Chapter 270 - 178: Compromise?

Chapter 270: Chapter 178: Compromise?

"Yes, 8 AM tomorrow. The heads of Gastroenterology and General Surgery will hold a joint consultation... No, you don’t need to come in tonight. She’s just a routine ER observation patient. Right, that’s all."

Zhang Sui hung up the phone and turned.

He saw Jiang He standing not far behind him.

Zhang Sui said, "What is it?"

"Dean Zhang, the special lab results are back."

Jiang He handed the report over.

Zhang Sui took it and quickly scanned the data.

[IL-6: 850 pg/ml]

[PCT: 3.8 ng/ml]

[CRP: 28 mg/L]

The rain was coming down harder now.

Incessantly.

’It’s just like the downpour on the night of the car accident...’

After he finished reading, Zhang Sui thought for a moment, then said, "The elevation in these three markers can be explained by a severe, acute gastrointestinal bacterial infection. She drank contaminated ice water, which led to acute gastroenteritis. This is just the immune system having a stress response."

Jiang He had expected this reaction from Zhang Sui.

’A medical post-doc who’d studied at Johns Hopkins University and the Mayo Clinic, yet he’s as stubborn as a rock, an old diehard.’

’A man like that would never casually overturn established guidelines.’

But the situation was urgent.

Jiang He didn’t have time for pleasantries and got straight to the point. "Dean Zhang, everyone has their specialty. You’ve been away from frontline clinical work for many years. Even when you were on the front lines, you dealt with chronic disease management in cardiology and the standardized response to acute MIs. The pancreas, however, is a different beast."

Zhang Sui frowned. "Just say what you mean."

"You think the rise in these three markers is a stress response from a bacterial infection caused by acute gastroenteritis? The patient’s current heart rate is 95, and her respiratory rate is 22. For a 17-year-old girl sound asleep under the effects of analgesics, that basal metabolic rate is unreasonable."

"I don’t believe this is a common bacterial infection, but rather an extremely early sign of Systemic Inflammatory Response Syndrome (SIRS) caused by sterile inflammation."

"The immune system has already been activated, and inflammatory mediators are attacking her vascular endothelial cells. Her blood pressure seems normal for now, but that’s only because her heart is desperately trying to compensate. Once that compensatory mechanism collapses and her capillaries begin to leak extensively, she’ll go into shock, followed by Multiple Organ Dysfunction Syndrome, or MODS."

Zhang Sui retorted, "But the amylase and the ultrasound don’t support your conclusion."

Jiang He quickly explained:

"Because the rupture of pancreatic acinar cells takes time."

"In the first few hours after onset, the level of amylase in the blood won’t even reach the diagnostic threshold. CTs and ultrasounds aren’t sensitive enough. Imaging and traditional biochemical markers have a lag. That’s the deceptive nature of early-stage SAP. By the time you see the amylase spike, by the time the ultrasound shows abdominal fluid and widespread necrosis, the optimal window for saving her will have already closed!"

Zhang Sui’s brow was tightly furrowed.

There were no obvious flaws in Jiang He’s pathological deduction, but it was still just speculation.

He couldn’t accept making a major medical decision based on speculation.

"This is just your personal clinical inference," Zhang Sui said. "The guidelines don’t list IL-6 and PCT as standalone criteria for diagnosing SAP. According to current treatment protocols, her management plan is observation, NPO, and fluid replacement."

The old diehard’s reaction was exactly what Jiang He had anticipated.

So, for his next step, he pulled out a printed research paper and handed it to Zhang Sui.

"What’s this?"

"It’s my research on a multi-biomarker predictive model for early severe acute pancreatitis. I submitted it to the *New England Journal of Medicine*."

Zhang Sui’s expression changed instantly.

He took the manuscript and quickly flipped to the first page.

Jiang He explained from the side:

"For this paper, I accessed medical record data from Affiliated Hospital No. 1 and extracted samples from the cryopreserved serum bank from ’03 to ’08."

"I also obtained authorization from Director Xu Wenpei of the General Surgery Department at Peking Union Medical College Hospital for their core data on SAP patients from the last five years. It’s a dual-center, large-sample, retrospective cohort study."

"In this model, I used joint modeling for IL-6, CRP, PCT, and basic physiological parameters like the patient’s age and heart rate, using logistic regression analysis..."

"The results show that when these markers show abnormal elevations in a specific combination, the probability of the patient developing severe acute pancreatitis within 48 hours is extremely high."

"The AUC (area under the curve) reached 0.915."

In medical statistics, an AUC value over 0.9 for a predictive model means it has extremely high accuracy and discriminative ability.

Of course, Zhang Sui was well aware of this.

Jiang He took out one last thing.

It was a screenshot printed from a computer in the ER.

"I had my tech partner work overnight to build a predictive software based on my paper’s underlying algorithm. I just finished entering all of Jiaqi’s data: her basic vitals, the IL-6, PCT, and CRP results from the lab, and the ultrasound findings."

[System Assessment: Probability of Severe Acute Pancreatitis (SAP): 87.8%]

[Risk Level: Critical]

Zhang Sui saw the message.

His composure shattered.

The person they were discussing wasn’t just some patient; it was his own daughter.

’If Jiang He is right... then what?’

Reason and emotion warred violently in Zhang Sui’s mind.

