Black Pean Information #24-25

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Medical commentary on episode 7 (1)

Not only this time but throughout the whole of Black Pean, we have focused on the duties and responsibilities of a lead surgeon towards their patients, and in this episode Dr Tokai summarised it in just six words: “There’s a patient. I save them”.

“No matter where I go, what I do doesn’t change.”

There were a lot of things in episode 7 that deserve medical explanations, so I don’t know if I’ll be able to explain them all, but this time I’ll discuss Kaori’s experience of medical malpractice.

Kaori’s experience of medical malpractice

Heart surgery is a bit more difficult than most types of surgery, because in most operations the medical engineer (ME) runs the heart-lung machine, the anaesthetist looks at the transoesophageal ultrasound image during the surgery, and a lot more surgical tools and lots of needles and thread are used so the scrub nurse also has a lot to do.

The (lead) operating surgeon needs the support of the first assistant, the second assistant, the ME, the anaesthetist, the scrub nurse, the manufacturers of the needles, thread, prosthetic valves and vessels and other medical devices, as well as various other people to perform the surgery, and they have to protect the patient’s life and save them. The need to have the kind of cooperation and leadership skills that let them give accurate instructions to people from various different industries and work with the highest level of teamwork. It’s no exaggeration to say that heart surgery is the ultimate team-based medical care, but in this drama, Dr Tokai often emphasises the “surgeon’s responsibility”.  If anything happens to the patient, the surgeon is fully responsible. There are cases where this is obvious and also cases where it’s not so obvious, like when an assistant makes a mistake during the operation, the patient’s condition gets worse or the nurse makes a mistake, which can really happen during surgery.

Kaori was also blamed for a medical error, and she has a sad past where she was thrown out of the hospital. In this scene, the patient’s condition suddenly deteriorated and they had to attach the heart-lung machine.

The heart-lung machine has appeared several times so far, and doctors working on the circulatory system use it to stop the patient’s heart and respiration. It is a medical device that works by replacing the functions of the heart and lungs, with a venous line going into the vein and drawing out venous blood, oxygenating the blood with an artificial lung, then pumping the oxygenated blood back into the artery through the arterial line. This means the body’s cells and tissues can continue to receive oxygenated blood from the heart-lung machine instead of the heart.

To explain specifically how to set up a heart-lung machine, we often hear Nekota say “bring the arterial and venous lines!”. The arterial line is inserted into an artery (usually the ascending aorta or the femoral artery in the leg) and the venous line is inserted into a vein (usually in the left atrium or the femoral vein). Next, the ME starts the circulation of the heart-lung machine (bringing it up to the operating field). At this point, the circulation goes into a single tube, connected to the artificial lung and the pump at the bottom (on the ME’s side). That tube (circuit) is split, with the arterial side going into the artery and the venous side going into the vein, then the heart-lung machine is started. If the machine is started connected the wrong way around, this will cause huge problems. A large amount of blood would be removed from the artery and sent into the vein, removing blood from the side that should be sending it to the tissues (from the arteries to the brain, heart and other organs), so no blood would reach the tissue, which would suddenly develop an oxygen deficiency; meanwhile, a lot of blood would be sent into the veins, on the route vein -> right atrium -> right ventricle -> lungs, so a large amount of blood would flow into the lungs at high pressure, causing the lungs to start bleeding. When setting up a heart-lung machine, every individual step of the set-up process must be checked, and if it is started without checking everything properly, this can cause a major accident. With the proper training, you can set up a heart-lung machine in about 10 minutes, but it takes some time to be able to do it smoothly and safely. Even during a patient emergency, you have to stay calm, make objective decisions and keep working quickly, so you need a strong mentality, dexterity, quick wits, intuition and good observational skills.

If you panic when the patient’s condition suddenly deteriorates, like the surgeon did in Kaori’s experience of medical malpractice, and you don’t know what to do, there are doctors everywhere who would raise their voices at the other staff members. When I was a resident and I panicked, I sometimes raised my voice. When I said “quickly, quickly, intubate!” (insert a tube into the trachea to support the patient’s breathing) to a nearby nurse, my superior slapped the back of my head really hard. “You can’t be the most panicked one here. In an emergency, you should be calmer than anyone else and give orders.”

Kaori passed the heart-lung machine's venous line to the lead surgeon as he ordered, sending the patient into cardiac arrest, but really this is entirely the lead surgeon’s responsibility. When connecting the circuit, you should also check that everything is correct, and before starting the heart-lung machine, you quickly make various checks to see whether it’s properly connected, whether there is air in the tubes, etc. This surgeon lost his cool, or maybe he wasn’t trained properly, and he made a mistake when he started the heart-lung machine.

No matter how you look at it, this is the lead surgeon’s responsibility, but Kaori was made to take the blame and was fired as a nurse.

If that surgeon had had the expected “There’s a patient. I save them” spirit, this might not have happened.

* In reality, it would be the assistant doctor and not the nurse who set up the heart-lung machine, and that doctor would have been trained in using the heart-lung machine, so this kind of thing shouldn't happen. Don’t worry.

Next time, although the set report also discussed this, I will talk about Dr Tokai’s surprising and moving surgery scene at Teika.

