Wu Quon looked over at Yao Changying again 'Dr Yao what have I done to hurt you? Why must you throw me under the bus?'

Yao Changying smiled widely at him. One of the things she enjoyed about her job was making the residents sweat.

Li Xiuying nodded: "Close up."

Wu Quon just stood still not moving as he watched Dr Li remove the laparoscopic equipment from the patient's abdomen.

Scrub nurse Meng Eu-meh spoke sharply: "Dr Wu wake up. Dr Li is asking if you would like to close up."

Wu Quon: "Yes thank you." He took the hemostatic forceps with a suture needle and thread attached from Nurse Meng Eu-meh. He felt excited to be involved, the other times he had been in theater he had only ever been allowed to watch. Most of the time there were always residents or trainees more senior to him and they always got priority when it came to a.s.sisting.

Wu Quon inserted the needle on one side of the incision and then the other: "Needle holder please." He took the needle holders from Meng Eu-meh.

Li Xiuying: "Hold your needle holders as if they were chopsticks."

Wu Quon: "Yes." He immediately changed how he held them then pulled the needle through. He placed the needle holders on the side before he began tying knots.

Li Xiuying: "Tighter. 7 times."

Wu Quon: "Yes." He tightened the thread as instructed. He felt immense pressure from having all these people watch him work.

After he had finished his first suture he looked up at Li Xiuying.

Li Xiuying: "Continue."

Wu Quon continued his task. 20 minutes later he had sutured all the port sites and sewed the skin were needed. He then cleaned up the sutured areas and put a dressing on them.

Li Xiuying: "Good." She left the operation table and started removing her gown and gloves. She went to scrub up again.

.....

Patient 3 was already anesthetized, draped and on the operating table. Li Xiuying had inserted the ports and had begun exploring the abdomen.

Li Xiuying: "D, Symptoms of patient."

Wu Quon: "The patient reported a 7 day history of absolute constipation. He has also had 2 episodes of vomiting brown liquid and loss of appet.i.te- both liquids and solids. He has said that he is belching more often. The patient did not report any pain or illness during this time."

Li Xiuying: "Examination findings."

Wu Quon: "The abdomen was soft but distended and was globally slightly tender. Bowel sounds were quiet. Also the patient had a slightly low blood pressure 110/70. "

Li Xiuying: "Important negatives."

Wu Quon: "The patient had normal vital observation i.e. not pyretic, pulse rate, normal respiratory rate. The abdomen was not hard and there was no guarding."

Li Xiuying: "Diagnosis?"

Wu Quon: "Bowel obstruction."

Li Xiuying: "Where?"

Wu Quon paused for a moment as he searched his brain for the answer. He spoke tentatively: "Small bowel obstruction?"

Li Xiuying: "Are you asking me or answering me?"

Wu Quon spoke with fake confidence: "Small bowel obstruction"

Li Xiuying: "General causes of bowel obstruction?"

Wu Quon: "Erm tumor, pseudo-obstruction, volvulus, foreign body?"

Li Xiuying was still looking at the screen and frowned: "Intraluminal causes, intramural causes, extramural causes."

Wu Quon: "Erm intraluminal causes: fecal impaction, tumors. Intramural causes: strictures, tumors. Extramural: hernia and volvulus."

Li Xiuying: "This patient has had previous abdominal surgery, what is the most probable cause of his bowel obstruction?"

Wu Quon felt his mind go completely blank 'Previous surgery, previous surgery. What could his previous surgery have been? I can't remember what he previously had done, Think Wu Quon think!"

Li Xiuying continued the surgery without even glancing in his direction.

Wu Quon finally knew what the pressure of silence felt like, 10 minutes had pa.s.sed and the entire theater was quiet except for the sound of machines.

Li Xiuying: "Look at the screen, what is that?"

Wu Quon stared at the screen; he tilted his head left and right and even squinted his eyes. 'What is that?'

Li Xiuying spoke to Meng Eu-meh: "Bipolar please."

