Chapter 92
*
From the moment the patient was freed from the rebar.
First, I checked the thigh of the patient that had been beneath the rebar.
At the time, the thigh was swollen to the brim and glossy.
As soon as I confirmed that, I immediately prepared for surgery.
There was no time to wait for a healer to use detox magic on the patient.
But Gregor's adjutant, who didn't know the situation, was horrified and stopped me.
“Saint!? Didn't you say you wouldn't cut it off?”
“I won't cut it off. I'll only split it open.”
“May I ask why?”
“It's compartment syndrome.”
Compartment syndrome.
It is a condition in which muscles swell severely inside the fascia due to fractures or contusions, and in that state press on blood vessels and nerves.
If this condition lasts too long, the patient's leg can go necrotic.
There was only one thing to do to prevent that.
Open the leg so the pressure can go down.
The principle is the same as opening the skull cap.
Just open the leg and lower the pressure.
“Could you lend me a hand?”
“I don't know how to operate!”
“It's fine. You only need to hold things in place.”
And so, with Gregor's adjutant as my assistant, I turned the space inside the car into a makeshift operating room and began the surgery.
I roughly disinfected the instruments and the wound.
Then I reached out to the adjutant and said,
“No. 10 blade.”
“Huh?!”
“Ah, no.”
I had, by habit, started treating the adjutant like the healers at Mercur Clinic.
Of course there was no way the adjutant would understand that.
'It's been a while since I had to beat the drum and play the gong all by myself.'
A forgotten feeling.
Ever since I'd trained the clinic healers to the level of 21st-century assistants, surgery had become much easier.
It had been a long time since I'd performed an operation all by myself.
“Do you know how to use Refresh?”
“Yes. At least a paladin can use that.”
“Then cast it every time I say Refresh.”
Tap tap tap.
Saying that, I felt my way downward from the patient's side.
First I checked the hard bone sticking out beside the hip, the greater trochanter.
Farther down, I checked once more at the lateral femoral epicondyle, the outer edge of the knee.
Connecting those two points in a straight line, I drew the dwarven-modified No. 10 razor blade all the way down.
Beads of blood welled up.
“Refresh.”
“Yep.”
That was the adjutant stopping the bleeding with Refresh.
Once the bleeding stopped, the side of the opened thigh came into view.
“Metzen... no, scissors please.”
“Yes, yes.”
The adjutant handed the scissors over with the blade facing me.
A proper healer would have been harshly scolded for that mistake.
I took the scissors I'd received from the adjutant and brought them to the long white band running over the muscle.
I cut through the iliotibial band of the thigh fascia with the scissors, following the grain of the fascia.
Freed from beneath the fascia, the muscle bulged up.
“Give me something like a hook. ...No, that's a curette. Right. The big hook.”
I took the retractor from the adjutant and wedged it between the muscles.
“Pull straight out in this direction.”
After having the adjutant lift the vastus lateralis,
I incised the lateral intermuscular septum with the scissors just as before.
Once again, the muscle trapped beneath the fascia popped up.
With that, the outer and front muscles of the thigh were freed.
The rest of the process was more of the same.
The adjutant pulled the vastus lateralis and I cut the posterior fascia to free that part too.
By the time I'd freed the thigh muscles in three directions,
“We've arrived, Saint!”
Gregor arrived at the scene with a healer slung over his shoulder.
“I'm here, Director Shun... ugh...”
The healer approached the patient while barely holding back motion sickness.
As he checked the thigh, he said,
“You finished the fasciotomy that quickly?”
“I had to deal with it before using detox magic.”
Detox magic is a spell used to deal with toxins pooled in the leg.
But if you use detox magic without resolving the compartment syndrome, toxins can be generated again by the trapped muscles.
In that case, you'd just be pouring water into a bottomless jar.
So I solved the compartment syndrome before the healer arrived.
“Every time I watch your surgeries, I'm astonished.”
The healer muttered as he cast Detox magic on the patient's leg.
