After I came here, 3 kg has been lost.
It's not me. Your mentor.
It's better to take a CT.
I will talk to him soon. Yeah.
As expected, an anesthesiologist. You noticed it well.
It's because I'm an excellent anesthesiologist.
Yeah. But I guess there's no surgeon who appreciate us, the anesthesiologist.
I had hard times too when I was young.
Once this small battery is complete,
The practical use of pediatric artificial heart will come closer.
We will complete the prototype as soon as possible.
I'm looking forward to hearing from you.
Thank you for your cooperation.
Welcome to L&P Hospital.
The development of your artificial heart is progressing, huh?
Thanks to you.
We might be able to solve the pending issue on battery reduction, by modifying the implantable defibrillator's charging system with contact-less type.
Looks like it's going well.
Since here isn't a university hospital, there's no need to be dragged into some worthless power struggle.
Moreover, with the backup from the parent company,
We can use enough funds for the researches.
Up until now, I always thought that medical treatments are not a business.
With the power of business,
A lot of patients can be saved.
A very interesting guy, huh? Eh?
Okamura Tadashi.
He isn't merely a management consultant that only pursuing profits.
For Okamura, there's an ideal medical treatment. An ideal treatment?
Then, with the power of business,
Okamura is making that ideality into a reality.
He's completely opposite with Asada, right?
However, there's still a secret in that guy.
It's about our Director Hagaki.
Yes.
Majority of the doctors who work here are gathered by his name.
Director Hagaki's contributions for this hospital are immeasurable, right?
Actually, I've noticed that Director's circulatory organ patients in here are decreasing.
Ah, surely after Team Dragon came,
Patients who choose Sakurai Hospital are increasing.
Since circulatory organ is director's specialty,
He should feel responsible and do something.
There's a patient with an aortic valve stenosis of the congenital bicuspid valve in here, isn't it?
Aortic valve stenosis (AS): a disease of the heart valves in which the opening of the aortic valve is narrowed.
A valve replacement, right? Something that Director Hagaki has been specialized in.
Does it possibly mean that director himself will perform the surgery?
Making a new operation time record,
Then after that, storm them by taking the patients back to L&P.
If director himself who will perform the surgery,
We can't do it the same way as the normal operation.
Indeed.
That's why, I want you to gather the best staffs.
How is it? Training at Sakurai Hospital?
It's the worst.
There's rarely a case that seems can be written for a thesis.
Since it takes too much times for the individual consultation,
There are many overtime works.
I want to go back to L&P soon.
Well, someday Hayakawa-kun will understand it too.
Then, have you decide your specialty? Still considering it.
Ah, but there's a department that I absolutely decided not to go.
Eh? Where? Anesthesiology.
Why? Why...
Because it has nothing special, the working hours are also long,
And the one who will be appreciated is only the surgeon,
They aren't being thanked by anybody, right?
I also used to think like that before,
then I guess my point of view has changed after I saw Arase-sensei.
Isn't anesthesiologist is surgeon's servant?
It isn't like that.
Arase-sensei is not Asada-sensei's servant.
They can do a high-quality operations because of their equal relation.
Such a thing is probably an idealistic theory, right?
A theory that's revolving around the surgeons in general hospital organization.
If we changed that condition from now on...
There's no reason to change it.
Excuse me.
First assistant of director's operation.
In other words, the next director is me! It's me!
The scrub nurse will be Yoneda. The circulating nurse will be Kaneko Ono.
Those all are L&P's best members for now.
Is the anesthesiologist a woman?
She's the most skillful anesthesiologist here.
I don't like female doctor. Noguchi-kun said that there's someone who is good at Sakurai Hospital?
Ah, do you mean Arase-sensei?
I guess that was his name.
However, Arase-sensei has works to do in Sakurai Hospital.
You're going to give me much help, aren't you?
Is it impossible for you to bring an anesthesiologist here?
No. Of course that's possible.
