Stop it. It's no use.
I've had enough of being ordered around. Thank you for everything.
If anyone leaves we can continue running, that's a real team.
Can that child be saved? Poor thing.
The patient exploited just for the survival of surgical department.
Enough!!
- Weak pulse. Shock state. - Incoming stretcher!
Echo!
Immediately ask for cardiac consult!
I've been trying to contact Asada-sensei in Joyo.
You can go, Ijyuuin.
Do a good consult, on behalf of Cardiology.
- Blood pressure less than 60! - It's too late!
- Sensei, please. - Eh?
Asada.. sensei.
- Asada-sensei..? This person? - Anyways,
bring him to Operating Room immediately. Contact OR. - Yes.
Pupillary light reflex is sluggish, check with Echo again!
- Yes. - Excuse me.
Tricuspid and mitral chordae are ruptured.
Severe blood reflux, especially at mitral valve,
it has stop functioning as a valve.
- Asada! - X-ray is here.
Acute heart failure, and also pulmonary edema.
Pulmonary edema? It's bad! O2?
Already 100% pure oxygen.
- PCPS standby immediately! - Yes. (TN: PCPS = percutaneous cardiopulmonary support)
Ijyuuin.
Kato-sensei needs a while to arrive.
Valve chordae is unexpectedly ruptured.
That doctor only has 6 years, no matter how great a cardiac surgeon,
with only 6 years experience, it's absolutely impossible.
Ijyuuin-sensei!
Asada..?
There's no doctor who can do the operation.
There's left ventricular dysfunction in the bypass here,
symptoms of bradycardia now, we can't leave.
What now? Kato.
Pupils are dilating.
If not operated on immediately, his heart may stop beating.
- Asada will die. - Kato-sensei..?
Now tied up in an operation, still needs two hours.
Operating room is ready.
Only you can save Asada now.
But, mitral and tricuspid valves reconstructive surgery, I..
- I can't do it. - There's no one else besides you!
What? What happened?
Don't move!
It's OK, I'm coming to you.
Didn't I say? I will save you.
But.. sensei, you are going to another hospital.
Who told you? It's not true.
I will save you. Surely!
Believe me.
Stay still!
Grab my hand.
Asada-sensei.
Sensei, blood pressure has not recovered!
But it's mitral and tricuspid valves reconstructive surgery!
- I cannot do it alone! - Kato and Arase
will rush over once their operation is completed. You are not alone.
I'm no longer part of the team.
Asada has been sharpening your needle holder,
for you to use when you return.
Asada has always treated you as part of the team. Even now.
Ijyuuin, save Asada!
Listen up intern, patient whose life does not matter
does not exist!
There's no medical case that is identical to textbook.
Therefore, a surgeon can only grow through numerous actual "cuttings". (TN: cuttings = surgeries)
If it's you, you can do it.
Not saving a life that can be saved, that is also a crime!
I will bear full responsibility.
Depending on the help of others is not a team,
putting forth your very best for your comrades,
That's what a team is. We can do it.
You'll do the Batista procedure. There's no other way.
- But.. - It's the only way out!
What binds doctors and patients, is not consent forms, but trust.
A doctor's job is to save patient. That's everything.
I'll... operate on Asada-sensei.
- Please bring patient to OR. - All right.
PCPS is ready.
Prepare disinfection.
It seems Ijyuuin-sensei will be the surgeon.
ST-segment is rising.
- Speed up the anastomosis. - Yes.
- How much is circulation flow? - It's around 3.5 litres.
- Be careful. Keep moving. - Yes.
- Xylocaine ready. - Yes.
- 8-0 please. - Yes.
- Preparing for disinfection. - All right.
Entering OR. Please.
[Asada Ryutaro]
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- He fell while trying to save the patient? - Yes.
- How's Toru? - He's now back at ward,
has calmed down, in the company of his mom.
- Is that so? - How is Asada-sensei?
- Operation's starting. - Who is doing?
Ijyuuin.
Severe valve regurgation.
Heart-lung machine ready!
- BP 47! - Be quick!
Now, commencing mitral and tricuspid reconstruction.
- Scalpel. - Yes.
- Tweezers. Gauze. - Yes.
Ijyuuin-sensei.
VF! Ijyuuin-sensei!
- Please prepare DC. - Yes.
- Electric knife. - Yes.
- Pump-ON. - Yes.
- Full flow. - Please stop PCPS.
Yes.
- Vascular clamp. - Yes.
No abnormal hemodynamics. (TN: hemodynamics = blood flow)
- Aortic clamp. Cardioplegia injection. - Yes.
Heart has stopped.
- Asada's heart.. - has stopped.
Mitral valve repair as priority.
Tricuspid valve, there's still time after temperature is recovered.
Incision of right side of left atrial to approach mitral valve.
- Electric knife. - Yes.
Mitral and tricuspid valves.
The two valves of the chordae tendineae are connected to the heart muscle with cord-like structures.
If the support valve chordae is ruptured,
blood pumped from the ventricle
will cause atrial regurgitation.
The ruptured valve chordae
is replaced with an artificial chordae.