As soon as I confirmed the spell was working properly, I loosened the tourniquet I'd tied off.
“Let's dilute the remaining toxins with IV fluids.”
Detox magic isn't perfect.
At best, it only resolves things enough so the toxins trapped in the leg won't stop the heart.
That's why, unlike in my previous life, I left the tourniquet on.
First I weakened the toxins as much as possible, then the remaining toxins would be diluted with IV fluids after the tourniquet was released.
In a way, it was an otherworldly version of emergency dialysis.
“Then, Director. Since I happen to have some divine power left, I can heal him right away...”
“No, don't.”
I stopped the healer who was about to cast a heal.
“While performing the fasciotomy, I checked, and right now internal fractures and vascular damage are suspected.”
When I opened the back of the thigh, I could also see a little of the back of the knee.
Blood was gushing up from there like crazy.
It didn't look that bad from the outside, but it meant the inside below the knee was wrecked.
'Well, of course a crush syndrome patient wouldn't be easy.'
That had always been the biggest problem with crush syndrome patients.
Right after they're rescued, there isn't any obvious trauma.
But once you actually open them up, the inside is often a disaster.
Compartment syndrome, complex fractures, severed blood vessels....
In short, it's a full gift set.
'It would've been nice if I could've gotten away with just one IV bag...'
Unfortunately, trauma cases never go easy.
The moment I confirmed that, I had no choice but to plan the next surgery right away.
“There's also suspected multiple fractures right now, so if we heal him now, ectopic ossification could happen.”
Ectopic ossification.
It's a condition where broken bone fragments grow inside the muscle and tear the surrounding tissues apart.
Ectopic ossification was a condition that plagued trauma patients even in a world without divine power.
But in this world, its notoriety was on a completely different level from my previous life.
'If you cast holy magic and the bone tears through the flesh, anyone would be horrified.'
It's not for nothing that treatment here developed toward amputation.
Heal them, and they die of sepsis because bacteria are left behind.
Heal them, and they die because blood has pooled inside.
Heal them, and they die because the bone rips through the flesh from the inside.
After going through that, you can only cleanly cut it off and use higher-level divine magic.
Anyway.
“The urgent parts are handled, so we'll do debridement at the clinic.”
“Understood.”
The healer seemed to understand what I was saying.
“Which district is your clinic in, doctor?”
“It's the Kivitas District 3 Clinic.”
“Is surgery possible at that clinic?”
“We're a little lacking in trauma facilities... so I think it'll be difficult.”
“Understood. Let's move him to D-1 Clinic.”
We immediately loaded the patient into the car and headed for D-1 Clinic.
'Brr. It's cold.'
Facing the cold wind blowing in through the door Gregor had torn off.
*
As soon as we arrived at the clinic, I immediately called the trauma specialists.
“30-year-old male. Rescued three hours ago from a viaduct collapse accident; right thigh was crushed. For crush syndrome, after full loading with 0.9% saline, emergency detox was administered with detox magic. At the scene, fasciotomy was performed immediately under suspicion of compartment syndrome accompanying crush syndrome.”
As we carried the patient on a stretcher toward the operating room, I explained the situation to the healers following behind.
“Decompression of the anterior, posterior, and medial compartments is complete, and while the protruding muscle has reduced some of the swelling, distal perfusion below the knee is extremely poor. During the fasciotomy, severe soft-tissue damage and fractures below the knee were suspected.”
The head healer of D-1 Clinic's trauma team answered at once.
“We'll prepare for radical debridement and an external fixator.”
Yeah, that's the good stuff.
Maybe because we'd worked together so much.
The moment I entered the numbers, the answer I wanted came out instantly.
That's why having a medical team in sync with you is important.
The tempo is on a different level.
I gave the team leader following me another order.
“Please prepare a silver cannula and vulcanized rubber tube.”
“What are you going to use them for?”
“It's a surgical method I'm showing you for the first time today, so I'll explain it as I operate.”
“Understood.”
Far from being flustered, the team leader's eyes lit up as he headed for the operating room.