No, I mean it's possible... but He's a troublesome guy.
He's not a type who will obediently listen to what people say.
There's no word of hear or not for anesthesiologist, right?
Excuse me.
Our patient is a 65 years old man.
There are fusiform aneurysm with the largest size 62mm in his distal arc.
Fusiform aneurysm: a localized dilation of an artery in which the entire circumference of the vessel is distended.
There's also an enlargement tendency, An operating indication.
Flexion of the iliac artery and arteriosclerosis are tough cases.
This time, let's do it with open stent.
You're right. That's the best.
Excuse me, does this conference counted in the overtime payment?
Eh? Hayakawa-sensei.
But it has been past 5 PM already.
Everyone can't gather in the daytime because of patient's examination, right?
Moverover, Hayakawa-sensei... Don't you want to enhance your surgery experiences?
Please report everything that is happening around them.
It's a training plan which is expecting Hayakawa-sensei, the excellent human resource.
I understand.
Well, let's resume the conference.
Ijyuuin, you'll do the surgery.
What?
For the stent graft, You are more experienced than me.
Ok. Show us what you've got, ok?
Please treat me well.
Arase-kun. Can we have a moment?
Asada please also come.
There was a request for Arase-kun to participate in an operation which will be held in L&P.
What?
Okamura-kun insisted that he want to borrow your ability no matter what.
Give me a break!
I came here because I'm sick of those unskilled surgeons.
I know that.
However, it's an essential thing for us now in our partnership with L&P.
I want to maintain this relationship also for the sake of the patients.
I also have accepted the offer from Okamura-kun about the joint usage of their catheter's Lab.
Thus for me,
As long as it doesn't interfere our medical treatments, I want to fulfill L&P's request.
What is the operation details? Patient is 7 years old boy.
He seems to have fallen during his soccer practice.
He's having an aortic stenosis which is derived from the bicuspid valve.
7 years old. Who will be the surgeon?
It seems that Director Hagaki himself who will perform the surgery.
Hagaki...
Director Hagaki appointed you after hearing your reputations.
Hagaki want me...? Would you try to consider it for me?
Do you know L&P's Director?
Well, I don't think he remember me though.
There was a time when I joined his operation in my intern times.
For a more reliable and safer surgery,
15 years ago
I've learned transesophageal echo which is not in common yet at that time.
Professor Hagaki, there is a plaque in the ascending aorta.
Please do the blood supply tube insertion in another location.
Who do you think you are? For an intern giving an advice to the professor...
Professor?
I don't hear your suggestions and so on...
That patient didn't regain his consciousness, then he died on the seventh day of the postoperative.
Those guys passed the responsibility of their own mistake, by saying that the intra-operative care from the anesthetic department was insufficient.
Then my medical adviser was moved to the rural area.
It's anesthetic department's job to make the patients awake.
However, whether it's possible or not,
I realized that it depends to the surgeon.
How ridiculous.
If I hung on a little more at that time,
I wonder would it be ended without letting the patient died?
Isn't that the way you are now, can save patients?
I'll join the operation. This time, I won't let him to do it as he wishes.
Boo! It's Kihara-sensei.
This is Arase-sensei who will be responsible for the anesthesia.
Hey, the surgery... is it painful?
It's not painful at all because it will be over while you're sleeping.
I'm not sleepy.
It's alright. because I will make you sleep.
So sensei is a sleep maker-san?
I guess I am.
Excuse me, I heard that Director will do the surgery...
Yes. Director will perform the surgery himself.
Is Director-sensei a great man? Yes he is...
He's the greatest sensei in this hospital. I see.
Then it will be fine, right? Yes.
It's really fine, isn't it? It'll be alright.
Great. That's great, right Ren?
Hey! Where's Director?
I suppose that he is in the director room since he's a director.
Which one is director's room? Wai... Please wait!
What do you want to do in director's room?
I've found the cause of the advanced left ventricular outflow tract stenosis.
