Saijô no Meii
Primary and secondary
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Saijou no Meii – ch24
To be used exclusively by Trinity Bakuma
Title: Primary and secondary.
Ryoma: So Saijou is gonna dress like a girl so he can observe?
Ryoma: That’s gotta suck for him.
Sena: I do feel bad for putting through this, but…
Sena: I just have this really bad feeling…
Ryoma: Well it’s not surprising.
Ryoma: Among pediatric surgeries, pulmonary atresia isn’t an especially difficult one to fix, but…
Ryoma: The littlest mistake can turn into a huge problem fast. There are a lot of cases that end up that way.
Ryoma: Do you know what pulmonary atresia is?
Sena: In a healthy heart, the blood circulates like this.
From the upper body To the rest of the body
To the lung To the rest of the body
From the lung To the lung
From the lung
From the lower body.
A healthy heart
Sena: A heart with a pulmonary atresia has its pulmonary valve closed. Instead a hole forms between the atriums for the blood to flow through.
Hole (how the blood flows through)
Closed off (pulmonary valve)
A heart with a pulmonary atresia.
Ryoma: That’s right.
Ryoma: But in that state, no matter how much blood flows through the hole, blood never gets to the lungs. The blood doesn’t get enough oxygen and the child will die.
To the lungs – To the lungs
Where the blood should flow.
Where the patient’s blood is flowing.
Even with a hole opened up, since the pulmonary valve is closed off, blood can’t get to the lungs.
Ryoma: It’d all be okay if you have this arterial canal, though.
Sena: With the arterial canal connection, blood can still make it to the lungs.
From the upper body To the rest of the body Arterial canal.
To the lung
From the lung The Pulmonary Atresia To the lower body. To the lung
From the lung
From the lower body.
Sena: Unfortunately, this canal naturally closes up soon after birth, so we have to surgically insert an artificial vessel in its place.
Artifical vessel. The arterial canal naturally closes on its own.
The pulmonary atresia.
*Everyone has this arterial canal and it always closes up on its own. For healthy people this isn’t a problem, but people with a pulmonary atresia will die without it.
Ryoma: But this arterial canal is narrow and extremely fragile.
Ryoma: In an actual case, one doctor unknowingly severed this arterial canal while peeling away other blood vessels in the vicinity.
Sena: If the arterial canal gets severed before the artificial canal is put into place, the blood won’t get to the lungs and get any oxygen…
Sena: That’d be the worst thing that could happen…
Ryoma: Hey, hey.
Ryoma: I understand that you’re worried, but there’s no need to be so scared is there?
Ryoma: It’s not like there’s definitely going to be a mistake.
Ryoma: No matter how stupid this guy is, he’s not gonna be stupid enough to cut what he isn’t supposed to cut.
Ayame: Guh…my stomach seriously hurts.
Sfx: *sharp pains*
Miyabi: Mine too.
Ayame: If I was cutting, this’d be no problem but…
Ayame: Our lead surgeon is this tool.
Sign: (Ayame’s dumbass senior) Chief physician of the cardio-vascular department – Haga Jyunichi
*The chief physician is like a chief in a regular company.
Ayame: This douche bag, all he does is show-off and brag about himself even though he has no skills or experience.
Miyabi: We have a problem Ayame.
Miyabi: Your chief is talking to Mikoto.
Miyabi: If he finds out who she is…
Ayame: It’ll be fine.
Haga: Toujou Meiko-san, is it? What a beautiful name. You’re the first one here to observe my surgery.
Haga: Recently, there’s been this upstart pediatric surgeon who apparently got the MSA in America, acting all high-and-mighty.
Haga: You know, pediatric surgeons aren’t even a big deal in America.
Haga: I would know, since I’ve been to Harvard.
Miyabi: That guy worked at Harvard?
Ayame: No, it was a study abroad.
Haga: I must have performed on at least a thousand bodies…
Miyabi: A thousand is an impressive amount.
Ayame: They were all on mice.
Ayame: You know how it goes.
Ayame: People who use their connections with their university medical department to study abroad, but all they do is practice on mice.
Miyabi: Ah yes, those people.
Miyabi: They have no skills or know any English, so all they can do is practice on mice.
Ayame: Yeah, that’s this guy.
Ayame: All he’s ever done is cut up mice, but when he comes back to Japan he starts bragging to everyone.
Haga: I’m sure there will be much to learn from observing a top notch surgery by an adult heart surgeon.
Haga: You appear to be quite the beauty, but you can’t become a great surgeon like me with looks alone.
Ayame: The only good thing about him is he’s too much of an idiot to be so close to Mikoto and not realize it’s him.
Haga: Oh, and Dr. Ayame.
Ayame: What is it?
Haga: Well, it’s not a big deal, but…
Haga: There’s only one observer so far, so maybe we should wait a little longer.
Ayame: This dumbass…
Ayame: Did he really think he’d get observers for this surgery?
Ayame: Listen, Dr. Haga.
Ayame: All we’re doing for this surgery is implanting an artificial canal in place of the arterial canal that will close up on its own. We’re only cutting through two thirds of the pericardium.
Artifical canal Arterial canal
Ayame: It’s one of the simplest of pediatric surgeries and is hardly anything new.
Ayame: So one observer is enough.
Haga: That’s where you’re wrong.
Haga: When that Saijou person operated, I heard that many people came to observe, even though it wasn’t an especially new procedure.
Haga: I bet he was just so jealous of my skills that he pressured the young doctors to come watch.
Haga: He’s such a deceitful man.
Ayame: Miyabi, can I please punch this guy?
Miyabi: Hold it in.
