Chapter 101
Fuck. We're. Done.
I sprang up and shot out without even bothering to lift my ass off the chair.
“Let’s go!”
“Yes!”
Baek Eunseo grabbed the chart and followed right behind me.
We started sprinting toward triage like crazy.
A few seconds later, we were crossing the hall.
My brain was already spinning at insane speed.
'PE. Pulmonary embolism.'
'STAT tag.'
Those two together could mean only one thing.
From the triage nurse's perspective, it meant the patient looked like they could die any second.
'Massive or submassive. That is the question.'
Massive PE.
Blood pressure drops below 90 and the heart is moments from stopping.
This was a pre-arrest situation.
We had to dump thrombolytics into the vein right away, or rush them to the OR so thoracic surgery could open the chest and pull out the clot.
Mortality?
Insanely high.
Submassive PE.
The blood pressure is still holding above 90, but the right ventricle is already under pressure from the clot and about to burst.
They're breathing for now, but it's a time bomb—no surprise if it tips into Massive and arrests at any moment.
'It does seem like PE for now... and all I can do is pray it's not the worst kind.'
I panted as I asked Baek Eunseo, who was running beside me,
“Eunseo, what did the triage note say earlier?”
“He's a 52-year-old man, and he has hypertension!”
Baek Eunseo, a first-year intern, briefed me from memory without even looking at the chart.
“The chief complaints are shortness of breath and chest heaviness. Vitals: BP 150 over 95, HR 110, RR 22, sat 94% on room air!”
“Okay...”
I rolled those numbers around in my head.
BP 150/95.
'...High, huh?'
The blood pressure was normal for now... no, actually, it was high.
So it wasn't Massive?
They said he had hypertension.
Either that was his usual blood pressure, or he was in so much pain and so short of breath that his sympathetic nervous system was going berserk.
HR 110: tachycardia.
RR 22: tachypnea.
And... 94%.
Low.
It looked normal, but it was low.
A healthy person has no reason to dip below 98%.
It was clear proof that the lungs were starting to fail.
'Submassive. The time-bomb one. Fuck.'
I swallowed the curse in my head.
Bzzzz—
The automatic doors opened.
The patient was a man in his fifties.
His face was deathly pale, and his tie was loosened as he clawed at the top buttons of his shirt.
His shoulders heaved with every breath.
Seeing that, Baek Eunseo shouted the additional information she'd just confirmed on the chart.
“He takes lisinopril 20 mg, and his medication adherence has been poor recently!”
'Got it.'
I nodded.
'A hypertensive patient who doesn't take his blood pressure meds properly. So that blood pressure doesn't mean he's stable.'
I stepped to the side of the patient's bed and grabbed his sweat-soaked shoulder.
“Are you okay? I'm an emergency medicine doctor.”
The patient looked up at me with terrified eyes.
“Ah, yes, yes, I'm okay... okay. But my breathing... haah... is a little hard right now.”
“What does the pain feel like?”
I pointed to the area around the patient's sternum.
His chest rose and fell irregularly with every breath.
“Is it sharp and stabbing? Or crushing? Or tearing?”
The patient wiped away cold sweat and frowned.
“Uh... well, I don't know if it's sharp and stabbing... or not... not really... it's just kind of a tight, painful feeling.”
He sucked in a deep breath, as if it was hard to keep talking.
“It gets worse when I move. Earlier, when I got out of the car and walked in, my breath just caught... ugh... it gets a little better if I sit down...”
Pain that worsens when you breathe in or move.
That meant a clot was irritating the pleura surrounding the lungs.
One of the classic symptoms of pulmonary embolism.
If it were an aortic dissection, the tearing pain should radiate toward the back, and if it were a myocardial infarction, the crushing pain should radiate to the left arm or jaw.
“You don't feel like the pain is moving around or migrating, right?”
I went in for the kill with a confirming question.
“It doesn't go to my neck or arms. Not to my stomach either... I think I might have a little in my back, but it could just be my imagination...”
'Back pain.'
Fishy.
PE can cause back pain too, but it was a sign I couldn't completely rule out an aortic dissection.
Still, the pain was pleuritic, so I'd stick with PE for now.
“Understood. Have you had anything unusual happen recently? An injured leg, surgery, anything like that?”
“Ah...”
The patient gathered his panting breath for a moment and thought.
“Nothing like that. Oh, I was on my way back from an overseas business trip today. I'd been on a plane...”
'...A plane?'
Bingo.
In my head, warning lights and eureka exploded at the same time.
If you sit crammed into a tiny seat for over ten hours, blood pools in the leg veins and clots form.
That's DVT.
The moment that clot gets off the plane, says 'ow, my leg,' and starts walking, one pump sends it through the blood vessels, through the right atrium and right ventricle, and bam—into the pulmonary artery, where it blocks everything.
That was the hell this patient was going through right now.
'Check the DVT risk first.'
I glanced at the hem of the patient's suit pants.
The ankles above his expensive shoes looked slightly swollen.
'Slight leg swelling, constipation or indigestion as usual...'
Every piece pointed to PE.
“Doctor! EKG!”
I could see Baek Eunseo pushing the EKG machine over while hurrying the intern along.
“Uh, yeah... right. Bring it quickly.”
