3 PM.
Ye Wushu started waiting for the workday to end. She was gradually getting used to life in the ICU, no longer as flustered as she had been at the start, chased around by the nurses' questions about medical orders.
She couldn't help but send a message to her close friend on WeChat: 【This is what growth feels like. After adapting, the ICU isn't so scary—the teachers here are all really nice…】
Before she could even finish typing, Teacher Wu Yue walked out holding her phone, cursing:
"Why is a post-op obstetric patient being sent to our unit?"
"What? A heart condition and they're preparing for cardiac surgery? Then why not put them in the cardiac surgery ICU?"
"Are they out of their minds? I don't agree. What? They want to put them on ECMO too?"
"What? Leadership already approved it?"
Ye Wushu heard her teacher swear and hang up the phone.
At the same time, a group of nurses had already gathered around Wu Yue because of the phone call's contents: "What? What?"
Wu Yue said helplessly, "A post-C-section patient with pulmonary hypertension is being transferred here. Apparently she didn't have pulmonary hypertension before pregnancy, but she has a history of systemic lupus erythematosus. She didn't follow up or adjust her medication during pregnancy. This morning she suddenly came to the hospital with chest tightness and shortness of breath…"
The family and the pregnant woman herself said it was "sudden," but the symptoms had actually been going on for a while. After evaluation, the obstetrics department decided on an emergency C-section. The family was hesitant, saying she was only 7 months along and the baby would likely be frail if born now.
Fortunately, it was during the day with full staffing, and the head of obstetrics was present. She told the family directly: if they didn't do the C-section now, it would be two lives lost—the mother wouldn't survive, and neither would the baby.
Only then did the family reluctantly sign the consent form.
Before surgery, consults were requested from cardiology and cardiac surgery. After reviewing the relevant test reports, cardiology simply waved their hands: "This is beyond our department's scope. Ask cardiac surgery if they can operate."
Director Zhong from cardiac surgery arrived with a dark face. After learning the history, he didn't say it in front of the pregnant woman and her family, but stated bluntly: "People like this don't care about their own lives. Her body was never suitable for pregnancy, and after getting pregnant she didn't follow medical advice. Now she comes to the hospital to save her life, and her pulmonary artery pressure is almost matching her aortic pressure. How am I supposed to operate on her? Medical resources get wasted on people like this?"
This patient would need a heart-lung transplant—both organs and blood products are precious resources.
The obstetrics director played peacemaker. She was the one who least wanted anything to happen to the pregnant woman—if a maternal patient died within 42 days after delivery, it counted toward the maternal mortality rate, a metric of utmost importance to the hospital.
The obstetrics director said, "Oh, Director Zhong, weren't you the one who used to love challenging yourself? I think you're becoming more and more like Director Song—more cautious and conservative by the day."
Director Zhong left without another word.
Now it wasn't up to her whether to accept the patient or not. The patient was admitted through the emergency department, and after the C-section she would definitely need to be transferred to the ICU, then wait for the right timing for cardiac surgery.
In short, the patient was already in—they couldn't let her die.
At least for those 42 days, they couldn't let anything happen to her.
The ICU became the biggest "victim" of this situation. The cardiac surgery ICU said they were at full capacity, and among all the ICUs, only the 6th-floor ICU had an open bed.
The nurse looked bitter. "Sister Yue, does this patient really have to be admitted? Do we really have to take her in?"
Wu Yue sighed. "The die is cast."
Wu Yue turned around and saw the two young ones. Looking at their youthful, innocent faces, she couldn't help but feel a deep envy.
Wu Yue took a deep breath. It's fine, the leadership is here. Besides, this patient's baseline condition is so poor… ahhhh, she couldn't calm down. This was a maternity patient—she really couldn't bear such a heavy burden.
"Perfect timing, let's use this opportunity for a quick clinical teaching session. Let me quiz you—what disease is systemic lupus erythematosus?"
Ye Wushu answered without hesitation, "An autoimmune connective tissue disease."
"Yes, that's right." Wu Yue said, "What we call an autoimmune disease is when the patient's immune system 'mistakes its target' and erroneously attacks healthy tissue. When the immune system attacks the pulmonary blood vessels, damaging the vascular endothelial cells, what do the damaged endothelial cells release?"
"Inflammatory factors."
"Correct!" Wu Yue gave an approving look. "Then the sustained damage and inflammation lead to pathological changes in the pulmonary vasculature—vasoconstriction, vascular remodeling, and continuously rising pulmonary vascular pressure, ultimately resulting in pulmonary arterial hypertension."
"What's especially unique about this patient is that she's pregnant. During pregnancy, a person's circulating blood volume increases, peaking at 32-34 weeks. That's why some people develop gestational hypertension. If it's not properly controlled and treated, it can become chronic hypertension after delivery."
"As for treatment, oxygen therapy is needed—all pulmonary arterial hypertension patients are hypoxic. The most basic treatments also include anticoagulation and diuretics, plus some targeted medications to delay disease progression as much as possible. Ultimately, the end result is progression to heart failure, requiring heart-lung transplantation… but this patient…" Wu Yue sighed. "There's really no medical treatment left for her. She's already reached end-stage. We'll wait for surgery."
"This patient will be arriving soon. Are you two off duty, or will you stay and observe for a while?"
Lu Junran instinctively wanted to leave, but he stopped himself first, waiting for Ye Wushu's answer.
Ye Wushu said without hesitation, "I want to stay and learn."