What? Even If we do a valve replacement, his heart won't get better.
There's some constriction release of the outflow tract right in front of the valve.
Director is only interested in breaking the time record in the aortic valve replacement.
Please don't say unnecessary things. Don't be ridiculous!
If we only do the valve replacement and leaving out the outflow constriction,
That will leave only the surgical wound for the patient.
Please give me a break! We're dealing with Director, you know.
Who are we to be able to say such things?
It's better for us to do the surgery as what has been told.
Do you get that?
Second opinion?
Depends of the condition of the illness, there might be different medical advices and also treatment policies.
But, the surgeon who will perform Ren's surgery is director, right?
They said aortic valve replacement is his specialty.
However, there's also a possibility that Ren's heart won't recover with only a valve replacement.
It won't be late even if we do the surgery after hearing some opinions from other doctors.
Second opinion is a common sense.
If he's a proper doctor, he won't be offended by such thing.
Second opinion?
Is that so? Alright then, to whom should I ask?
In Sakurai Hospital near here,
There's an excellent heart surgeon who is called Asada.
Asada!
Ren-kun's heart isn't just having an aortic valve constriction,
It's also accompanied by a left ventricular outflow tract stenosis, due to the hypertrophic interventricular septum.
Furthermore, he's starting to have an irregular pulse because of a cardiomyopathy.
Cardiomyopathy: (literally "heart muscle disease") the measurable deterioration of the function of the myocardium (the heart muscle) for any reason, usually leading to heart failure.
If we loose the constriction of the left ventricular outflow tract,
We might not be able to withdraw it from the heart-lung machine.
Then what should we do?
We'll try the aortic valvuloplasty by using the valve itself,
Aortic valvuloplasty: the repair of a stenotic aortic valve using a balloon catheter inside the valve.
In addition, we should do up to the ablation surgery to prevent the development of the ventricular tachycardia and left ventricular outflow tract dilation.
If we do that, will Ren's heart become better?
Yes.
If so...
I would like to ask Asada-sensei for his favor.
I understand.
What are you guys doing?
Arase-sensei, anesthesiologist.
This is Asada-sensei, a surgeon from Sakurai Hospital.
You are that anesthesiologist, huh?
So, what does a surgeon from Sakurai Hospital do in here?
The best method for the patient...
It has been decided that the best method was me who will perform the surgery, right?
At this state, although you only do the valve replacement of the artificial valve,
Patient's heart won't recover.
I wonder if you have ever succeed in aortic valvuloplasty for the aortic valve stenosis which is the same as this case?
No.
Don't recommend a surgery that you've never done before to many patients.
Is that ok with you?
The advancements of the medical treatments nowadays are brilliant.
Now, we'll do a time consuming surgery with a high risk in here, those all are for your son, don't we?
After a few years there's a possibility of the medical treatment will be safer and more reliable than what we have now.
However, re-surgery might be required for this surgical method.
Then if we do a re-surgery, the risk will also increase.
Above all, he'll be haunted by the mental burden of undergoing a surgery again.
Don't you have your real reason to oppose my surgery?
I heard that Sakurai Hospital's management is having difficulties.
That's why they are stealing our patients, and seem to try to do some unnecessary surgeries.
Because if there are many surgical procedures, more points will be added, then hospital's profit will also increase.
Please think well which one that will be your real choice for your son.
Well then.
Looks like patient has chosen to take director's surgery.
Well, it's an obvious thing isn't it? It's a wise choice, right?
Indeed. I've been thinking about what would happen when Arase-sensi went out of control.
Excuse me? Ah, thank you for the hard works.
Ok. Excuse me.
I'm sorry. Though it's been troubling for you to come here.
No.
I'll also give it up. If it just a valve replacement, then it will be fine if I don't do it, right?
Are you okay with that? Eh?
We don't know what will happen to that kid's heart.
You won't be able to do something, If you are on the outside of the operating room.
