The semifinals were about to begin.

A white screen was pulled across the center of the hall, dividing the venue in two.

The front half was filled with dozens of single-person desks.

The back half contained rows of stainless steel operating tables and stands for shadowless lamps.

The spectator area was set up in the tiered stands on either side.

By now, the stands were already quite full. Aside from the contestants’ friends and family, most were third and fourth-year students dragged here by their class counselors to fill the seats.

Jiang He found his exam number and sat down in a seat in the third row.

On the desk were only two black gel pens and a few sheets of blank scratch paper.

At eight o’clock sharp, a professor walked to the front of the stage, microphone in hand.

"Good evening, everyone."

"This semifinal round of our university’s Clinical Pathology and Reasoning Competition will combine theory and practical application. The total time allotted is one hundred and twenty minutes."

"In a moment, a real, complex clinical case will be displayed on the large screen. You are required to write down your preliminary diagnosis, an analysis of the pathophysiological mechanism, and the core steps of your proposed surgical plan on an answer sheet."

"After finishing, you will turn in your papers at the lectern and proceed directly to the practical skills area behind the screen. There, you will perform the most critical surgical step on a model, based on the surgical plan you’ve written."

"Remember, if your theoretical diagnosis is wrong, you will receive a score of zero for the practical portion, no matter how beautifully you perform it. Now, the competition begins."

As his voice fell, a slide was projected onto the screen.

All eyes in the hall were fixed on it.

[Patient: Male, 68 years old. Admitted via gurney from the emergency room for "sudden onset of severe, persistent, and generalized abdominal pain for 4 hours."]

[Past History: 10-year history of rheumatic heart disease with atrial fibrillation, non-compliant with medication.]

[Physical Examination: Temp 37.8°C, BP 100/60mmHg. Patient is pale, drenched in sweat, and tossing restlessly. Abdomen is flat and soft, with only mild tenderness throughout. No significant rebound tenderness or muscle tension. Bowel sounds are diminished. No gurgling sounds heard.]

[Auxiliary Examinations: WBC 22×10^9/L, serum amylase 110 U/L (within normal range). Abdominal X-ray shows mild small intestine dilation, with no obvious air-fluid levels.]

[Questions: 1. Preliminary diagnosis? 2. Explain the pathological mechanism for the discrepancy between the patient’s symptoms and physical signs. 3. Propose a surgical approach and core procedure.]

The moment the questions appeared, the entire hall fell silent.

Whether they knew the answer or not, they were all medical students. It was never wrong to at least think about it...

Zhou Yang frowned. "What is this? He’s in so much pain he’s rolling around on the bed, and he’s so pale he looks like he’s about to go into shock, but his abdomen is soft? Not even any muscle tension?"

He made his own judgment. "It has to be acute severe pancreatitis. With this kind of radiating, agonizing pain and such a high white blood cell count, it can’t be anything else."

Beside him, Lin Yue glanced at the amylase data on the screen, hesitated for a moment, then habitually chimed in, "Definitely."

In the examination area, most of the contestants also wore grave expressions.

Li Wei, for example, was already starting to sweat.

He knew this definitely wasn’t pancreatitis, but as for what it actually was, he simply couldn’t piece it together with his third-year knowledge of pathology and diagnostics.

’A disconnect between symptoms and physical signs... No air-fluid levels, which rules out a mechanical intestinal obstruction... What on earth is this disease?’ Li Wei chewed on the end of his pen, his mind in turmoil.

Pan Wen, a fifth-year student sitting in the front row, also had his brows tightly furrowed.

His experience from his emergency department internship told him that the past medical history was the crucial clue.

’Atrial fibrillation can easily dislodge an embolus... If it goes to the brain, it’s a stroke. If it goes to the abdomen... a mesenteric artery embolism?’

His eyes lit up as if he had grasped a lead, and he immediately began to write the diagnosis on his answer sheet.

But when he got to the pathological mechanism and the proposed surgical procedure, his pen stopped.

’The embolism causes ischemia, but how does that explain the soft, non-tender abdomen? And where should the resection be made during surgery? How much should be preserved?’

He had only seen early cases treated conservatively with internal medicine in the ER; he had never scrubbed in for a surgery of this level.

On another side, the senior student Tang Pei was going through a similar struggle.

She had identified it as a vascular emergency, but when it came to the resection margins for the necrotic bowel and the method of anastomosis, the textbooks only offered a few vague, principle-based sentences. She had absolutely no confidence in writing a specific surgical plan.

Both of them wrote in fits and starts, their brows knitted in concentration.

In the VIP seats at the very front of the stands, Professor Yang Xu and Professor Wang Xiaoqing sat side-by-side, their gazes sweeping across the examination area.

Wang Xiaoqing asked in a low voice, "Professor Yang, this question... was it taken from a mortality case file from Affiliated Hospital No. 1 last month?"

Yang Xu nodded. "Yes. Superior mesenteric artery embolism. The onset is rapid, and the early symptoms are extremely severe, yet the abdominal signs are very mild—a classic mismatch. By the time doctors at lower-level community hospitals detect rebound tenderness and signs of peritonitis, the entire small intestine is already necrotic. It’s too late to save them."

Wang Xiaoqing looked down at the contestants scratching their heads, shook her own, and said, "This question is far beyond the curriculum."