Not exactly a desirable attitude when the patient is dying, but
doctors are the kind of creatures whose hearts race when they hear about a new surgical method, so it couldn't be helped.
“Student Aila.”
“Yes! I'll observe!”
I also called our Saint of the Lamp—my personal healer in charge of unlimited Refresh.
After sending the patient into the operating room.
While the anesthesia healer diligently put the patient under with ether.
I put on my gown, tied my mask for the last time, and washed my hands.
Just as I was about to cross the threshold into the operating room,
“...Saint.”
Gregor called to me softly from behind.
It was a tone completely different from his usual booming voice.
It was so different that for a moment I was slow to realize it was Gregor's voice.
When I turned around, Gregor was standing a short distance in front of the operating room entrance.
He wasn't standing there with his chest puffed out or showing off his muscles like usual.
Gregor spoke to me with his shoulders slumped and both hands politely folded before his chest.
“Saint. May I ask a favor?”
“Go ahead.”
“Could I... perhaps watch that surgery from the side too?”
A question mark popped up over my head.
Why would a paladin want to?
Unlike holy healers, paladins can't use divine magic to heal other people.
Watching a surgery wouldn't help him in the slightest.
The adjutant, startled, also tried to stop Gregor.
“Lord Gregor! What bizarre thing are you suddenly doing again...!”
“I want to see that patient live with my own two eyes.”
The large man cut off the adjutant and spoke in an unusually subdued voice.
“There is a reason I must see with my own eyes the one I saved come back to life.”
That voice was far more serious than usual.
Maybe that was why.
Even the adjutant who had been stopping Gregor fell silent.
“...Understood.”
I allowed Gregor into the operating room.
I didn't ask why.
Because I thought I knew why.
“Be careful not to touch the patient or the other healers.”
“Thank you, Saint.”
Gregor bowed to me and then carefully entered the operating room.
Gregor cowered in a corner of the operating room like a borrowed sack of barley.
I left him be and started the surgery.
“DeBakey forceps.”
“Forceps.”
“Clamp.”
“Vascular clamp.”
When I called them out, the instruments were echoed back and placed perfectly into my hand.
It was all done without a hitch.
I began explaining to the healer while searching for the patient's arteries amid the mashed-up muscles.
“Team leader. Do you know what artery this is?”
“It's the femoral artery and the popliteal artery trifurcation. It's almost severed.”
“Right. What surgery do we usually do in cases like this?”
“We did a TIVS (Temporary Intravascular Shunt).”
The trauma team leader answered in trainee mode for the first time in a while.
It was so gratifying to hear the answer I wanted right away.
This is why I made this person team leader.
When I leave for the academy, someone has to run the clinic, after all.
“Correct. When a blood vessel was severed, we performed TIVS and then slowly reconstructed it afterward.”
TIVS (Temporary Intravascular Shunt).
It's a procedure that temporarily connects the severed ends of a blood vessel with an artificial vessel.
High-level healers are severely undersupplied compared to demand, and they're the kind of personnel who can't always stay at the clinic.
So we used this surgery to buy time for the leg, either while tracking down a high-ranking healer or before reconstructing the vessel.
“Do you think we could perform TIVS on this patient too?”
“I thought it might be possible... but.”
“Unfortunately, no.”
But this isn't a surgery we can do for this patient.
“First, the injured area is a special one.”
The damaged blood vessels are behind the knee.
One of the most mobile parts of the human body.
It's a part that moves even if the patient doesn't walk, just tosses and turns.
What happens if you connect an artificial vessel to a place like that?
“If you do TIVS in a place with this much movement, the vessel can come loose.”
The temporary vessel would just go pop! and slip right out.
Then you'd have a major disaster on your hands.
There was another reason too.
“The inside is a mess as well. I don't see any soft tissue that could hold the vessel in place.”
Another reason is that the tissues around the knee vessels are damaged far too severely.
Normally, when you insert an artificial vessel, there has to be muscle or some other tissue to support it.