Wu Quon stood uncomfortably by Li Xiuying's side.

Li Xiuying frowned again: "Adhesion." She cut through the adhesions, which were most likely caused by the previous intrabdominal surgery the patient had, had.

Wu Quon: "Ohhh."

Li Xiuying continues to look at the small intestine and mesentery to search for any other possible adhesions.

Sometime later Li Xiuying spoke: "Finished."

Yao Changying looked at the patients observations: "All good."

Li Xiuying removed the equipment and watched as the abdomen deflated: "Prolene 3-0."

Meng Eu-meh handed Li Xiuying the hemostatic scissors with the needle attached.

Wu Quon felt a little disappointed that he wasn't allowed to suture. He a.s.sumed that it was because of his poor performance on answering the questions Li Xiuying had asked.

Wu Quon was mesmerized by Li Xiuying's suturing technique. Although she did the same basic technique he did, she was much faster and more accurate. Her movements flowed so naturally that it appeared effortless.

Li Xiuying walked away from the table and gestured for Wu Quon to follow her to the scrubbing up area.

Li Xiuying: "When answering questions you should always have a structure, whether it is by anatomical structures or systems based. You can use a surgical sieve mnemonic like VITAMIN CDEF. Vascular, infection, trauma, autoimmune, metabolic, iatrogenic, neoplastic, congenital, degenerative, endocrine, functional. "

Wu Quon nodded and made a mental note of the mnemonic.

Li Xiuying: "Did you personally go and take a history and examine the patient."

Wu Quon: "Yes Dr Li. I went to speak to some of the patients yesterday evening and some this morning."

Li Xiuying didn't see any deception in Wu Quon's face: "When presenting examination findings you should present everything. Present the patient again."

Wu Quon: "The patient looked comfortable at rest, his hands were warm. He had a capillary refill time of 3. Pulse rate was 75, normal volume and rhythm. There was no conjunctive pallor or icterus. The patient did not have a raised JVP. The abdomen appeared distended. On palpation it was soft and there was general widespread tenderness. There was no guarding. Bowel sounds where quiet. No organomegaly."

Li Xiuying: "Normal capillary refill?"

Wu Quon: "2 seconds or less."

Li Xiuying: "Why is capillary refill particular important to test for in this patient?"

Wu Quon: "Erm peripheral perfusion of tissues and erm ..."

Li Xiuying waited.

Wu Quon: "I don't know."

Li Xiuying: "Quick way to a.s.sess dehydration status. The patient also had a BP less than his normal baseline. The patient hasn't had an adequate intake of solids and liquids due to his lack of appet.i.te."

Li Xiuying: "Did you not check the patient's mouth for any pathology?"

Wu Quon: "Yes, erm there was no angular stomat.i.tis, no glossitis and no ulcers."

Li Xiuying: "Importance of checking for ulcers?"

Wu Quon said the first thing that came to his mind: "May affect the insertion of an artificial airway?"

Li Xiuying frowned: "No. It may be a sign of Crohn's disease. Crohn's disease can result in inflammatory strictures which can result in bowel obstruction."

Wu Quon really wanted the earth to swallow him whole at the moment. He was so embarra.s.sed by his idiotic response.

Li Xiuying: "Scrub up."

Li Xiuying went to scrub again.

Wu Quon tried to put a smile on his face as he followed Li Xiuying.

....

Qin residence

Qin Song: "Everything is fine baby brother, I've sorted Li Xiuying's problem. Let's get you to school now its getting late. You've already missed quite a few days this term."

Little 4th crossed his arms across his chest and glared at his oldest brother: "Why did you s.n.a.t.c.h the phone like a burglar? I was talking to my big sister."

Qin Song: " I didn't s.n.a.t.c.h it, I just politely grasped for it. And I think you mean thief not burglar."

Little 4th waved his hand as if to dismiss his brothers words from the air: "Both are illegal and punishable."

Qin Song was about to retort when his phone started ringing, he picked up.

Male voice: "The job is done Boss."