Arase, the one who can save the patient,
is only you...
It's an honor to be able to join Director's surgery.
Since it will be less than 42 minutes.
Keep this well in your memory, okay?
Standing platform. Ok.
1... 2... 3...
6... 7...
Ok. Pass out.
Oh, seems that what they referred as fast is real.
Director.
After all, we should also do the treatment for the left ventricular outflow tract stenosis.
Are you still going back to that thing again?
If the constrictions of the outflow tract are not removed,
Left ventricular internal pressure differentials may still remain, then, this may cause SAM.
SAM (Systolic Anterior Motion): abnormal motion of the anterior mitral valve into the aortic outflow tract caused by asymmetric septal hypertrophy.
I'm the one who decide the surgery's plan.
I hope anesthetist remain silent and follow the instructions.
Are you intending to commit the same mistake again?
What are you talking about? 15 years ago.
You've let a patient die without listening to my opinion.
15 years ago?
There's a patient who died due to the thrombotic occlusion in the cerebral infarction,
because of the intubation of some parts which had plaques, right?
I don't know anything about such patient.
I'm not surprised if you don't remember.
You did nothing but throwing the responsibility to the Anesthesiology Department, right?
The conductor in the operating room is the surgeon.
Anesthetic is only thinking on how not to disturb the surgeon.
From now we'll perform an aortic valve replacement with a mechanical valve for aortic valve stenosis due to congenital bicuspid valve.
Please.
Scalpel. Ok.
Electric scalpel. Ok.
Starting.
Here. O..OK.
Ok. Ok.
15 minutes have passed.
16 mm mechanical valve. 21 minutes 53 seconds have passed.
Hurry! OK.
Excuse me.
How is the time? Breaking time is 23 minutes 30 seconds.
It's fast, right? Yeah.
Should we go with the cardioplegia? Don't need. Keep going as it is.
Cardioplegia is intentional and temporary cessation of cardiac activity, primarily for cardiac surgery.
Is it today? Yes.
Aorta declamp. Back up.
Aortic valve replacement is complete.
Aortic cross clamping time is 41 minutes 20 seconds.
You've broken the time record in valve replacement.
If there's no annoying anesthetic, it might be less than 40 minutes.
I think I've made Arase-kun have an unpleasant thought.
He doesn't care about such thing.
But, he's worried that he can't take the best way for the patients.
Sensei?
Sensei!
Are you alright? Sensei!
Next, I'll leave the chest closing to you.
It's VT. What?
VF. Prepare the DC!
Hurry up! Ok!
Paddle! Ok!
Charging finished! Detach, then ON!
It doesn't return.
Continue to massage his heart to take out the pressures.
Ok.
ME!
Put him on the heart-lung machine again! Ok!
Give the instruction quickly. You're the conductor, aren't you?
Shut up! Don't dictate me!
Sensei. We have to remove the outflow tract stenosis.
Let's remove the constriction through the mitral valve.
Ah, let's do that.
You can't do that! What?
There'll be a risk of damage to the mitral valve if you do that.
In addition, do a small incision int the left ventricular apex, Then remove the outflow tract stenosis from there.
Also do the ablation.
Don't interfere though it's a surgery that I've never done before!
Are you afraid because it's a surgery that you've never done before?
I've said that I'm the one who have the rights to decide before, haven't I?
Do you want to cause a patient die again because of your wrong decision?
Just follow my instruction!
Please follow Arase-sensei's instructions.
What did you say?
We cannot let a patient die because of your wrong decisions.
You aren't a conductor any longer.
Do you know to who are you talking to!
Director Hagaki.
There's no place for you to be here any longer.
I've broken the time record for the valve replacement.
Please leave the room.
Hey! What to do now?
You do the surgery. What? But...
I'll give the instructions. Just do as what have been told.
But.... Placing the heart-lung machine.
Second Run. Ok.
Add a small incision in the left ventricular apex.