But this patient is a mushy mess inside.
And considering that the area is, of all things, the knee, I had to assume the TIVS would definitely come loose.
“Lastly, due to crush syndrome, hypercoagulability(*hypercoagulable state) is suspected. That means the risk of thrombosis(*blood clot formation) is extremely high.”
On the way here, I drew a very small amount of blood from the right leg.
It coagulated way too fast.
“If we connect the artery around the right knee to save the right instep, the blood will clot and block the vessel.”
It'd be heartbreaking if we went to all that trouble only for it to clog up.
That's why we don't do TIVS in cases like this.
Instead, another surgical method was prepared for patients like this.
“I told you not to cover the left leg with the drape.”
I pointed to the patient's sleeping left thigh.
“We're going to save it by connecting the relatively healthy left femoral artery to the right ankle. The operation is called Cross-Limb Vascular Shunting (CLS).”
After finishing the explanation.
I had the trauma team leader move to a position where he could see the surgery well, and then.
I opened the left thigh and found the femoral artery.
“Heparin-coated silver cannula and vulcanized rubber tube, please.”
I applied heparin generously and connected the silver cannula to both ends of the vulcanized rubber tube.
Then I tied off the left femoral artery and the upper part of the mashed-up right popliteal artery with sutures.
“Vessel loop.”
“Vessel loop.”
“Clamp.”
“Clamp.”
“Ah, that's too far in. A little farther out. Yes. There. Yes. We're going to do a side-biting. Tighten the clamp when I say so. Not yet.”
The clamp stopped over the healthy thigh artery.
After putting the team leader on standby, I connected the silver cannula to the artery below the right knee.
And then.
“When I signal, clamp it. One, two... now.”
“Clamping.”
While the team leader blocked the artery for just a moment,
I jabbed the femoral artery with the silver cannula.
“Release the clamp.”
“Releasing.”
The team leader released the clamp.
Some of the blood from the left artery flowed through the patient's groin and down to below the right knee.
With that, the surgery was almost over.
Once I could catch my breath a little, I asked the healers.
“When did they say the high-ranking healer could come?”
“There are still a lot of people booked ahead, so they say he won't be able to come until the day after tomorrow.”
As expected.
CLS was necessary.
A leg starts to rot quickly once four hours pass without blood flow.
That's why surgery like this is necessary.
If we didn't do it, by the time the high-ranking healer arrived, we might have to amputate the leg.
“Good. When they arrive, assign them to this patient.”
“Yes.”
Whether in the 21st century or now,
medical resources are not equal for everyone.
Like people waiting for organ transplants or for reconstructive surgery.
Even in a world where miracles of divinity exist, that's why time-buying surgeries are still necessary.
“Let's check whether blood flow has returned, healer.”
“Yes.”
The bat-eared healer placed a stethoscope on the patient's leg.
Normally, a Doppler ultrasound device would be ideal.
Of course, it was the kind of equipment you couldn't expect in a world like this.
So we used a stethoscope instead.
By teaching a beastkin healer whose hearing was dozens of times better than mine.
'Good thing I learned how to use a stethoscope.'
For reference, it's a technique not normally used in 21st-century Korea.
Because South Korea is a medical-equipment superpower where you can even find a Doppler ultrasound on an island.
It was the kind of technique usually used by doctors who volunteered overseas a lot.
Yeah.
People like the sucker-fellow I was, who'd get fooled by a promise of tonkatsu.
“Blood flow's back.”
“Now... next...”
And just like that, the immediate crisis was put out.
“Let's start the debridement.”
*
After that, it was time to suture the shredded muscles and remove the bone fragments,
a savage hour of assembling the bones with nails and a hammer.
“Phew...”
It felt like I was completely drained after doing CLS for the first time in a while.
Still, I was a little proud.
Handling blood vessels again after so long had my adrenaline pumping and all that.
Thanks to that, I ended up in a strange state where I was drained but not tired.
“Good work, Student Aila.”
“You worked hard too, Director.”