I gestured for them to move the patient to the nearest bed in Area A.
With that level of dyspnea and hypoxemia, he wasn't a patient for Area B.
Let's ask him a few questions before they even bring him here.
You have to squeeze out information even in the brief moment while attaching the EKG leads.
I looked at the patient's legs as he sat on the bed.
“Sir, when did your legs start swelling? Did it begin after the flight?”
If they suddenly swelled yesterday or today, that would strongly suggest acute DVT.
“Uh...”
The patient answered with a groan.
“No, not that... maybe for the past two or three months...?”
'...Two or three months?'
I froze for a second.
DVT usually develops acutely.
A few days, at most one or two weeks.
But swelling for two or three months?
That's chronic.
Of course, someone with chronic swelling can still develop DVT.
But....
“Ah... I see.”
Trying hard to seem calm, I asked the next question.
“Any family members with heart or lung disease? Parents or siblings?”
“Well...”
The patient searched his memory again.
“My father is healthy, but my mother... had heart disease in her sixties...”
'Heart disease.'
An ominous word.
Not PE, not MI
(* myocardial infarction)
or dissection
(* dissection)
either.
He'd been on a plane.
There was a DVT risk.
So PE was likely.
But the leg swelling was chronic, and there was a family history of heart disease.
...It was just my imagination that something was starting to feel off, right?
Was it not PE?
Or was it PE, but... the clot came from somewhere else, like the heart, not the leg?
Or was the root cause of all these symptoms somewhere else entirely?
I shook my tangled head and snatched the EKG printout Baek Eunseo had just pulled out.
'Let's look at the worms in front of me first.'
“Doctor! I'm about to order heparin...”
Just as Baek Eunseo was about to carry out the textbook next step, I raised a hand to stop her without taking my eyes off the EKG printout.
“Eunseo, wait a second. Hold heparin.”
“Huh? But why...?”
Baek Eunseo's voice was tinged with confusion.
He was short of breath, tachycardic, oxygen saturation was down, and he'd even been on a plane.
All the evidence pointed to a pulmonary embolism, so why was I saying to hold off on anticoagulation?
“...”
I didn't answer.
Because every nerve in me was focused on the worms printed on the paper.
Baek Eunseo stared at the EKG printout over my shoulder.
“It's S1Q3T3, isn't it? An S wave in Lead I, a Q wave in Lead III, and even T-wave inversion...”
“...”
“At this point, we have to call it PE...”
Baek Eunseo's voice began to fill with confidence.
“No, wait.”
I looked back at the printout.
“The T-wave inversions go all the way to V1, V2, and V3... it feels too broad, maybe...?”
The T-wave inversions seen in PE are usually shallow and sharply pointed.
But these were broad and deeply notched.
Fishy.
The chronic swelling and the family history of heart disease I'd heard earlier.
And this EKG now.
The puzzle pieces weren't fitting together; they were grinding.
I recalled the old special lecture from the Cardiology Ghost.
“You damn medical slave! EKG isn't a formula! It's a matching game! If the patient's history and the EKG picture don't match, remember that you have to throw away the formula you know! If you force the patient into the formula, that's a quack, not a doctor!”
...Yeah, let's ask.
I pretended to glance toward the patient's bed and brought up the blue interface in my pupils.
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[Dead Medical Scholar Gallery]
[Urgent] Need a Goddamn Heart Question ASAP!!!!
Author : HellJoseonSlave1
(EKG photo)
52/M. Flew in with chest pain/shortness of breath. O2 sat 94%. S1Q3T3 present. But the T-wave inversions are insanely broad and deep from V1-V4. Chronic leg swelling for 2-3 months, and mom died of heart disease. Feels off to force PE. Thoughts?
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[Comments]
ㅇㅇ (118.235) : O2 sat 94% on RA + RR 22? Short of breath and only 94%? Wouldn't Massive PE usually dip below 90...? Seems a bit off from the classic PE picture.
CardiologyGhost : Hey. What does the patient look like? Tall and skinny?
ㄴ HellJoseonSlave1 : Why do you ask all of a sudden?
ㄴ CardiologyGhost : Stop babbling and answer. Are his fingers and toes long and skinny?
The patient was still clutching his chest and gasping shallowly.
I pretended to take his pulse at the wrist while studying his hand closely.
Long.
ㄴ HellJoseonSlave1 : Just looked. He's over 180 cm tall and skinny. His fingers are ridiculously long.
ㄴ CardiologyGhost : Marfan sign. You know it?
I could feel the blood in my entire body go cold the moment I saw that comment.
Marfan syndrome.
An extremely high-risk group for aortic dissection.
S1Q3T3?
EKG finding?
If blood flows backward into the heart or an aortic dissection blocks a coronary opening, T-wave inversions can show up like that.
It's not PE.
...Ah.
Fuck.
I sprinted back to the station.
Baek Eunseo looked at me with a flustered expression.
“Eunseo.”
“Yes, doctor!”
“Let's get a CTA.”
“Huh? Not CTPA?”
Baek Eunseo was aghast.
We suspected PE, and now you want to image the aorta instead of the pulmonary artery?
“Yeah. CTA. Aorta. From the chest to the abdomen. With contrast. Right now. Hurry.”
I picked up the intercom connected to radiology.