Chapter 102
“Doctor, what is this…?”
Baek Eun-seo grabbed me with an expression that said she couldn't understand.
“Quickly. Is the order in?”
“Yes, it's done. If we send him to the CT room now….”
Echo
(* cardiac ultrasound)
let’s just take a quick look.
Cardiac ultrasound is an important turning point in the differential diagnosis for a patient like this.
Because even the short time it takes to get down to the CT room, even the brief wait for the elevator, has to be saved.
If it really is a dissection, he could even die on the street on the way to the CT.
“Bring the portable here, now.”
“Ah, yes!”
Startled, Baek Eun-seo shouted over her shoulder, and an intern came huffing and puffing, dragging the bulky portable ultrasound machine toward the bed.
I squeezed a generous amount of gel onto the patient’s epigastrium.
“I’ll just take a quick look with the ultrasound. Hold your breath.”
I placed the probe on him.
The black-and-white heartbeat undulated on the screen.
My eyes moved quickly.
Checking for pericardial effusion, checking wall motion.
Baek Eun-seo, watching the monitor beside me, swallowed hard and said,
Doctor, the RV
(* right ventricle)
… seems mildly dilated
(* mild enlargement)
I think?
Baek Eun-seo’s voice carried certainty.
“Eunseo, hold on.”
I cut her off, tightening my grip on the probe.
Yes, I can see it too.
The right ventricle had enlarged and was laboring.
“What’s going on?”
Then a cool voice came from behind me.
It was Professor Cheon Eun-jeong.
She was approaching with a coffee in hand, frowning at the sudden commotion.
“Professor!”
Baek Eun-seo quickly explained the situation as if she had found her savior.
The patient has dyspnea, tachycardia, and an S1Q3T3 pattern, and on echo there’s RV dilatation
(* right ventricular enlargement)
findings, so we strongly suspect PE… but Dr. Han Hyun-jae said to get an aortic CT.
Professor Cheon’s eyes turned to me.
If I were to interpret that look from my perspective….
It could mean, ‘What are you up to now?’
Or it could mean, ‘He probably has something again.’
Well, the professor’s expression was always hard to read anyway.
“Not PE…? Hyun-jae, why go out of your way to…
I swallowed dryly and voiced my hypothesis.
“From what I can see… it’s the RCA
(* right coronary artery)
being invaded by an aortic dissection
(* tearing of the aortic wall)
—that’s what it looks like.”
“…What?”
Professor Cheon’s eyes widened.
“Dissection? The aorta?”
Yes. The patient shows findings suspicious for Marfan syndrome. And this RV dysfunction
(* right ventricular dysfunction)
…is probably not from PE, but from the aortic dissection tearing into the right coronary artery ostium and causing an RV infarction
(* right ventricular infarction)
is most likely.
Silence.
Professor Cheon closed her mouth and looked back and forth between my face, the patient, and the ultrasound screen.
The gist of my argument is this.
The blood vessel going to the heart was blocked by the torn intima of the aorta.
So the heart, especially the right ventricle, stopped because it couldn’t get blood.
That’s why the right ventricle enlarged.
As a result, the ultrasound looks exactly like PE, but the cause is the exact opposite.
If we mistook this for PE and used anticoagulants or thrombolytics?
Blood would gush out of the torn aorta, and the patient would die on the spot.
Cheon Eun-jeong walked up silently and stared at the monitor.
Her gaze sharpened.
‘Phew, thank goodness.’
I let out a sigh of relief inwardly.
It was a relief that the professor had come.
The theory sounded plausible, but honestly…
‘Even so, it’s hard to tell from ultrasound with my own eyes.’
Whether what I was seeing was really a flap from the dissection or just an artifact.
Whether that right ventricle wasn’t beating because it was blocked, or because it couldn’t beat due to pressure.
With my eyes as a second-year resident, I couldn’t be 100% certain.
‘Ha, if I bring this up, I’ll get chewed out again by the cardiology ghost.’
Cardiology ghost: Hey, you blind-ass Lee Sin bastard! Can’t you see that fluttering thing over by the aorta? Can’t you see it?! Are your eyes just decorations?!
It felt like that ghost’s comment was appearing as a hallucination.
Honestly, even to my eyes right now, it just looked like PE, since the right ventricle was enlarged and moving like shit.
Baek Eun-seo seemed right.
But my gut, and the ghosts, were screaming that it wasn’t.
I quietly took a step back behind Professor Cheon.
Shifting responsibility?
No.
This was respect for my superior.
Of course it was.
‘Professor, help me.’
I looked at Professor Cheon’s back with desperate eyes.
Please find it for me.
That fluttering piece of blood vessel.
“The root… ahem… uh….”
Professor Cheon Eun-jeong muttered, leaning in so close it looked like she might stick her nose into the monitor.
Professor Cheon’s pupils were desperately chasing something in the black-and-white screen.
And then she suddenly whipped her head around.
“Hey, get a CTA. Push him to the CT room right now.”
“Huh.”
Baek Eun-seo froze with a dazed expression.
She had just been certain it was PE, and now they were suddenly scanning the aorta.
Her brain had clearly short-circuited.
“Uh… yes?”
“Can’t you see this? Here. This faint fluttering line inside the ascending aorta. And here, it’s curling into the RCA opening.”
“….”
To be honest, I still couldn’t see it well.
It just seemed like an illusion, or maybe noise.
But the cardiology ghost said it was right, and the professor said it was right.
Then it was right.
“…Ah, I think I can see it properly now.”
I added while staring at the monitor with an intentionally serious expression.
“I can see it clearly! The flap has come all the way up to the valve.”
‘What do you mean I can see it? I can’t see jack shit.’
Either my eyes were messed up, or her eyes were microscopes.
