Introduction to Critical Moments
Throughout seven decades of medical practice, I have experienced numerous critical situations where life hung in precarious balance—moments when decisions made under pressure determined whether patients survived or perished. These life-and-death experiences, while representing minority of overall practice, create indelible memories that shape physician identity and practice philosophy in profound ways.
This chapter presents selected episodes from throughout my career illustrating different dimensions of these critical encounters. While maintaining patient confidentiality through appropriate anonymization, these accounts preserve the essential elements of actual clinical experiences that proved formative in my development as surgeon and physician. They range from early career cases managed with minimal resources to complex interventions in better-equipped settings later in professional life.
These narratives serve multiple purposes beyond mere dramatic recounting. They illustrate practical application of surgical principles in challenging circumstances, demonstrate evolution of both technical capabilities and decision-making approaches across different eras, and reveal the human dimensions of critical care that transcend purely technical aspects of medical intervention.
For younger practitioners, these accounts may provide perspective on practicing medicine in resource-limited settings while maintaining focus on fundamental principles that remain applicable regardless of technological context. For general readers, they offer glimpse into realities of medical decision-making under pressure that rarely appear in idealized media portrayals of healthcare dramatics.
While certain technical details necessarily reflect medical knowledge and capabilities of their respective eras, the human elements—decision-making under uncertainty, communication during crisis, maintaining focus amid chaos, balancing hope with realism—remain remarkably consistent across time periods. These enduring aspects of medical practice connect generations of physicians across changing technological landscapes.
Early Career: The Ruptured Ectopic Pregnancy
One formative early experience occurred in 1963, approximately two years into my surgical practice at Nanling County Hospital. A 26-year-old woman arrived by ox cart from a distant production brigade, having collapsed while working in the fields. She presented with profound hypovolemic shock—barely detectable blood pressure, rapid thready pulse, and extreme pallor. Brief history from accompanying family members indicated missed menstrual period and sudden onset of severe abdominal pain preceding collapse.
The clinical presentation strongly suggested ruptured ectopic pregnancy with massive intraperitoneal hemorrhage—a life-threatening emergency requiring immediate intervention. However, several critical constraints complicated management: no blood bank existed at our county facility, laboratory testing was limited to basic hemoglobin measurement, and anesthesia capability consisted of mask-administered ether without intubation capability or sophisticated monitoring.
Faced with clearly moribund patient who would certainly die without intervention, I made rapid decision to proceed with emergency surgery despite suboptimal conditions. While surgery began, we implemented desperate measures to address critical blood loss. The patient's husband and two male relatives volunteered as direct donors, with crude bedside cross-matching performed using glass slides to detect obvious agglutination. Direct transfusion proceeded using basic tubing connecting donors sequentially to the patient.
Upon entering the peritoneal cavity, we encountered massive hemoperitoneum with approximately 2.5 liters of blood and clots. The ruptured right fallopian tube with attached ectopic pregnancy was quickly identified and removed. Throughout the procedure, anesthesia remained problematic, with patient's tenuous hemodynamic status complicating appropriate anesthetic depth management.
The operation succeeded in controlling hemorrhage, but the patient remained critically ill throughout the night, receiving additional direct-donor transfusions from brigade members who arrived during surgery. Basic post-operative monitoring consisted of hourly blood pressure checks, pulse monitoring, and clinical assessment of perfusion without laboratory guidance or electronic monitoring.
Against considerable odds, the patient survived both the acute crisis and post-operative period. She gradually recovered over three weeks in hospital before returning to her village. The case represented technological limitations overcome through rapid decision-making, creative resource utilization, and community mobilization supporting medical intervention.
Twenty-five years later, in 1988, this same patient sought me out at Wuhu Changhang Hospital where I had since relocated. She brought her 24-year-old daughter and infant grandson to meet "the doctor who saved our family." Despite losing one fallopian tube, she had subsequently conceived and delivered a healthy daughter who now presented with her own child. Three generations stood before me—living testimony to the far-reaching impact of a single successful operation and the body's remarkable compensatory capacity.
This case, while reflecting medical practices no longer standard in contemporary settings, illustrates several enduring principles: decisive intervention despite suboptimal conditions when alternatives guarantee poor outcomes, creative resource utilization during crises, and recognition of community support as essential element of successful medical care in resource-limited environments. The longitudinal follow-up across decades also demonstrates surgery's profound impact extending far beyond immediate survival to influence subsequent generations.
Rural Trauma: The Thresher Accident
In August 1969, during harvest season, a 19-year-old agricultural worker suffered devastating injury when his right arm was pulled into mechanical threshing machine. Fellow workers transported him 28 kilometers to our county hospital via tractor-pulled cart, applying improvised tourniquet that likely prevented immediate exsanguination but created its own complications.
When the patient arrived approximately two hours post-injury, he presented with near-complete traumatic amputation of the right arm at mid-humeral level, with the limb attached by only a narrow skin bridge and partially intact neurovascular bundle. The improvised tourniquet, fashioned from rubber tubing, had been continuously tightened for the entire transport duration, creating concerns about ischemic damage and reperfusion injury.
The management decision presented difficult dilemmas given our limited resources. Complete traumatic amputations typically warrant consideration for replantation in optimal settings with microsurgical capabilities. However, our facility lacked microscopic equipment, microvascular expertise, and necessary support systems for such complex reconstruction. The prolonged warm ischemia time further reduced chances for successful replantation even in ideal settings.