Yang Xu lifted his thermos and took a sip of tea, his gaze falling on the third row.

He said slowly, "Someone has to be able to think outside the textbook. This isn’t just a test of knowledge; it’s a test of clinical intuition. Professor Wang, didn’t you have high praise for that perfect-score paper earlier? Today is the perfect opportunity to see what level his skills are really at."

Wang Xiaoqing also turned her gaze toward Jiang He, a flicker of anticipation in her eyes.

’Kid, can you solve this one?’

At this moment, Jiang He was leaning back in his chair, spinning a pen in his hand.

The total time he had spent looking at the big screen was no more than five seconds.

First glance: history of atrial fibrillation plus severe abdominal pain. Locked in: superior mesenteric artery embolism.

Second glance: soft abdomen and diminished bowel sounds. Confirmed: currently in the ischemic-spasmodic stage. The intestinal wall has not yet undergone transmural necrosis and exudation, hence the absence of peritoneal irritation signs.

It was completely without difficulty. He solved it instantly.

But he didn’t start writing immediately.

He was mainly considering how to answer it according to the medical standards of 2008.

’I’d better not accidentally answer beyond the curriculum...’

After a moment of contemplation, Jiang He stopped spinning the pen and uncapped it.

His writing was as smooth and fluid as flowing water.

[Preliminary Diagnosis: Acute superior mesenteric artery embolism.]

[Pathological Mechanism: Atrial fibrillation caused a mural thrombus in the left atrial appendage to dislodge, obstructing the main trunk or branches of the superior mesenteric artery. In the early stage, severe ischemia and spasm of the intestine cause intense colic (severe symptoms). However, at this point, the intestinal wall has not yet undergone full-thickness transmural necrosis, and there is no inflammatory exudate to irritate the parietal peritoneum. Therefore, the abdomen is soft on palpation with no rebound tenderness (mild signs). As ischemia worsens, the intestine becomes paralyzed, and bowel sounds subsequently diminish.]

[Proposed Surgical Plan: Emergency exploratory laparotomy to assess small intestine viability. If the bowel is confirmed to have undergone irreversible necrosis, perform a necrotic small bowel resection. To ensure blood supply to the anastomosis, the resection must be extended 15-20 centimeters in both directions from the grossly determined margin of the normal bowel, followed by an end-to-end small intestine anastomosis.]

After writing the last word, Jiang He capped his pen and folded the answer sheet in half.

He went to turn in his paper.

Pan Wen subconsciously lifted his head and saw Jiang He walking toward the lectern with his paper.

He frowned and glanced at the wall clock.

Less than five minutes had passed since the competition began.

’What’s going on? Did he give up?’ a thought flashed through Pan Wen’s mind.

Tang Pei also turned her head for a glance. She recognized him as the legendary third-year junior who had gotten a perfect score in the preliminary round.

Seeing Jiang He turn in his paper, she bit her lower lip, forcing herself to think faster.

As for Li Wei, he was already soaked in sweat...

In the stands, the students also reacted differently, whispering among themselves.

Chen Hao silently marveled to himself: ’Old Jiang is a fucking beast.’

He didn’t for a second doubt whether Jiang He was right or wrong.

’When Jiang He turns in his paper, it means he’s absolutely sure. He’s a god of diagnostics!’

To be honest, Chen Hao’s admiration had already become a bit blind.

Jiang He walked toward the practical skills area at the back.

Passing through the screen, the light in the practical skills area was even brighter than in the front.

Several shadowless lamps, simulating an operating room, hung overhead.

On operating table number one, a green sterile drape was laid out, with a segment of silicone tubing in the middle to simulate human intestinal tissue. 𝒇𝙧𝙚𝓮𝙬𝙚𝓫𝒏𝓸𝓿𝓮𝒍.𝓬𝙤𝓶

On a stainless steel tray nearby, basic surgical instruments were neatly arranged: a needle holder, forceps, tissue scissors, sutures, and a scalpel handle.

Jiang He walked over to the sink at the side.

The conditions were basic. There was no standard surgical scrub sink, so he could only use antiseptic solution to perform a standard seven-step surgical hand scrub, washing all the way up above his elbows.

He then dried his hands with a towel, shook open a pair of sterile gloves, and put them on.

SNAP.

The familiar sensation was incredibly nostalgic...

Jiang He sighed internally. He didn’t rush to make an incision. Instead, he first picked out two intestinal clamps from the tray and steadily clamped the silicone tubing at both ends of the intended resection line.

In clinical practice, this is done to prevent intestinal contents from spilling and contaminating the abdominal cavity.

Only then did he pick up the No. 3 scalpel handle, fitted with a No. 10 blade...

Although this was just a silicone model, and although this was just a university skills assessment...

...the moment the scalpel handle settled into his palm, Jiang He’s gaze became intensely focused.

You have to be serious during routine training so you don’t falter when it’s time to perform.

This was the mindset a qualified attending physician should have.

He adjusted his grip, his wrist hovering, and gently pressed the blade against the predetermined resection line on the tubing.

’Time to review.’

He was clearly holding on to this simple thought.

But he had no idea that this smooth and fluid opening sequence of his had a completely different flavor in the eyes of the audience outside.

It was a confidence born of overwhelming superiority—

’Let the show begin.’