But just because I couldn’t see it didn’t mean the disease wasn’t there.
Then Professor Cheon drove the nail in.
“And most importantly, the septum
(* interventricular septum)
Look. The right ventricle isn’t pressing hard on the left ventricle, right? You get the picture?”
“Ah.”
Only then did I nod.
Right?
If this were a massive pulmonary embolism enough to cause hypoxia, pulmonary artery pressure would skyrocket and the right ventricle would swell up tight.
And that pressure should squash the left ventricle into a D shape.
But the right ventricle on the screen was enlarged, yet it wasn’t pushing hard enough to crush the left ventricle.
It was just panting weakly.
It wasn’t because of pressure.
It was because of ischemia.
It couldn’t generate force because blood wasn’t getting through.
“Then the probability of PE goes down a bit… It does look like the dissection has latched onto the RCA.”
Professor Cheon’s assessment was complete.
“Push him to the CT room. His vitals are still stable, so we need to scan him as quickly as possible and get him up to the OR.”
“Yes, doctor. I’ll push him…”
Just as I reached for the bed rail, Professor Cheon slapped the back of my hand.
“No, Eunseo will push him.”
Professor Cheon’s eyes turned to me.
“You call thoracic surgery.”
“…Ah, yes.”
“Who’s on thoracic surgery call? Call them and tell them aortic dissection is suspected and we may need emergency surgery. Tell them we’ll send the CT up as soon as it’s done.”
Professor Cheon’s gaze turned grave.
“You know this patient is a ticking time bomb, right? After you call them, contact the family and let them know in advance that he needs surgery. Have them come right away. We need consent before he goes into the OR.”
Ticking time bomb.
Aortic dissection.
The ER’s most terrifying catastrophe, one that could go off at any moment and kill him suddenly.
I watched Baek Eun-seo’s back as she pushed the bed away, and solemnly picked up the receiver.
“Yes, understood. I’ll contact them right away.”
My hand trembled slightly as I lifted the phone.
‘Please, just hold on without blowing up until we get the CT.’
Praying inwardly, I dialed thoracic surgery’s on-call room number.
Rrrring
Rrrring
Click.
From beyond the receiver, I heard harsh breathing and someone snatching up the phone.
[Yes, this is Kang Min-seong, third-year thoracic surgery resident.]
I swallowed dryly and began pouring out the details I’d organized in my head like a machine gun.
“I’m Han Hyun-jae, a second-year emergency medicine resident. I’m urgently calling about a male patient in his fifties who came to the ER. We strongly suspect aortic dissection, specifically Type A.”
[Type A?]
The voice on the other end instantly tightened with tension.
Type A is a tear in the ascending aorta, the worst thoracic surgical emergency, and if you don’t operate right away, the mortality rate goes up by 1% every hour.
“Yes. The patient came in complaining of chest pain and dyspnea after getting off a plane, and he has physical features suspicious for Marfan syndrome.”
[What about the vitals?]
“BP 150/90, HR 110. He’s still holding on, but…”
I steadied my breathing and started explaining the potentially confusing part.
“On the initial EKG, there was an S1Q3T3 pattern and T-wave inversion in V1 through V4, so at first I suspected PE
(* pulmonary embolism)
and that’s why, right now…”
[Just a moment, ER doctor?]
Kang Min-seong cut me off.
“Yes, doctor!”
[So you got an EKG and it showed S1Q3T3? He was on a plane, he has dyspnea. I mean… isn’t that just a textbook pulmonary embolism?]
It was the reaction I expected.
I would have reacted the same way.
From thoracic surgery’s perspective, if emergency medicine was holding on to a PE patient and calling to ask, ‘Isn’t this an aortic tear?’ they’d think, ‘Why are you already making a fuss? Just get a CT and call us when you’re sure.’
“No, I mean, on the echo…”
I hurriedly continued.
“We also thought it was PE at first, so we looked at the echo. But there’s RV dilatation
(* right ventricular enlargement)
findings, but there isn’t a clear D-shape in the LV
(* the shape seen when the left ventricle is compressed)
It looks less like pressure overload pushing the septum toward the left ventricle, and more like RV wall motion
(* right ventricular wall motion)
being reduced overall, which is an ischemic finding.
[…Ischemic?]
“And most decisively, there was a shadow suspicious for a dissected intima near the aortic root, and blood flow to the RCA appears reduced. The aortic dissection has invaded the opening of the right coronary artery, causing an RV infarction
(* right ventricular infarction)
and I think that’s why the right ventricle enlarged.”
I kept talking without even a chance to breathe.
“We’re already taking him down for a CTA with Professor Cheon Eun-jeong’s approval. If this is a Type A with the RCA blocked, the patient could arrest during the scan, so I called to let you know in advance!”
Silence fell over the receiver for a moment.
Dr. Kang Min-seong seemed to piece together the information I had blurted out.
It has S1Q3T3, but it’s not PE.
The right ventricle is enlarged, but not because of pressure.
The aorta tore and blocked the coronary vessel.
Conclusion?
[……Hah, shit.]
A small curse came through.
It was a sign that he had grasped the situation.
Yeah, sorry, but this was a super-emergency surgical case a hundred times tougher than PE.
[Ah, yes. Understood. I understand what you’re saying.]
His voice was clearly different now.
[I’ll contact the professor right away and assemble the surgical team to come down to the ER. Please send the CT up as soon as it’s done. I’ll also notify anesthesia and the OR so we can take him straight upstairs for surgery as soon as we review the images.]
“Yes, thank you!”
[Please keep his blood pressure from spiking. You have the labs and blood ready, right?]
“Yes!”
[Understood. We’ll be there soon.]
Click.
The call ended.
I put down the receiver and let out a long breath.