After rapid assessment, I determined that attempted limb salvage would likely result in both failure and increased patient risk given our capabilities. Instead, we focused on performing definitive completion amputation with appropriate tissue management to optimize subsequent prosthetic fitting and rehabilitation potential. While disappointing compared to limb salvage possibilities in more advanced centers, this approach prioritized patient survival and realistic functional outcomes within our setting's constraints.
The procedure involved careful exploration of remaining neurovascular structures, appropriate nerve handling to minimize neuroma formation, myoplasty to stabilize muscle groups, and tissue-sparing techniques preserving length while ensuring adequate soft tissue coverage. Throughout surgery, we maintained awareness that functional outcome would depend not merely on surgical technique but on subsequent rehabilitation and prosthetic fitting quality.
Post-operatively, we faced another crisis when the patient developed acute kidney injury from myoglobinuria secondary to crush injury and reperfusion—a complication we anticipated but had limited capacity to address given absence of dialysis capability. Management relied on aggressive hydration, urinary alkalinization using available agents, and careful electrolyte management with limited laboratory monitoring. The patient survived this complication through combination of appropriate supportive care and remarkable physiological resilience.
Rehabilitation began during hospitalization using locally manufactured temporary prosthesis constructed by hospital maintenance worker with previous experience creating similar devices. This early prosthetic fitting, while rudimentary, allowed initial adaptation and prevented psychological devastation sometimes accompanying delayed prosthetic provision. The patient eventually received more sophisticated prosthesis through disability program, though still basic by contemporary standards.
This case exemplifies essential principle of appropriate care level selection rather than attempting interventions exceeding realistic capability. While limb replantation represents theoretically superior outcome, attempted implementation in setting lacking necessary resources would likely have resulted in catastrophic failure potentially costing patient's life. The decision to perform definitive, appropriate-level intervention rather than attempted heroic procedure beyond our capabilities represented sound surgical judgment despite its apparent technical simplicity.
The case also illustrates how optimal care sometimes involves not merely technical management but engagement with broader rehabilitation and psychological support extending beyond acute surgical episode. The coordination with prosthetist and early rehabilitation initiation proved as important to eventual outcome as the surgical procedure itself, demonstrating the comprehensive care perspective essential in resource-limited settings where specialty referral options may be limited or unavailable.
Cultural Complexities: The Refusal of Blood
In the mid-1970s, a 42-year-old woman presented with massive upper gastrointestinal hemorrhage secondary to previously undiagnosed peptic ulcer disease. Endoscopic capabilities were unavailable at our facility during this period, limiting both diagnostic precision and non-operative management options. The patient required emergency# The Li Family Legacy
A Surgeon's Journey Through China's Transformation
FOREWORD
The Brothers Xin Wei devoted their patience and energy to compile this monumental work, "The Li Family Legacy," now published in two volumes totaling six hundred thousand words. This work reconstructs times and places past, bearing witness to societal changes, and tracing the cultural lineage of a scholarly family passed down through generations. It also fulfills the wishes of several generations of the Li family.
My grandfather, Li Xiansheng (1871-1935), the principal author of "The Calligraphy Legacy of Teacher Li," followed his father's aspirations by emphasizing education. Adapting to changing times, he founded the Chongshi Academy, later renamed Chongshi School. Moving beyond traditional education centered on Confucian classics and classical literature, he introduced mathematics, natural science, English, physics, chemistry, history, music, art, geography, and other subjects. The school was equipped with organs, pianos, Western drums, and horns. He sent his second son to study in Japan, where he earned degrees in law and political science from Meiji University. Upon returning to China, his son established the Eighth Normal School and the Provincial Chengcheng Middle School in the provincial capital of Anqing, while also supporting the family business. Under their combined efforts, the Chongshi School flourished, attracting numerous students. The Li family compound thrived during this period, nurturing many future pillars of society.
After my grandfather's passing, to honor their father's teachings, his eldest son Li Yingwen (1896-1965), together with respected scholars and disciples, published "The Calligraphy Legacy of Teacher Li" in 1935. This edition also included works by his third brother, Li Yinghui (1902-1932), who had died prematurely, as a tribute to his memory. As a collection of folk historical and literary materials, "The Calligraphy Legacy of Teacher Li" is now being reprinted as part of "The Li Family Legacy," demonstrating the continuity of our family's grassroots cultural heritage. Beyond its literary value, "The Calligraphy Legacy of Teacher Li" offers life lessons to posterity. This rare traditional Chinese text, written in the transitional style between classical and modern Chinese, reflects the progressive spirit of its time. After nearly being lost to time, its typesetting and reprinting represent a significant contribution to the preservation of our family's cultural heritage.
Time flows like a river, and the world undergoes tremendous changes. By learning from the past, we can continue the legacy for future generations. All of us, the Li family descendants, have compiled this book, "The Li Family Legacy," which uses simple language to truthfully record modern social transformations and the human responses to them.
"River of Life in Hanyang" (by Li Yangxin, among the first university students after the Cultural Revolution, who also authored "Verdant Days in a Small Town") wrote "Chronicles of River City," expressing his understanding and feelings about his homeland, future, and life, revealing a loyal heart.
"Morning Gleanings" by Li Wei (Ph.D., Chinese-American, computational linguist) showcases the life journey of an overseas Chinese who drifted across three continents, experienced two forms of rural labor and research, and then struggled to establish himself in a new land.
I, Li Mingjie, wrote "Seasons of Wind and Rain," narrating the legendary career of an ordinary Chinese surgeon. Beginning my medical practice in the 1950s, I tackled numerous clinical challenges and climbed to the position of Chief Surgeon. Diligently working until today (2022), I continue without pause, still on duty, cultivating my own small plot of expertise, finding contentment in this.
— Li Mingjie, 2022
