Chapter 113
“We need to check whether it's an ovarian teratoma.”
“Huh? Ovarian? A teratoma?”
Joo Jeonghyeon's eyes went wide.
That was only natural.
It would have been hard to blame me for suddenly saying I wanted to look for an ovarian mass—a gynecological condition—in a patient who was rampaging while complaining of auditory and visual hallucinations.
“Yes.”
“I mean... it wouldn't be technically impossible to use the contrast while you're doing a brain CT and then sweep all the way down to the pelvis, but... there has to be a reason for Radiology to approve it. Otherwise it'll get cut for insurance review, too...”
Joo Jeonghyeon still looked unconvinced.
I looked around and lowered my voice, whispering so only Joo Jeonghyeon could hear me.
“I think it's anti-NMDA receptor encephalitis.”
“Huh? NMDA encephalitis?”
Joo Jeonghyeon froze.
A disease that in the past had been misdiagnosed as schizophrenia or demonic possession, leaving countless patients locked away in psych wards or dead.
But in reality, it was an organic brain disease caused by autoantibodies attacking receptors in the brain.
“The clinical symptoms are too similar. Things like the lip movements you saw earlier, or how severe the autonomic symptoms are.”
I rattled off the points the gallery anon had pointed out.
“Her vitals are too unstable to just call this first-episode psychosis. And you know one of the most common causes of this disease is antibodies from an ovarian teratoma.”
“Ah...”
Joo Jeonghyeon nodded then.
Doubt hadn't become certainty, but Joo Jeonghyeon had at least reached the stage of rational suspicion—enough to justify checking.
“I see. We need to rule out a paraneoplastic syndrome...”
“Yes, exactly.”
I checked the time.
“Psychiatry doctor, it looks like it might take a while to do the test and get the results, so you can head up to the ward. You're busy, so there's no need to keep waiting here. It's fine.”
“Ah, no. I'd still have to come back down if I got called anyway... um...”
Joo Jeonghyeon hesitated.
Joo Jeonghyeon seemed worried that something might happen during the test.
“Right now we're suspecting a neurological cause, and even if the test comes back clean and it turns out to be psychiatric after all, it'll still take a while to decide on admission. I'll take responsibility and get the whole workup done.”
At my words, Joo Jeonghyeon let out a sigh of relief.
When another department doctor is this proactive about digging up an organic cause, who'd refuse? Seriously.
“Ah, yes... then I'll go upstairs. Please contact me right away if anything happens.”
“Yes, thank you.”
As soon as Joo Jeonghyeon disappeared toward the elevators, I plopped down in the station chair.
'Phew... at least I bought us some time.'
First, I need to order the CT.
Tap-tap-tap-tap.
If anyone complained about why I was ordering a pelvic CT for a psych patient, I'd just write r/o Anti-NMDA Encephalitis in the memo.
As soon as I hit Enter, another worry came crashing in.
'Should I start acyclovir... hmm....'
NMDA encephalitis was strongly suspected, but it still wasn't confirmed.
The scariest thing in the ER is trusting one diagnosis you've latched onto and missing the real culprit.
What if this wasn't NMDA, but herpes encephalitis?
The later HSV encephalitis is treated, the faster the brain starts melting.
Its mortality is high, and the sequelae are severe.
'If encephalitis is even a possibility, the standard move is to cover with antivirals too...'
I was glaring at the monitor and tearing at my hair when—
“Hey.”
Kim Jihoon had finished treating another patient and somehow come over beside me.
“What's this? Isn't this that psych patient from earlier? Why are you doing an abdomen-pelvis CT?”
To Kim Jihoon, it must have looked like I was ordering unnecessary tests.
Ordering an abdominal scan on a patient with a headache.
If HIRA found out, they'd be foaming at the mouth.
“Shut up. I can't concentrate.”
“No, you idiot. You need an indication
(* proper indication)
to order it, right? Did the patient say her stomach hurts?”
Kim Jihoon thumped his chest in frustration.
“Ah, what is it? Tell me.”
Kim Jihoon kept pestering me relentlessly.
“Have you seen the movie The Exorcist?”
“What the hell are you suddenly talking about movies for?”
“You know that rumor about the girl in that movie being sick, not possessed by a demon?”
“You're talking about NMDA encephalitis?”
Oh, so Kim Jihoon wasn't a total idiot after all.
My internal rating of Kim Jihoon went up a notch.
“Yeah, that. But do you know what causes more than half of that disease?”
“What?”
“An ovarian teratoma. That's why we need to scan the abdomen.”
As he listened to my explanation, Kim Jihoon's mouth slowly fell open.
...
“Whoa... that's chilling. Are you a genius?”
“Yeah, I'm a genius.”
Thanks to that gallery anon, bro.
“Anyway, that's why I'm ordering it. Otherwise... well, we'd just get yelled at, that's all.”
“Worth a shot.”
Kim Jihoon nodded.
Then Kim Jihoon noticed the drug search window open in one corner of the monitor.
“But acyclovir? Are you adding that too?”
“Yeah. That's the dilemma. It does look like NMDA, but if it's HSV, every second we don't have the drug in is another second brain cells are getting damaged.”
Kim Jihoon folded his arms and sank into serious thought.
“Let's give it.”
Kim Jihoon gave a terse conclusion.
“Why?”
“It's a probability game. If it's NMDA and you gave acyclovir, you just stop it. Aside from a bit of extra cost and a little strain on the kidneys, there's not much to lose. We can just give plenty of IV fluids with it anyway.”
