Draining the Abdominal Flood
Draw the water out of the belly—paracentesis. It's a simple procedure. You poke a hole in the abdomen and drain out the accumulated fluid.
What's the benefit? For starters, it relieves abdominal discomfort. Imagine liters of fluid sloshing around in your gut. How uncomfortable would that be?
Severe ascites also comes with a host of other symptoms.
It presses on the diaphragm, hindering breathing. Or squeezes the gastrointestinal tract, making it impossible to eat properly.
Treatment paracentesis resolves these issues too.
Of course, paracentesis has another crucial purpose: identifying the cause of the ascites.
Liver cirrhosis, cancer, heart failure, infection... the causes are legion. You can only confirm the exact culprit after sampling the fluid and analyzing it.
But where are we? Medieval murim world. Obviously, no lab analysis of ascites samples here. So today's paracentesis was purely therapeutic.
"Still, the color can give clues about the cause. Your ascites is probably a clear pale yellow. Maybe a bit darker."
"Y-yes..."
"So just hang tight. Even draining this will make you feel worlds better."
"O-okay... Um, Doctor..."
"Yes?"
"Do I really need to have the water drained from my belly?"
Good question. A fundamental one. And a necessary one.
Jeon Sam, male, mid-forties. Newly diagnosed decompensated liver cirrhosis. Does this patient need paracentesis right now?
If this were a university hospital? I'd get chewed out before I could finish asking. Of course you do!
"You've been short of breath just from a little movement these past few months, right? Belly so bloated it's hard to breathe, so you've been lying down all day."
"That's true, but..."
"Even a little food makes you bloated, so you can't eat properly. You're losing weight while your belly swells up, yeah?"
Symptoms disrupting daily life? No time for hesitation—that's a luxury.
Plus, protocol for new-onset ascites calls for tapping to check the cause anyway.
So I had the patient lie on his left side on the pallet. Boiled water to sterilize the instruments. Sent Cho Hyang to fetch disinfectant baekju. All on reflex.
But once set up, doubts crept in. Could I perform safe paracentesis here, at Namgye Clinic?
Normally, you'd run blood tests first to rule out bleeding risks.
Cirrhotic patients have thin blood—the liver doesn't produce clotting factors well.
For large-volume taps like this, you monitor vital signs, especially blood pressure.
Blood tests in Namgye Village? Blood pressure checks? I'm tired of even saying it. Obviously impossible.
After major drainage, you'd infuse albumin to compensate, give antibiotics to prevent peritonitis if needed—tons of little add-ons.
But none of that's possible here!
And my biggest worry was something else...
"Uh, Doctor. You want the basin here? Like this...?"
The equipment and setup—or lack thereof.
Following Cho Hyang's gaze, there was just a single basin under the pallet where the patient lay.
In a modern hospital, paracentesis is poke a hole, insert a hose, and suction sucks it out automatically.
But of course, no suction device in Namgye Village! No sterile intra-abdominal tubing either.
So drainage options narrow to a few.
One: gravity-fed natural drainage. Two: kneading the patient's belly to squeeze it out.
For Jeon Sam's dignity, I'd go with option one.
Hence positioning him sideways at the pallet's edge, basin below to catch the flow. That was the plan.
If I did this in a modern hospital? Front-page news. Colleagues would roast me.
Are you insane? Trying to cause peritonitis? Forgot sterile technique?
I'd never done paracentesis like this either.
Which is why...
"Doctor, if I quit the booze like you said, take the meds steadily, avoid raw freshwater fish... Can't we just try that first? Do I really need this...?"
His plea shook me.
Procedure with inadequate setup and environment.
Try medical management with drugs and observe? Or risk it for the procedure?
Both have rationale, benefits, risks.
Experts are experts because they weigh risks and benefits to decide—even without perfect options.
"You need it."
That was my call as an internist.
Quitting booze isn't easy anyway. Who knows how well this era's drugs will work.
With cirrhosis, you might need to titrate hepatotoxic doses slowly.
Drugs take time to kick in.
So risking the procedure was the best way to help Jeon Sam.
I explained my reasoning.
"If you put it that way... Fine. Let's do it."
Patient consented at last. Procedure underway.
Site: left lower quadrant.
Herbal boiler sterilizing fine needles, large needle, small scalpel since earlier.
No Betadine, so swab skin with baekju. Insert fine needles at acupoints for local anesthesia.
Sidenote: acupuncture local anesthesia is one thing I like about medieval murim.
Hit the points with a few needles? Pain vanishes in a flash! The dream of pain management!
If I returned to the modern world with this, maybe add anesthesiology to my practice?
Others might flip out over scope creep. But business is like the jianghu—get stronger if you don't like it.
Anyway, time to make the hole.
Small scalpel for a 2mm incision. Carefully slide in the sterilized large needle.
"Might sting a bit. Don't move."
Slowly apply pressure with fingertips.