However, the length of artificial chordae can only be determined visually,
requires a wealth of experience and concept of accurate imaging.
But, Ijyuuin-sensei he
does not have enough imaging experiences.
Can only bite the bullet. Hurry, Ijyuuin!
Left atrial incision.
- Scalpel. - Yes.
- Drain. - Yes.
- Metzenbaum. - Yes.
Can't see. Expand surgical field.
Yes.
- Next, prepare Cooley atrial retractor. - Yes.
- Cooley atrial retractor. - Yes.
Please maintain this state.
Yes.
This..?
Anterior papillary muscle is damaged.
In addition, P3 tendon is damaged too.
- What!? - Eh?
Papillary muscle is damaged?
That means even the base of the chordae is damaged.
Not only that, P3 tendon is damaged also.
The valve has completely lost its function,
hence the severe reflux.
In this state, to perform a reconstruction..
it's too late.
Sensei, excuse me.
I've heard everything. Switch to prosthetic valve replacement.
With the current valve state, reconstruction is impossible. There's no time.
Ijyuuin-kun!
No. I will continue valve reconstruction.
What are you saying? Are you trying to kill Asada?
If valve replacement is done, there's undesirable after-effects.
I want this valve.. No..
I want Asada-sensei to make a full recovery!
- Impossible. - I'll do it.
Ijyuuin!
I am.. the surgeon.
Ijyuuin-sensei.
Enough.
- Pledget with CV-5. Hurry! - Yes.
Attaching papillary muscles to chordae tendineae.
Kid.. No.. Believe in Ijyuuin.
A surgeon makes his decision after diagnosis.
An excellent surgeon will not attempt something he's not confident of.
Prepare another monitor.
- Yes. - Let's hurry up here.
- Pull back with Cooley retractor. - Yes.
Adjusting the length of artificial chordae,
this is the most time-consuming.
Success depends on this.
- Testing reflux. - Yes.
So close..
All right.
- LAD anastomosis. - Yes. (TN: LAD = Left anterior descending artery)
Nice.
But it took too long.
Next is the tricuspid valve.
- Metzenbaum. - Yes.
- What is this? - The tricuspid valve itself
has cracks, has teared into part of annulus.
This is the Koch's Triangle right? (TN: Koch's Triangle = a triangular shaped area in the right atrium of the heart)
Yes. Koch's Triangle
is an important part of the electrical pathway of the heart.
Located close to tricuspid valve. A very delicate position.
If you damage the pathway, will lead to antrioventricular block. A disastrous ending.
Carefully without damaging the pathway,
and to complete suturing very quickly.
It's like dismantling a bomb.
Should we temporarily close the left atrial, and repair the tricuspid valve with a beating heart?
No, continue in this state of cardiac arrest.
- The heart remains stopped. - For tricuspid valve
reconstruction, it's much more easier in cardiac arrest state.
As a surgeon, it's the right decision.
But with prolonged cardiac arrest state,
the damage to the heart is unpredictable.
Starting reconstruction.
- 4-0 Ethibond. - Yes.
Immediately terminate the operation.
It's impossible for you to do reconstruction.
- Just stop right away. - But..
It's Asada.
If he dies from improper handling, how will you answer?
Wait for Kato-sensei to arrive.
Ijyuuin! It's President's orders!
Enough. I'm going down.
Kato-sensei.
Good. She made it.
Hurry, Kato as the surgeon.
Do not fear. Insert the annular thread a little deeper.
Kato-sensei.
You'll continue on like this.
You will be the surgeon.
You'll do it. Ijyuuin-sensei.
Yes.
I will expand the surgical field.
My standing set.
What the..?
What are you talking? Kato! Immediately replace him.
I've been watching his technique via monitor.
Perfectly completing mitral valve reconstruction alone.
Hence, Ijyuuin will continue as surgeon.
Asada would have made the same decision.
This is orders from President!
I'm responsible for this team.
I will bear full responsibility.
Outsiders please shut up. OK. Cut extension.
Yes.
From now on, you just concentrate on the operation.
We will fully assist you.
Asada.. will surely be saved.
- Starting valve leaflets repair. - 6-0.
It's significiantly faster.
OK. Closing left atrium.
- 4-0 Proline. - Yes.
- Soon we will begin rewarming. - Yes.
If anyone leaves we can continue running, that's a real team.
Mitral and tricuspid reconstruction.. completed.
- It's over. - No.
It's not clear if the pathway was damaged.
Until the heart resumes beating, we can't be sure.
- Flow down. - Yes.
- Aortic clamp released. - Back up.
- Body temperature? - Recovered to 36c.
Asada, come back.
Asada.
Asada-sensei.
Asada.
All right.
Please. Asada Ryutaro-san.
Stable condition. Please.
OK.
You did well, Ijyuuin-sensei.
If not for you, Asada wouldn't be saved.
As a member of the team, I'm grateful to you. Thank you.
It was brilliant.
Asada's condition?
Hemodynamics has stabilized.
But these 2-3 days will be crucial.
Why do you go against me?