Lu Junran: He knew it.
His junior sister was his partner in crime. If she wasn't leaving, he wasn't leaving either.
At 4:45 PM, the patient was transferred to the ICU.
Unexpectedly, this was an awake patient. Even the ICU's chief director, Cong He'ai, was shocked. "This kind of patient wasn't put under general anesthesia? The anesthesiology department didn't intubate?"
The anesthesiologist who brought her back said, "Director Song considered that this patient has already progressed to Eisenmenger syndrome. After bringing her into the operating room, Director Song performed an ultrasound and assessed a PASP of around 100-plus. The pulmonary vascular resistance already exceeds the systemic vascular resistance, with right-to-left shunting…"
In the pulmonary artery flows venous blood. The biggest difference between venous and arterial blood lies in oxygen content. When pulmonary vascular pressure exceeds systemic circulatory pressure, venous blood enters the arterial blood, resulting in hypoxia. The patient becomes cyanotic and purple, ultimately dying from circulatory failure.
"If this patient receives general anesthesia, it may worsen the right-to-left shunt and carry significant risk. While general anesthesia combined with ECMO would be somewhat better, ECMO requires heparin anticoagulation, which could increase bleeding risk. After discussion, Director Song decided to use epidural anesthesia instead, maintaining her systemic circulation pressure as much as possible."
General anesthesia would cause greater hemodynamic fluctuations. If systemic pressure dropped suddenly, the high-pressure pulmonary vessels would be more likely to shunt venous blood into the arteries, turning the patient blue all over.
Cong He'ai had no objections: "Director Song is an expert in cardiac anesthesia. His plan must be the most appropriate."
The anesthesiologist added one more note: "But this patient's baseline condition is very poor. You should be prepared for the possibility of cardiac arrest at any moment."
Wu Yue felt his vision go dark.
"Oh, right, this patient's family is also quite difficult to deal with. Be cautious about what medications you use and what procedures you perform."
Wu Yue felt like he couldn't breathe.
Ye Wushu couldn't yet empathize with her senior attending's frustrations. She was simply curious, observing this new patient admitted to the ICU.
She didn't know how to describe it, but at first glance, she could tell this person was dying.
The new patient, Ge Yun, was 36 years old, petite in stature. She could barely lie flat, gasping for breath with every ounce of strength, as if each breath consumed all her energy. The oxygen mask was filled with condensation from her exhalations.
Her legs were severely swollen, her feet purple, their original shape completely unrecognizable.
"Xiao Ye, go take the patient's history, then issue a critical condition notice. Have the family sign the informed consent for invasive rescue, ECMO, and self-funded medical device consent forms. I'll go examine the patient."
So Ye Wushu went out with a stack of documents. Taking patient histories and obtaining informed consent were two "tasks" she had fully mastered, but she hadn't expected this family to have so many questions.
"What does 'critical condition notice' mean? Hasn't she already given birth? How could there be problems? She was perfectly fine before the pregnancy, wasn't she?"
This was asked by the husband.
The mother-in-law also jumped in: "So where's my grandson? When can he come out?"
After Ye Wushu spent considerable effort explaining that the old lady's "grandson" was in the neonatal intensive care unit and that they needed to communicate with the doctors there about when he could be transferred out, the old woman curled her lip: "All your hospital cares about is making money. They won't even let us see the baby after he's born."
The family seemed completely unaware of how serious Ge Yun's condition was. The mother-in-law even said smugly, "The last hospital wanted us to abort the baby. Good thing I didn't agree. Isn't everything fine now?"
Ye Wushu recalled the "dire state" of the mother and couldn't understand how the old woman could say "everything is fine."
Ye Wushu simply couldn't communicate with the family, so she turned back and reported the situation to her senior.
Wu Yue sighed, asked a colleague who hadn't left yet to cover for him, and went out with a stack of consent forms.
Ge Yun had already been transferred to the ICU ward. Because of her special condition, she could only stay in a private room, which required self-payment—much to the family's displeasure.
Ye Wushu watched her through the glass window. Even with high-flow oxygen, Ge Yun's oxygen saturation was only 79.
"Too dangerous." Ye Wushu couldn't help but sigh. "Was it really worth it?"
Lu Junran had walked up behind her at some point without her noticing. "Everyone has to be responsible for their own choices. This was her choice."
Ye Wushu turned around, staring at him blankly. "Senior Brother, you're so rational."
"Let's go." Lu Junran could tell she had something on her mind. "It's already past work hours. Let me treat you to dinner."
Ye Wushu: "?"
Lu Junran: "Aren't you in a bad mood?" Since things had come to this, let's eat first.
Ye Wushu thought for a moment. "Then let me treat you instead, Senior Brother."
They changed back into their own clothes in the locker room and slipped out through the side door. As they were leaving, they saw Teacher Wu Yue in the consultation room talking with a family member.
The consultation room door was half open.
The family member was emotionally agitated, grabbing a piece of paper from the desk and tearing it in half. "What do you mean by this? What do you mean she can't survive? No! She has to survive. My kid is only seven months old—how can they grow up without a mother?"
Across from them, Wu Yue's face remained calm, but inwardly he was already cursing. Why didn't you think about all this when you got your wife pregnant?
Seeing the family member growing more and more agitated, Ye Wushu rushed in without a second thought, and Lu Junran followed immediately.
No problem—they weren't wearing white coats. They were just ordinary passersby stepping in to help.