Kihara. Do the incision in parallel to the running of the anterior descending branch.
Also think about the margin to sew up when you do the suturing.
Scalpel. Ok.
Carefully.
Scissors. Ok.
Aaah! Calm down.
Sucker up. Ok.
3 cm will be fine. Lift it up with the felt after the incision.
Ok. Felt. Ok.
Wait. Ok.
2-0 Prolin. Ok.
OK.
Can you see the septum that has thickened? Yes.
Do the ablation first. Ok.
Pen type. Yes.
Burn the surrounding papillary muscles. Ok.
Starting the ablation. Count.
I heard that Director was pulled out?
Kihara? Ablation is complete.
Ok. Listen up. Next is the dilation of the left ventricular outflow tract.
Ok. Try to touch it with your finger.
2 cm longitudinally from the thickened septum,
1 cm in the minor axis direction. Cut it into strips.
What is this anesthesiologist? It was my first time to see a anesthesiologist instructing the surgeon.
How many minutes it is after the cardioplegia? 10 minutes have elapsed.
It's a hypertrophic cardiomyopathy surgery. Do the cardioplegia rapidly.
After the removal has finished, put it backwards. I can do it anytime.
Ok. Return the cell saver blood. Ok.
Myocardial septum removal is complete.
Ok. You've done it well. Next, check the mechanical valve from the left ventricle,
If there's no problem, do the suturing then it's complete.
Ok. Restore body temperature.
Don't! What's wrong?
The encounter of the artificial valve are out of the place. They are detached.
It's because of the sloppy suturing and the mechanical valve are forcibly pushed to the small heart.
I will suture it one more time.
Wait!
Ross. What?
Do the Ross Operation. Ross...
Substituting patient's own pulmonary valve with the detached artificial valve,
Then implant the artificial valve by the side of the pulmonary valve which has been extracted.
If it succeed, then the frequency of the re-operation will be small.
But on the other hand, the difficulty level will be much higher.
I can't believe that he let Kihara to do that.
You forcibly decide to do the Ross Operation, don't you?
Calm down, 84 kg!
You can do it if you do it as what I say.
I will...
You, please stay here.
I said it's completely impossible!
The one who can do a Ross Operation in this situation is the one who is as good as Asada.
I will make you be a Asada.
Right now, only you who can save the patient in here.
Do it.
I definitely won't let this patient die.
I got it.
From now we'll perform a Ross Operation which is reconstructing the pulmonary valve with the stentless valve,
and doing an autograft for the self pulmonary valve to the aortic valve position.
Ok.
Dissect the aorta, then inject the cardioplegia selectively to the left and right coronary artery.
Ok. Scalpel. Ok.
Remove the pulmonary valve, make sure to not to damage the right ventricle.
Pulmonary valve removed.
Trimming the pulmonary valve is the base reconstruction of aorta.
OK.
Put the cardioplegia firmly in front of the reconstruction.
Cardioplegia. Ok.
Right angle. Scissors. Ok.
Aortic valve's base reconstruction is complete.
Next, starting to reconstruct the pulmonary valve with the stentless valve.
Ok. Scissors.
Reconstruction of the coronary artery is complete.
Ok. Rewarming. Ok.
Dropper. Ok.
Flow down. Ok.
Good. Aorta declamp.
Backup. Backup.
The left ventricular outflow tract stenosis have also been removed.
No problem with the heart's motion and also the pulmonary valve which has been autograft.
And no air.
We can detach him from the heart-lung machine. Ok.
Do the continuous ?-blocker for a while, ok?
Ok.
You are...
Arase-sensei is a great conductor, isn't he?
It seem to be a difficult surgery.
Thank you very much, sensei.
There was a sudden change during the operation... It was a very dangerous state for a while.
I wonder what would it be if it has happened to an average doctor.
Sleep maker-san.
It didn't hurt at all.
I've promised to you, haven't I? Yeah.
Sleep maker-san is awesome, right?