Pop.
Peritoneum punctured, felt it in my fingers.
Gush.
Pale yellow, clear ascites flowed out. Color confirmed cirrhosis.
"Whoa... I've never seen anything like this!"
"W-what? That's been inside me all this time...?"
Two first-timers stunned by the sight.
Jeon Sam would see it often, though. Ascites refills; you'd tap again each time.
"Hold like this for a bit. Let me check your pulse."
Remove needle, let ascites drain naturally by gravity. Basin below filled with clear yellow fluid.
"How long? Draining it all?"
"Drain too much, you get dizzy. We'll take enough to ease symptoms, manage the rest with meds."
"Y-yes..."
Palpated radial artery at wrist.
Normally, palpable pulse means systolic over 80 mmHg.
Normal BP is higher, so unless it's an emergency shock patient, it's usually fine.
But with Hong Yak's delicate touch, I could gauge BP changes by pulse strength, not just presence.
Monitoring Jeon Sam's BP this way. After a while—second basin change by Cho Hyang—
The pulse changed.
...Hm?
Shallower. Faster too. Clear sign of dropping BP.
Expected. Drain ascites, intra-abdominal pressure drops. Compressed vessels dilate, blood pools. Circulating volume falls, BP drops.
University hospital: albumin, fluids, vasopressors if needed.
Here? Nothing. If BP tanks to shock, we're done.
"That's enough."
"Huh? Still a lot left, right?"
"It's fine, Cho Hyang. This is plenty."
About 70% of target volume. Better safe than greedy.
"Jeon Sam, dizzy or weak?"
"Nah, not really."
"Okay, roll onto your back. Pulse is shaky; I'll watch it."
Supine position. Waited; pulse stabilized.
"Wrapping up. Cho Hyang, grab the ointment?"
No Betadine gauze, so salve on the site. Pad with bandage over, wrap belly lightly for pressure dressing.
"Doctor... my breathing...? Feels easier!"
Perfect. Symptom improvement confirmed. Goal achieved.
But cirrhosis needs long-term management. Let him rest, prepared meds.
Priority: diuretics. Control ascites via urine.
Modern medicine combines types—loop, MRA, etc. No such distinctions here.
Grab anything diuretic, observe. Poria (fuling) and alisma (ze xie). Stocked at clinic pharmacy, luckily.
Issue: liver flukes...
Medieval Central Plains has primitive anthelmintics: betel nut (binrang), thunder pill (roe hwan), etc.
Do they work on flukes? Good for intestinal worms like roundworms. Flukes live in bile ducts—different spot.
Praziquantel? Not in clinic stock.
Need to forage more herbs. What can you do?
Other things I couldn't do: no endoscopy for esophageal varices. No lactulose for hepatic encephalopathy. No hepatitis screen. No liver function tests...
Argh.
Half-assed treatment. Didn't satisfy. But best under constraints—take the win.
"Wound heals in days. Change dressing daily, I'll check pulse too."
"Got it. Haven't breathed this easy in ages... Truly grateful!"
"Meds ready—take 'em daily. More to come later."
Jeon Sam, several kilos lighter than arrival, stepped out.
Cho Hyang approached, basin of ascites in hand.
"Doctor, dump this?"
"Yeah. Nothing more to do with it. Good work, Cho Hyang. Rest up... Oh, need more herbs."
"Herbs? I gathered all the regulars."
"Betel nut and thunder pills. Tomorrow okay?"
"Betel nut's out of season... I'll look! Then I skip morning shift? Drop 'em off evening!"
"Do what you want."
Tomorrow: field duty for Cho Hyang. Listed other shortages too.
"Got it, Doctor! See you tomorrow night!"
Thrilled by the outing? She left with a brighter face.
Namgye Clinic's day finally done.
Cicadas chirping into the evening.
In my room next to the clinic, I reviewed the day.
Many villagers with chronic issues. Internistic cases—fun to treat after so long.
But... that cirrhosis case lingered, unsatisfying.
Paracentesis wasn't perfect.
No suction, so ascites trickling down the belly skin to the basin below—not pretty.
A thin tube would've been cleaner.
And prognosis for cirrhosis in medieval murim, sans modern drugs? Grim.
Qi meridians exist—maybe a breakthrough? Probed liver-area meridians.
No gain; patient no martial artist. Just confirmed liver meridians wrecked.
Short on equipment, tools. Knowledge here, but no means. So much lacking.
Desk time again.
Hong Yak's traditional medicine knowledge? Burned in my brain—no review needed.
Growth elsewhere.
Yanluo Life-Seizing Art.
Hong Yak's manual—now mine. Requires inner power, so medical art (yigong).
Today: initiate new technique.
Thump.
Excited, nervous. Long curious about this one.
Life-Pursuing Needle.
Draw blood thick with inner power via needle. Analyze to check inner power status.
Qi meridian blood test, basically?