Chapter 118
“Huh? That patient? He can talk just fine?”
“Yes. That’s what makes it more dangerous. It’s called a lucid interval. It’s a very frightening sign that appears with an epidural hematoma.”
“A lucid interval?”
“Even if a blood vessel in the brain bursts, until the blood actually pools, the patient can look perfectly fine. They can talk, walk around, and even say they want to go home.”
I tapped my temple with a finger.
“But a lot of people die because of this, so we need to lay him down and get a CT scan right away. This is the ER—you can’t be fooled by appearances.”
I finished speaking and hurried toward the patient who had disappeared behind the curtains in Area A.
But for some reason, it felt like I’d gotten better at talking.
Was it just my imagination?
Clack.
I pulled my latex gloves on tight to my wrists and approached the bed where the patient was lying.
First-year Park Seong-jeong, two nurses, and one paramedic quickly gathered around me.
Watching that, the PD must have thought it made for good footage even in the middle of all this and slyly came over to ask me a question.
“There are a lot of doctors gathered here. Is the patient in very serious condition?”
I flicked the fingertips of my gloves as I answered.
“Strictly speaking, there are only two doctors here—me and that first-year Park Seong-jeong over there. The person in the coat over there is a paramedic.”
“I see. Then what role does the paramedic...”
The PD tried to swing the microphone over.
This was not the time to casually explain job titles.
“Sorry, but let’s talk about that a little later.”
The PD flinched and quickly stepped back.
The cameraman also tactfully moved to the back and started filming the scene from a position where he wouldn’t get in the way.
“First, I’m going to get 18-gauge lines in both arms. Hang fluids wide open and get the monitor on immediately. Set EKG, SpO2, and NIBP at five-minute intervals, and don’t take off the neck collar.”
“Yes.”
The nurses moved in perfect unison.
Eighteen gauge.
It’s a fairly thick needle.
There’s a reason we use it.
If the brain hemorrhage is severe enough that he has to go straight to the OR, he may need massive transfusion.
Better safe than sorry.
While the nurses held the patient’s arms and searched for veins, first-year Park Seong-jeong stuck to the bedside and hurried through a Q&A with the patient.
“How’s your headache now? Is it worse than before?”
“It feels a little foggy... I think it’s throbbing a bit more than before...”
The patient answered with a furrowed brow.
He was still lucid.
His speech was also relatively clear.
But that “throbbing a bit more” part kept bothering me.
“What about the guardian? Were you able to contact them?”
“My friend is calling from outside...”
“We need consent for the CT. We have to check whether there’s bleeding inside the head. We’ll be using a drug called contrast—have you ever had any allergies to it before?”
“No, nothing like that. But doctor...”
When the patient stopped speaking mid-sentence, Park Seong-jeong looked up from filling out the consent form on the chart board.
“Go ahead.”
“I feel a little sick to my stomach...”
“Your stomach? You feel nauseous?”
“All of a sudden... it feels like my stomach’s turning over... ugh...!”
Park Seong-jeong sensed something was wrong and grabbed the patient’s shoulder.
“Whoa, patient? Patient!”
The patient’s eyes lost focus in an instant and began to go blank.
Then his mouth opened, and a wet gurgling sound rose up through the airway.
Park Seong-jeong turned his head in a hurry and looked for me.
“Dr. Han Hyeonjae!”
The instant I heard him, I whipped around.
“Uweeeeeek!!!”
The sight of vomit blasting out of the patient’s mouth like a fountain.
‘Oh, fuck.’
Projectile vomiting.
Loss of consciousness.
Forehead contusion.
The answer was clear.
IICP, increased intracranial pressure
An artery had burst inside the skull.
Blood gushed out at tremendous speed and began crushing the brain.
As intracranial pressure shot up, it stimulated the brain’s vomiting center and at the same time compressed the brainstem, shutting off consciousness like a switch.
‘The lucid interval’s over. Fuck.’
The patient’s head flopped weakly to the side.
“Suction! Give me the suction tip! Hurry!”
What was most dangerous right now wasn’t the brain hemorrhage itself.
It was the vomit.
If vomit gets into the airway while the patient is unconscious, it can cause aspiration pneumonia—and right then and there, it can block the airway and suffocate them to death.
I pried the patient’s mouth open, and Park Seong-jeong grabbed the suction machine.
Krrrrrr-
The suction tip swirled around inside the patient’s mouth, sucking out the foreign matter.
But the patient didn’t react.
No gag reflex either?
“Oxygen saturation is dropping!”
A nurse’s shout rang out.
The brain was being compressed, and the respiratory center was being paralyzed too.
We had to open the airway.
Right now.
I handed the suction tip to Park Seong-jeong and shouted at the nurse.
“I’m intubating right now!”
“Yes!”
“Give me the kit now! And a 7.5 tube...”
Without even time to calculate the drug doses in my head, I shouted out the numbers that came out on instinct.
“Rocuronium 70 and etomidate 18 mg—hurry!”
This was a patient with high intracranial pressure.
Ketamine was out; it can raise intracranial pressure.
Propofol, which can lower blood pressure, was dangerous too.
Etomidate, which protects the brain and is hemodynamically stable, was the right choice.