You've worked hard.
Thank you.
No, he's indeed great but after all it's the success of the teamworks..
Sensei, today please stay asleep as you are.
Don't treat me as an old person! I'm alright now.
Other than that, how was the operation?
Seems that Arase had safely made it succeed. I see.
Sensei, please have a medical checkup as soon as possible.
Patients are waiting. I have no time to have a checkup.
We are here.
We will watch over them while you are being away.
I understand by looking at yesterday's operation.
Times where surgeons reign over the top has come to an end.
Anesthesiologist accumulates methods and results of surgeries as databases.
That's why they can give accurate judgments based on those rich data.
You kinda lift my mood, huh?
From now on, we will create a medical system which is focusing on the anesthesiologist.
For that reason, I want you to join in L&P.
I'm sorry. I don't have intention to be teamed up with the others other than Asada.
Surely if you both are teamed up, it's possible to do beautiful and perfect operations, isn't it?
However, just like what sensei had proven personally yesterday,
If there's you, even Kihara-sensei can become Asada-sensei.
It's impossible to gather 10 Asada-sensei.
But by making you, the excellent anesthesiologist as the conductor,
We can make those 10 Asada-sensei.
As the result, the number of patients who can be saved will increase.
That's a wonderful story, huh?
But it's impossible to do as long as that director is still there.
Director Hagaki has resigned.
Resigned?
I'm seriously planning to make a hospital which is focusing on the anesthesiologist.
Such thing is impossible.
Even if you replace the director to someone else, I don't think that anyone will be able to agree to your idea.
The next director will agree.
Does that kind of guy exist?
Don't say that you personally are planning to be the director?
No. Then who is it?
The next L&P's Director...
Arase-sensei,
It's you.
Hahaha... Don't say such a fool thing.
If we have you join us as the director,
L&P really can make a new start as the most advanced medical facility.
Fujiyoushi-sensei's regenerative medicine,
Also Katou-sensei's research on the artificial heart for children,
And if we have Sensei to be on the top,
We will be able to move forward more efficiently and effectively, won't we?
Arase-sensei, Let's create an ideal hospital which is focusing on the anesthesiologist.
I think I'm in trouble. I've done a selfish thing.
I'm the reason why Director Hagaki moved from Higashinihon University Hospital.
And you think that he has done enough with his role.
Have you decide for the successor?
It's Arase-sensei.
Arase? Yes.
There's no reason for Arase to be the director.
He's the most unsuitable guy for this case.
He'll do it.
With this, we approach one more step to our real goal for the overseas expansion.
In the future, please decide after I refused, ok?
After that, how is your mentor?
He is stable for the time being.
I think it's better to take a detailed examination soon.
I know.
Bring him to L&P. L&P?
I'll become L&P's Director.
Of course if there are operations here, I will join just the same as always.
Also my kid will be a primary school student in the spring.
I've been out of my character lately,
Then, I come to think of the next generation...
I see.
You can do it.
Arase-sensei is L&P's Director...
I can't imagine it at all.
Considering our situation right now,
we are saved by the strengthening of our partnership with L&P.
No matter how hard we try,
We have patients that can't be examined in here.
I know that. But...
Everyone has gone to L&P, It feels lonely somehow.
Still, we should have gathered here with the same feeling...
Excuse me.
Oomura-san from room 301 said that he's unable to sleep...
I understand.
Welcome to L&P.
Sorry to get straight to the point, but there's a patient that I want to examine.
Finally you are willing to take an examination, huh?
There's no reason for not to come, If it's Director himself who have made the appointment for me, isn't it?
Okamura-chan, that guy...
It's the first time for Noguchi-sensei to see him, right?
I'll introduce him after we have finished the inspection. Director Sakurai from Sakurai General Hospital.
Sakurai Shuuzou?
Is there something wrong?
He is Asada's mentor? Yes, I've heard so.
Eh, I see. This has become more interesting, huh?