It’s not mentioned in any textbooks.