Jiang He continued:

"Dean Zhang, the model projects a full-blown cytokine storm will erupt very soon. My recommendation is to transfer her to the ICU immediately. We need to establish a central venous line and begin aggressive fluid resuscitation. We also need to be prepared to start hemofiltration to clear the inflammatory mediators from her blood. If necessary, we might even have to resort to protease inhibitors like Ulinastatin and a targeted immunosuppression protocol."

Silence filled the rainy night.

Lightning flashed, illuminating their profiles.

A roll of thunder followed.

Finally, Zhang Sui spoke. "No."

Jiang He asked, "Why?"

Zhang Sui replied, "Your paper hasn’t been published. Your model hasn’t been validated or tested. I can’t trust it."

"Besides, the treatment plan you’re proposing is very risky."

"What if she just has a simple case of severe acute gastroenteritis? Is it really necessary to perform such a high-risk treatment?"

As he spoke, the rims of Zhang Sui’s eyes grew red.

"Jiang He, are you asking me to break SOP and perform an extremely high-risk overtreatment on a 17-year-old girl, all based on a computer program that hasn’t been clinically validated? What if your model is wrong? I absolutely will not allow that to happen."

His rebuttal was logical and well-founded.

Zhang Sui wasn’t just protecting his daughter; he was also defending the medical principle he had followed for half his life:

Never perform a highly invasive intervention without conclusive evidence.

Lightning cracked again.

Jiang He’s gaze was surprisingly calm, as if he had anticipated everything.

He said, "Dean, you’re right. According to the rules, what I’m asking for is a textbook case of overtreatment and a violation of protocol."

Zhang Sui nodded, sank weakly into a chair, and pressed his forehead in anguish.

Jiang He suddenly changed the subject. "Dean Zhang, let me tell you a story."

"...I have a friend."

"He’s just like you, someone who reveres SOP. Every single one of his medical orders was in absolute compliance with the Chinese Medical Association’s clinical guidelines."

"Late one night, a male patient in his thirties was admitted to the ER, his chief complaint being severe chest pain. My friend ran a full set of tests on him. EKG, normal. Troponin, normal. Following SOP, he ruled out an acute MI and made a preliminary diagnosis of gastroesophageal reflux or musculoskeletal pain. The treatment plan was to give him painkillers and keep him for observation."

"But the patient kept crying out in pain, sweating profusely."

"My friend stood by the hospital bed, and based on his years of clinical intuition, he had a nagging feeling something was wrong. He suspected it might be an extremely subtle case of aortic dissection."

Zhang Sui interjected, "If he suspected that, why not do a CTA?"

"Because SOP didn’t support it. A CTA requires injecting a large dose of iodine-based contrast agent, which carries the risk of contrast-induced nephropathy and severe allergic reactions."

"The patient’s vital signs were stable, and all his basic lab values were within the normal range. Ordering an expensive and risky CTA without a clear indication would have been against protocol. So he hesitated for a long time, and ultimately decided to follow the rules and continue observation."

"Two hours later, the patient went into ventricular fibrillation on the observation bed. His blood pressure instantly became unreadable. The aortic dissection had ruptured. Blood burst through the vessel wall, filled his pericardium, and caused an acute cardiac tamponade. They tried to save him for forty minutes, but he didn’t make it."

"Afterward, the family sued the hospital. But after the court and the medical review board examined all the records and medication logs, they ruled that my friend was not at fault."

"Because every step he took complied with the medical guidelines of the time. He won the lawsuit and kept his license."

"But three months later, he resigned. He never picked up a scalpel again."

Zhang Sui was silent.

Right now, of course, he had no way of knowing.

Jiang He was telling a true story from the future, one that would happen to one of Zhang Sui’s best students.

"So, Dean Zhang, you just said that if my model is wrong, an extreme intervention would harm her. Let me ask you this..."

"What if my model is right? What if the cytokine storm completely destroys her endothelial system, leading to multiple organ failure? What will you do then?"

Zhang Sui was utterly speechless.

’He’s right. What if Jiang He is right?’

’What if I miss this last chance to save my daughter?’

’I probably wouldn’t even get the chance to resign. I’d just have to live out the rest of my days in endless regret.’

’This is my daughter.’

’Even with her crazy dyed hair and heavy eyeliner, she’s still my daughter.’

’When you were born, I swore to God that I would love you forever. Even if you grow into someone I don’t recognize, I will still love you. Not even the end of the world could change that...’

Zhang Sui slowly turned his head, looking out at the downpour.

In the face of this cruel reality, his reason crumbled, piece by piece.

A full five minutes passed.

The rims of Zhang Sui’s eyes were completely red now. He said:

"I’ll contact Liu Jianbang. Get Jiaqi transferred to the ICU. Establish a central venous line and put her on a critical care monitor. Draw an ABG every thirty minutes, and check her intra-abdominal pressure every hour."

As vice dean, this was the greatest concession he could make.

"I won’t agree to prophylactic hemofiltration or targeted immunosuppression for now. Those measures are still too aggressive. But..."

"The moment her blood oxygen saturation drops by two percentage points, or her intra-abdominal pressure shows any upward trend, we immediately proceed with your plan."

Jiang He looked at the father before him, who had been pushed to his breaking point.

He knew that getting him to agree to an ICU transfer and a central line without any gold-standard indications was the greatest compromise he could have hoped for.

’It’s enough.’

’It’s enough to buy us the golden window to save her.’

But Jiang He was thinking one step further.

’Who’s going to do the surgery?’

’Teacher Yang isn’t here.’

Jiang He stood up. "Dean, I’m going to step out and make a call."