Crystal clear.
Our guiding principle.
Cover the more dangerous one first.
When the diagnosis is uncertain, the right move is to treat the disease that can kill the patient first.
“Okay.”
I nodded and hit Enter.
“We'll cover for now until the CSF results come back.”
“Good.”
And so we wrapped up our badass strategy meeting.
Now the dice had been cast.
Please let the CT machine find a teratoma in that patient's abdomen.
***
“Hey, listen.”
I opened my mouth while staring blankly at the monitor.
It had been 10 minutes since I placed the order.
“What?”
Kim Jihoon, who was sorting charts beside me, answered absentmindedly.
“No matter how I think about it, I think we made the right call with acyclovir.”
“Right?”
Kim Jihoon agreed too.
“It takes forever for PCR results to come back anyway. Even if you draw CSF and send it to the lab, the result doesn't come back immediately.”
“True.”
We tried to shake off our anxiety by reaffirming that our decision had been reasonable.
“I'll call Neurology for now.”
I picked up the receiver.
I had already coordinated with Joo Jeonghyeon from Psychiatry, but if an organic brain disease was suspected, Neurology's confirmation was essential.
If it was encephalitis, Neurology would be the department to admit her and take over as the primary team.
Rrrr-ring.
The ringing went on and on.
Either they didn't want to answer, or they were unbelievably busy.
…
Or maybe they'd gone to the bathroom.
[This is Hwang Juhyeok, the Neurology night-duty doctor.]
A sharp voice.
I was already feeling uneasy.
“Hello, doctor. This is Han Hyeonjae, second-year resident in emergency medicine. I'm calling because I have a patient I need to consult on. She's a woman in her twenties showing acute psychosis and autonomic instability...”
I briefed him on the patient's symptoms, the treatment so far, and the possibility of anti-NMDA receptor encephalitis and HSV encephalitis we were suspecting.
But the response was cold.
[…And? Did you get imaging?]
“We're sending her down for it now. The images should be up soon.”
[What about the CSF test?]
“The patient's still sedated, and we haven't even gotten the CT yet, so we couldn't do it.”
[Sigh... doctor.]
A deep sigh came through the phone.
[You don't have any objective data right now. No CT, no CSF
(* cerebrospinal fluid)
results, and no MRI. You should've seen Psychiatry first.]
“Psychiatry already saw her, and they said ruling out an organic cause should come first...”
[Then call me again when you have data. What are we supposed to do without any images? Call me back when the CSF results are out. I'm hanging up.]
Click.
The call ended.
“...”
I stood there for a moment, holding the dead receiver, blankly.
From Neurology's perspective, it might seem like there wasn't enough evidence.
But that attitude, tone, and manner are absolutely unacceptable.
Why is it so hard to speak nicely?
“Crazy bastard.”
I slammed the receiver down roughly.
“Why, did you get rejected?”
“Yeah. He says to call him when all the test results are in. What a damn high-and-mighty bastard.”
“Who's the Neurology night-duty doctor?”
“Hwang Juhyeok.”
“What, wasn't it Dr. Kim Najeong today?”
“That's what I saw on the duty roster too, but it's Hwang, goddammit.”
We looked back at the monitor.
And then, at that very moment.
Ding-dong.
A notification chimed brightly.
“Ah, CT's up. The brain CT came up first.”
As I double-clicked the Brain CT tab, black-and-white cross-sectional images of the brain began appearing on the monitor.
It was the moment I rolled the mouse wheel and swept through the ventricles, brain parenchyma, and the blood vessels supplying the brain.
….
Clean.
Too clean.
Brain hemorrhage?
None.
Brain infarction?
Not visible.
Tumor?
None.
Edema?
The sulci were still clearly visible, so it didn't look swollen either.
“Nothing there... Hey, Jihoon!”
“What?”
“Come look. What do you see?”
Kim Jihoon leaned his face close to the monitor and rolled the wheel up and down.
“...No. To my eyes too, it looks damn normal. It just looks like a healthy twenty-something's brain.”
We both sighed at the same time.
Of course, this was the result we'd expected.
“But CT isn't supposed to show anything in the first place, right? Most CTs come back normal anyway. You'd need an MRI to see anything useful.”
Kim Jihoon said, folding his arms.
“A CT is for ruling out hemorrhage or a big mass, not for diagnosing encephalitis.”
Ding-dong.
A second notification chimed.
“Oh, the abdomen's up!”
I cut Kim Jihoon off and hurriedly moved the mouse.
“Damn it, if a person starts talking, at least let them finish... huh?”
Kim Jihoon muttered and then stopped.
I stopped too.
The screen showed a pelvic CT image.
Our eyes locked on the same spot as if by agreement.
On both sides of the uterus.
The place where the ovaries should be.
There was something there that should not have been.
A huge mass sat where the right ovary should be.
A bizarre lesion with white, calcified areas mixed with black fatty components.
A grotesque shape, as if another life form were growing inside the abdomen.
A tumor containing tooth tissue and fat.
A cry of amazement burst from my mouth.
“Damn, this...”
Kim Jihoon's mouth dropped open.
“Teratoma. Holy shit...”
There it was.
That bastard had been producing the antibodies that were attacking the patient's brain.
She wasn't possessed by a ghost.
The demon wasn't in the patient's head, but hiding in her lower abdomen.
“Found it.”
I clenched my fist tightly.
A shiver ran down my spine.
We found the cause.