After getting a light Refresh from Aila.
I called over the forgotten sack of barley.
“Mr. Gregor.”
“Yes, Saint.”
“Let's go to my office.”
The muscular man bowed and followed after me.
Gregor and I sat facing each other on the office sofa.
“Would chamomile tea be all right?”
“Thank you, Saint.”
Gregor answered with his shoulders slumped.
A steaming cup of tea was placed in front of the muscular man.
Sip.
We sipped our teacups in silence for a while.
A few minutes passed like that.
Gregor broke the silence.
“...Saint. May I ask you something?”
“Go ahead.”
Beneath my raven mask, I took a slow breath.
Because I could guess what he was about to ask.
Between my past life and this one, I had over a decade of trauma-surgery experience.
In a mood like this, the words that come out are always the same.
“...When saving someone who'd been crushed under something... was I always supposed to be this careful?”
Gregor lowered his gaze.
“Do you have to do all these complicated things—give fluids, call in a healer who can use detox magic, cut open the leg...—for a person to live?”
“...Yes.”
Saving lives was never easy to begin with.
How could you easily save someone who'd been pinned under that massive structure?
You had to watch for crush syndrome, solve compartment syndrome, deal with fractures, vascular damage, DIC, internal bleeding, infection, bone-marrow embolism....
There were more than one or two problems to consider while operating on today's patient.
“Human life... is heavy like this from the start.”
“Then...”
“...”
“Then... how many people has this one... who only knew how to lift things... killed with good intentions...?”
As I thought.
Hearing that question, I gently closed my eyes.
It was a common concern.
An inner demon that I, my seniors, and my juniors all go through at least once.
“How many people has my ignorance... led to death?”
His voice came out from beneath his deeply bowed head.
I said to the fully exposed crown of his head,
“Probably countless.”
His voice trembled.
“Then... am I a sinner?”
“...Yes.”
I continued,
“You and I are both sinners.”
?!
Gregor gasped and lifted his head.
“Saint?”
“Don't look at me like that. I had my shortcomings too.”
I had a time like Gregor's too.
The firefighter I lost because I didn't know tension pneumothorax.
The few mothers from Limbus Pit I lost because my obstetrics knowledge was lacking.
The patients under the black flag whose treatment was delayed because of my incomplete emergency triage.
No, let me correct that.
Maybe even now I'm still in that kind of time.
Because I had never once been perfect.
It was only thanks to the misunderstanding-fic correction that results beyond my ability appeared.
I was always nothing but a mistake-ridden, ignorant human being.
“Have you ever thought about why we can't hold sand in our hands, Gregor?”
“...”
“If even a handful of sand slips through, how many lives do you think have slipped through these hands?”
If I had been a little more capable, if I'd tried harder.
There were many patients I could have sent back to their families.
From my resident days until now.
There wasn't a single day I didn't regret something.
And yet I never let myself be buried by regret.
There were many methods I learned from my seniors.
Some relieved it with alcohol or cigarettes.
Some relieved it with games or movies.
Some turned to religion.
But the most effective method seemed to be this one.
“Then, Saint... how did you overcome it?”
“At times like that, I always think like this.”
This is a method a senior from pediatrics taught me.
“It's unfortunate for the people involved, but what can you do? Bury it in your chest, vow to do better, and move forward. Endure this era so the tragedies of those who passed through my hands won't be passed on to the next generation. All while hoping that, someday far off, a junior far better than me will appear.”
My memory's a little fuzzy, though.
I think that senior said something like this:
— [They'll call us quacks in future generations, but what can we do? Being born early is the crime. This damned rare disease will someday have a treatment too. Until then, we just have to hold on. If you don't have the confidence to solve it.]
“Our sin is that we were born too early into the world. So all we can do is endure this era and hope that, someday, this tragedy will be solved.”
*
While speaking with Gregor,
I remembered something the bishop, Gregor's godfather, had once said.
They say Gregor wasn't originally this cheerful a young man.