Ijyuuin can continue based on his skills.
I didn't see anything wrong.
Of course, if anything happens, I will follow-up.
Such confidence. Skilful surgeons are arrogants.
President, weren't you the same before?
Therefore, your self-indulgence is intolerable.
Remember this point.
Asada.. can he still operate after recovery?
Yes.
If he can't, then he is just an ordinary patient.
What!? Noguchi-sensei was transferred?
Yeah, seems like after Li Qiang Zhong case, he is dropped.
President Kito is too ruthless.
How sad. He's so high and mighty before.
Farewell, Noguchi-sensei. But
I'm glad Asada was saved.
- Asada-sensei is incredible. - What?
To go so far for a patient.
Yeah, certainly it's incredible.
Although has not yet regained consciousness,
- But his life is spared. - Asada-sensei..
- Me.. it's my fault that Asada-sensei.. - Don't worry.
Asada-sensei will surely recover. Surely.
Ijyuuin, your skills are incredible.
Awesome!
Great! It's simply Godhand.
Asada-sensei.
Today, for the first time, I stood in the same position as you,
as the surgeon role of that team.
For the first time, I saw through your eyes, the scenery you always see.
I am not the only person fighting.
That is..
That is.. a team, right?
Hourly urine volume is still not stable.
OK.
President.
- What happened? - I don't know.
Along with the fish food, there's this thing.
[Until I return, please take care of "Shoko". I'll be back.] President, Shoko is your name right?
It seems to be the Arowana's name also.
Noguchi seems to have been transferred.
- Yeah. - You're not surprised?
I have no interest in power struggle. I'm always alone.
What's your goal coming to Japan? Even coming to Meishin when
you've had such remarkable successes in the U.S.
I heard that the best team is here.
I want to witness it myself.
[Patient care record form - Asada Ryutaro]
How's Asada?
Still unconscious.
Is that so?
I heard everyone rushed in to help save Asada?
How long more do you want to keep pretending?
It's great that Asada's saved.
But if he died, who will take responsibility?
You? Or Kato?
"Comrade" or "Team",
when something bad happens, everyone's true nature will be revealed.
Kuroki-sensei, weren't you a cardiac surgeon once?
Old story.
[Kouhoko University Hospital. Cardiac Surgery. Kuroki Keijiro.]
[Medical malpractice. Year 1995]
[Cardiac surgery negligence]
Surgical negligence?
Why does Kuroki hate surgery so much?
15 years ago, I worked in Kouhoku University Hospital,
that's where I met Kuroki.
At that time, he's
very proud, but was a talented surgeon.
One day, an aortic stenosis patient was admitted,
aortic valve replacement surgery was to be done.
Kuroki served as an assistant.
However, the surgeon Professor, for his own ambitions,
requested the aortic valve replacement to be changed to Ross procedure.
Ross?
In consideration of patient's QoL, Ross is the best.
But, with our level, Ross is impossible.
It'll be fine, if it's this team, we can do it.
Kuroki had stated many times that Ross was impossible.
But the Professor did not listen.
In the end, it failed. The patient died.
However, the Professor, to escape responsibilities, placed Assistant Kuroki as the scapegoat.
The team members, in fear of Professor's retaliation,
sided with the Professor. Kuroki took all the blame.
In the end, he was expelled from the hospital.
Betrayed by the team he trusted,
and the patient's death. That operation completely changed his life.
I see.
The patient who died.. was his fiancee.
How much "shock" he suffered, I cannot imagine.
His loved one trusted Kuroki and thus accepted the surgery,
as a result she died in his hands.
Bearing the heavy cross, he turned to catheter interventions.
Kuroki's catheter is a form of revenge towards surgeons.
After being surgeon of that operation, I understand
that intense desire to save the patient.
and the fact that I have my comrades' support.
I realized for the first time, what I've done thus far is actually meaningful.
You're still saying these naive words?
I'm sure Asada-sensei.. No
Dr. Ross who developed the Ross procedure, would have the same feelings.
When the going gets tough, your comrades will likely betray you.
Kuroki-sensei, you taught me catheterization procedures,
I really appreciate it, but I'm unlike you.
I want to believe in team again. That team.
You want to return?
I am a surgeon.
Thank you for everything.
Yes. As scheduled, the operation is three weeks away.
I understand. OK.
After 3 days, still unconscious.
Kato-sensei.
Suspend all scheduled cardiothoracic operations.
With Asada's condition, you have no choice.
Please wait.
- Operations will be done, as scheduled. - What?
Operation is not a promise to you, but a promise to the patient.
Can you do it? Without Asada.
If anyone leaves we can continue running, that's a real team.
Asada will recover. Surely.
That is.. Asada-sensei.
You understand, right? Failure is not tolerated.
Asada-sensei.
Yes. Eh?
What?
- Really? - I'll go now.
Please hold my hand.
Please take a deep breath.
Asada-sensei, oxygen mask. Sensei, how much O2?
- 5 litres. - Yes.
- Asada. - Asada. - Asada-sensei.
Let's perform operation together again.
Operation?
What operation?
Who..?
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