“Seong-jeong, check the pupils! Hurry!”
“Yes!”
With trembling hands, Park Seong-jeong took out a penlight and flipped up the patient’s eyelids.
“The right one is blown! Over 5 mm and no light reflex!”
“The other side!”
“It’s 3 mm! It’s reactive!”
Okay.
Right epidural hematoma.
The brain was being pushed aside.
If we didn’t open it up now, the brainstem would be crushed and the heart would stop.
“Medication going in!”
The nurse pushed the syringe into the IV line, and I stood by the patient’s head.
Breathing hard, I shoved the laryngoscope into the patient’s mouth.
***
‘Ha, got it.’
I placed the stethoscope against the patient’s chest.
Every time I squeezed the Ambu bag, clear breath sounds came from both lungs.
There was no sound from the stomach.
“It’s not esophageal intubation. Breath sounds are clear bilaterally. I’ll secure it at 22 cm.”
I tossed the laryngoscope onto the tray and let out a short breath.
Intubation complete.
‘Ha...’
I still couldn’t believe it.
I hadn’t hesitated even once just now.
Even though my field of view was a mess from the vomit, I instinctively found the epiglottis and opened the vocal cords.
It was like my hands moved before my brain did.
‘Look how far you’ve come, Hyeonjae.’
Screw the god of scalpels and all that—this was pure skill earned from my time in the trenches.
My airway management—the only thing I ever got praised for even on the gallery.
Praise me.
But there was no time to get sentimental.
The intracranial pressure was still rising.
“I’ll run 100 g of 15% mannitol wide open.”
Mannitol.
A drug that uses osmotic pressure to pull water from the brain into the blood vessels and lower intracranial pressure.
In a situation where we couldn’t open the skull right this second, it was the only lifeline we had.
“I’ll wheel him straight to the CT room. Right now, can you call NS
(* Neurosurgery)
on-call, Seong-jeong?”
I raised the bed rail and asked the first-year Park Seong-jeong, who was standing beside me with a dazed expression.
No, this is basically an instruction now, isn’t it?
“Ah, yes! I’ll do it!”
The moment Park Seong-jeong startled and pulled his phone out of his pocket, the transport staff began pushing the bed.
“Careful! Don’t let his head shake!”
Rumble-rumble.
The medical staff surrounded the patient and sprinted toward the CT room.
I took off my gloves, splattered and ruined with blood and vomit, and shoved them into the trash.
Then I roughly brushed my disheveled hair back and sat down at the nearest PC.
Click, click, clack-clack.
Then I heard Park Seong-jeong’s voice beside me.
“…Yes... the patient vomited... and his consciousness... uh... so...”
I could almost hear the irritated shouting of the neurosurgery resident over the receiver.
Hmm, that’s a complication.
I should keep it to the essentials.
The patient’s head is about to burst, and he’s reciting classical poetry like Jeong Cheol or something.
I walked up behind Park Seong-jeong.
“The phone.”
“Ah, y-yes!”
Park Seong-jeong handed it over with the look of someone who had just met a savior.
“This is second-year emergency medicine resident Han Hyeonjae. I’m calling about a patient strongly suspected of having an epidural hematoma.”
[Yes. Go ahead.]
“Male in his twenties, fell off a kickboard. He had a lucid interval right after arrival, then projectile vomiting five minutes ago and slipped into a coma. The right pupil is dilated to 5 mm with no light reflex. He’s currently in the CT room on mannitol after RSI. I’m calling because it looks like brain herniation is in progress.”
[Ah, yes. Understood... Please call me as soon as the images are up. I’m heading down now.]
Click.
I hung up and handed the receiver back to Park Seong-jeong.
“The call... uh, never mind. I’ll teach you separately later.”
“Yes... thank you...”
I turned my gaze back to the monitor.
Then I sensed someone beside me.
It was the PD.
“Doctor?”
“Yes.”
“Could that situation earlier have been...?”
The PD couldn’t finish the sentence.
A young man who had been talking normally suddenly vomited, and then his eyes rolled back.
And then the sight of a tube being shoved down that young man’s throat.
Maybe even scarier than a horror movie?
“When an artery bursts, the patient can still look fine until the blood pools; then once it crosses a threshold, the brain gets compressed and they can die suddenly. As you just saw, it happens in an instant with almost no warning signs.”
“Then will that patient live?”
“If we get the CT now and go straight into surgery to remove the pooled blood, he’ll live. I can’t promise it, though.”
I looked straight into the lens.
Toward the viewers watching nationwide, especially the young people who like riding electric kickboards.
“This is why you need to wear a helmet.”
I delivered the warning with real sincerity.
“Anyway, yeah. Please wear a helmet. Once your head cracks, there’s no fixing it. If you’re going to ride a kickboard, don’t bet your life on it—please wear protective gear. Or just walk.”
The PD nodded.
That’s a very satisfying message.
As expected, that’s me.
“Once the CT comes up, the diagnosis will probably be confirmed. I’ll tell you more then.”
The charting was done.
Now onto the next step.
“But, PD. I, uh... need to report to the professor, so could I get a moment off camera?”
The patient was critical, so I had to notify the on-call professor.
The PD understood and quickly stepped aside.
“Sure. Go ahead.”