More precisely, he had been cheerful to begin with, but by the time just before he met me, he'd lost that brightness.
— “He was just an ordinary kid to begin with. A simple, innocent child who became a paladin because he admired heroes.”
But the tragedy began because he loved people too much.
Though he was a paladin, he couldn't bring himself to cut people down.
So he focused only on rescue.
But as you can infer from the questions he asked me,
his rescue efforts didn't save people.
As an inquisitor, he couldn't cut people down.
As a paladin, he couldn't save people.
A world where good intentions alone can't bring about the best outcome.
Amid repeated failures, within the society called the Order, he was branded an incompetent man.
People of the Order gradually began to turn their backs on him too.
As one year, then another, passed like that,
Gregor supposedly became a young man who spoke less and less.
The farthest corner seat in the dining hall.
The very back row at mass.
The most remote patch of sand on the training grounds.
And when only the edges of rooms had become his nest,
— “And then you... Saint, chose my son.”
They say I chose him.
— “That boy... is hiding himself inside his muscles right now. If he doesn't do that... it would be impossible for him to endure.”
Gregor, who came out of his room because of me, looked imposing from the very first meeting.
A boisterous young man overflowing with confidence, loving his own muscles, and proud of the history of his Erdenu sect.
But in truth, he was only wearing muscle as armor and acting confident.
— “I understand that the boy is a burden. But... that too will be temporary. He is getting better. If you could just... just bear with him a little longer, I would be grateful. I'll talk to him properly.”
It was a kind of bluff.
To hide his own incompetence.
And to avoid disappointing me, the saint.
So I never disliked this proud side of Gregor's.
If anything, I liked his way of doing things.
Because when I'm having a hard time, I act ridiculous and bluff too.
If that gives the people around me strength,
then they usually end up overcoming it somehow.
So I tend to respect Gregor's way.
Me volunteering to be a clown was also one way I dealt with the dogshit reality of my previous life.
“Gregor.”
“...”
Back to reality again.
I called out to the muscle-bound giant who had shrunk as much as possible.
“You can't save people with good intentions alone. You and I are both sinners. Maybe all we can do is just endure. But...”
Gregor collapsed.
The moment he witnessed that his good intentions had been headed in the wrong direction.
I poured tea into the poor man's empty cup and kept talking.
“Even so, we have to keep moving forward. If we chose the wrong answer, we record that too so later generations won't repeat it. If you think of us as nothing more than a bridge of hope leading to the answer at the end, it becomes a lot easier on the heart.”
“Saint...”
“Even if you're afraid of making mistakes, puff out your chest proudly and shout as you always do. Someone will surely find hope in that majestic attitude of yours.”
It's impossible not to make mistakes.
So.
It would be better to at least try to pass on hope.
“Wouldn't it be a little better if you took pride in the role of reminding people not to forget hope and composure?”
Gregor's shoulders trembled slightly.
“...Then... you're saying I'm not just some lowly beetle?”
Beetle.
It was Gregor's insult of choice.
It was a jab at his muscles—hard as stone, yet useless for anything.
I didn't much like that sort of slur.
So I denied it. He wasn't a bug.
“If you just lift your head a little, you'll see the people who love you waiting for you to come out of your room. So you can't go around calling yourself a bug.”
People don't want bugs appearing right in front of them.
Put differently, if there's even one person waiting outside the room,
the one inside the room isn't a bug.
And among the people waiting for him is the bishop.
There are also the paladins who follow him.
And the citizens he saved.
For a bug, he was receiving far too much love.
“Didn't the gods give you such tremendous talent because they love you? Wasn't that why you were offering prayers of thanks every dawn?”
“...”
I smiled faintly beneath my mask.
Though he wouldn't be able to see it.
Gregor lowered his head without saying a word.
Drip-drip.
Droplets fell into the teacup he was holding.
Pretending not to notice, I lifted my mask a little and sipped my tea.
“A cup of tea you drink after saving a life is special. Isn't it?”
Nod.
Gregor nodded in silence.