Haga: We will now begin the operation on a one month old with a pulmonary atresia.
Haga: Hmph. In the end, only one observer came.
Haga: Oh well.
Haga: Even if it’s just one person, at least someone is learning from my abilities.
Haga: I’ll show her just how amazing a cardiovascular surgeon really is!
Haga: Cutting through the middle of the chest.
Haga: Removing the right thymus.
Haga: Debakey forceps.
Miyabi: Hmm. He’s quicker than I thought.
Miyabi: Despite his loudmouth and idiocy, could he actually have above average skills?
Haga: Beginning severing of the brachiocephalic trunk.
* The bottom diagram is a view of the heart without the pericardium. The brachiocephalic trunk is circled. In the diagram there are gaps between the blood vessels, but in actuality there aren’t any. When performing surgery, it is necessary to peel them apart.
Miyabi: No, he’s just trying to show off by speeding through. He’s not being careful at all.
Haga: Hand me the electric scalpel.
Ayame: Heh, his speed as surpassed his actual skills.
Ayame: When it comes to surgery, it’s more important to do everything properly and carefully, rather than quickly. But this guy…
Ayame: What’s that?
Ayame: There’s something…
Ayame: Wait a second, Dr. Haga.
Haga: Finished peeling away the brachiocephalic trunk.
Ayame: I said wait a second!
Haga: Shut up!
Haga: The surgery is going well.
Ayame: Like hell it is!
Ayame: Look! There’s a major bleed!
Haga: Oh that.
Haga: While I was peeling away the brachiocephalic trunk, I had to cut an abnormal blood vessel. It doesn’t go anywhere important.
Abnormal blood vessel.
Haga: An abnormal heart like this is bound to have extraneous blood vessels like this.
Haga: Anyways, I’m binding them with a ligature now, so be quiet.
Ayame: Listen to me!
Ayame: It’s true that extraneous blood vessels aren’t surprising for a heart like this, but…
Ayame: What you just cut…
Ayame: Was probably the second arterial canal!
Haga: The second arterial canal?!
Ayame: Some children have two arterial canals, but the one on the right (the person’s right, the diagram’s left) is hard to find before you open the person up.
From the upper body To the body
To the body Hard to find
To the lung The Pulmonary Atresia
From the lung
* Not only is the right arterial canal rare, but when it does exist it gets hidden behind the lung on images (x-rays, sonogram, etc.) so it is extremely hard to find during examinations.
Ayame: You don’t even know about that?!
Haga: I-I do know about that!
Haga: But, even if that’s what I cut, if I connect the artificial canal right away…
Miyabi: This isn’t good, Ayame.
Miyabi: I started transfusion and administered phenylephrine, but the oxygen is still dropping!
Miyabi: It looks like he did cut the arterial canal.
Haga: Now, everyone calm down.
Haga: I told you, since there are two, if the other one can hold…
Ayame: Are you fucking serious?!
Ayame: That’s sometimes the case, but since the oxygen saturation is still dropping, the one you cut must have been the primary canal and while the other one is the secondary canal!
From the upper body To the body Secondary
To the body Primary
To the lung The Pulmonary Atresia
From the lung
Ayame: The secondary canal hardly does anything!
Haga: No way…
Haga: This can’t be happening…
Haga: I, I didn’t know. It’s not my fault…
Haga: Do something about this.
Ayame: Useless piece of shit.
Ayame: But now’s not the time worry about him.
Ayame: Get a heart-lung machine ASAP!
Ayame: And call for any clinical engineers to get in here!
Ayame: Miyabi, have you given him prostaglandin?!
Miyabi: I did!
Ayame: Good, then lower his body temperature as low as you can and…
Miyabi: Already on it!
Miyabi: I’ve lowered the room temperature and am preparing ice packs and cooled down transfusions.
Miyabi: You don’t need to worry about my end. You just concentrate on your part.
Ayame: Thank god he’s reliable!
Ayame: But no matter how good he is…
Ayame: It’ll take at least fifteen minutes to setup and attach the heart-lung machine.
Ayame: Even if we do save his life, the lack of oxygen will affect his brain.
Ayame: Cutting the pericardium!
Ayame: poor thing…
Ayame: He’s just a little baby…
Ayame: What would…
Ayame: What would Mikoto…
Ayame: What would he do?
Ayame: That’s right! Mikoto!
Ayame: What’s he doing?!
Ayame: With his help, maybe we can do this quicker…
Mikoto: It’s no use Ayame.
Mikoto: We won’t make it in time with that.
Haga: Is that Saijou Mikoto?!
Haga: What did he…
Ayame: What do you mean we won’t make it? Do you have another idea?
Mikoto: I prepared these while I was putting on my gown.
Mikoto: We’ll stick these right into the heart!
Ayame: Two indwelling needles and…an IV tube…
Ayame: Wait! Are you thinking…!
Ayame: Are you thinking of sticking them into the aorta and the pulmonary artery to act as the arterial canal?!
(ligatured to stop the bleeding) Aorta
Ayame: Are you serious?! That’ll cause a major bleed!
Mikoto: If we attach the tube right away, we can avoid enough bleeding.
Mikoto: Right now, getting oxygen into the blood is more important than some bleeding.
Ayame: Are you sure, Mikoto?! If you mess up, you could lose your medical license!
Miyabi: He’s right Mikoto.
Miyabi: Even if you succeed, who knows what repercussions there’ll be.
Mikoto: But I can’t just let him die.
Mikoto: There’s this one doctor whom I respect the most.
Mikoto: He sacrificed everything to save a child.
Mikoto: I don’t care if I lose my license.
Mikoto: I’m still a doctor.