Medical commentary on episode 7 (2)

Tokai’s surgery at Teika

Heart surgery requires team-based medical treatment and is performed by the lead surgeon and first assistant, plus at university hospitals etc. the second assistant, residents, and so on, so there can be up to four or five people in there. The procedures for the lead surgeon, first and second assistants are all fixed for each type of surgery; for example, when suturing an aorta, the lead surgeon holds the needle holder and 4-0 thread in their right hand and the DeBakey in their left hand, the first assistant arranges the thread with their right hand and uses their left hand to hold up the appropriate part of the aorta with a DeBakey to make it easier to suture, and the second assistant holds the suction tube to remove blood with their right hand and uses a DeBakey in their left hand to move surrounding tissue out of the way. If the first or second assistant is too slow, the lead surgeon will quickly get annoyed. In other words, the lead surgeon usually can’t work without the support of the assistants.

However, in Black Pean and particularly with Dr Tokai, there are many scenes where people operate without needing much help from the assistants. Even in episode 2, the Spartan Dr Tokai made Sera suture a prosthetic blood vessel by himself. He’s not a Brazilian football player, but without relying on your own abilities, this kind of thing is impossible. A top-class surgeon can rely on their own abilities, no matter what is going on around them. They may even go and operate at a different hospital, but can still perform just as well even in this kind of unfamiliar setting. Just by operating together for a few minutes, you can tell how good your assistants really are, give them the instructions they need and complete the surgery. Dr Tokai’s level is even higher than this, and he can do most surgeries all by himself. This time, we saw a scene that demonstrates this where he operated at Teika.

Actually, the first person to say that this scene should give the feeling of operating alone was Ninomiya. He said “Is there a kind of surgery that can be done by one person? I want to operate by myself at Teika,” and I answered that a coronary bypass can be done by just the lead surgeon and a single nurse. Actually, you technically could do without the nurse by preparing your own instruments. And we set up various things to produce this scene... I was honestly surprised and I think it’s amazing that Ninomiya, who didn’t know anything about heart surgery, thought of this way to demonstrate the character’s real abilities as a surgeon.

We also discussed it with the director, and I was told that they wanted the operation to start with a real bang, with Dr Tokai giving orders in a rage, so we created the line where he lists off the tools needed for a coronary bypass.

Whenever we want to add new lines on the day, we usually add only one or two specialist terms to make it easier for the viewers to understand, but this time we got to add the list of tools “stabiliser, CO2 blower, holder, Beaver scalpel, micro-scissors, micro-needle holder and 8-0” on the day.

We also saw a coronary bypass in episode 3.

“This operation involves suturing the patient’s own blood vessel (grafting) onto the blocked or almost blocked coronary artery around the heart to create a new route for blood flow (make a bypass). While using the rib retractor in order to do a bypass graft using the internal thoracic artery (which is quite difficult), deciding on the eyeline needed when removing the internal thoracic artery while sitting in a chair, deciding how to hold the right hand and saying a long line, order the assistant to remove the saphenous vein (a vein in the leg used for a bypass graft). Once the internal thoracic artery is removed, tell the assistant that he was too slow at removing the saphenous vein and remove it yourself. For the bypass anastomosis (where the graft and the coronary artery are sutured together), hold microtweezers in your left hand and use the Beaver scalpel in your right hand to cut the coronary artery, expand the opening with the microscissors, insert the shunt tube, make an incision for the graft and use the 8-0 thread to attach everything. When suturing the anastomosis, your posture should be as if you’re peering in, and please suture it and tie the knots at this sort of speed.”

I told him that, he said “yes, I understand,” and... he was able to do it all in the real take.

When I watched this scene on the monitor, I happened to meet the director’s eyes and we both burst out laughing, because I honestly didn’t think he’d be able to do it. He remembered the angles of the tweezers and electric scalpel when removing the internal thoracic artery, his eyeline, the feeling of a first-class heart surgeon and even that long line, perfectly. His pronunciation when he said “You take out the saphenous vein”, his tone of voice when he said “You’re too slow!”, his movements when removing the saphenous vein and his posture when suturing the coronary artery, the ordering and positioning of tools, the way he handled them, the metallic sound when he put them down -- everything was just like a first-class heart surgeon. I wrote before that heart surgery is both art and science, but I really felt like I was looking at a work of art.

The blue pencil-like tool in the operating field was the CO2 blower, which blows carbon dioxide into the blood coming from the vessel (coronary artery) and makes it easier to suture. Properly, the assistant should hold this tool, but we prepared a holder so that Dr Tokai could set it up himself and didn’t need an assistant. While operating away at Teika, he did a perfect coronary bypass all by himself. Not only did this scene show his outstanding surgical technique, but it also showed Ninomiya Kazunari’s stunning talent.

At the end of the scene, his lines “Doctors with no skill should just die. You can write that in your paper.”, “There’s a patient. I save them. That’s it.” and “No matter where I go, what I do doesn’t change” really shook me.

Does such a striking drama really exist?

Next time, I’ll talk about aortic valve replacement surgery using the Caesar and about clots in the left atrial appendage.

I probably won't have time to translate part 3 before episode 8 airs (since they haven't posted it yet), so I'll post that separately later.