Chapter 119
“A 22-year-old man. Single e-scooter crash. He arrived with a GCS of 15 and was lucid, but he just had projectile vomiting, dropped to a GCS of 7 or lower, and fell into a coma. He showed right pupil dilation, so under suspicion of acute epidural hematoma and brain herniation, we performed RSI, gave mannitol, and sent him into the CT room.”
I continued the briefing in a dry tone.
Today’s emergency medicine attending professor was Kim Seong-chan.
Well, just a standard EM professor.
“…Quick. Vitals?”
“Before intubation his BP was 160 over 90, but after sedation it’s holding at 140 over 80. I called neurosurgery, and we’re planning to send him to the OR as soon as the CT comes out.”
“All right. Well… good work.”
“Yes, understood.”
And so I headed back to Zone A, where the PD was waiting all alone(?).
“Hoo….”
All that was left now was to wait.
The PD cautiously extended the microphone.
“Doctor. Did you just report to the professor?”
“Yes. It’s the process of reporting to the on-call attending, who is the final authority, and getting approval.”
“I see….”
The PD nodded, then asked in a light tone as if trying to change the subject.
“By the way, doctor. Do these kinds of patients come in often?”
“Not just often—they’re regulars in the ER. Especially on nice spring and fall days, or summer nights.”
I pointed toward the ER entrance with my finger.
“For young trauma patients, motorcycles and e-scooters account for most of the causes. Patients like these are pretty gruesome.”
“Is there a particular reason?”
“Because a lot of them come in with their bodies ground raw against the asphalt.”
The PD’s face crumpled.
Just imagining it was horrifying.
“Especially the scooters. At least on motorcycles a lot of people wear helmets, but on scooters they really ride bareheaded. And because the wheels are small, they get caught on even little bumps and throw you off.”
I launched into a sincere tirade.
“On scooters, since you’re standing up and riding, most of the time you hit the ground headfirst. Facial fractures, brain hemorrhages, cervical spine fractures—everything.”
I shuddered.
“The thing I feel worst about while working here is that, if they’d only worn a helmet, they could’ve walked out of the ER….”
Without realizing it, I got emotional.
“Please, wear helmets.”
I naturally wrapped up the campaign-style line with a dead-serious expression.
Then it happened.
Ding~
The most welcome—and terrifying—notification sound in the world, breaking the station’s silence.
A new entry popped up on the PACS monitor.
It was probably that patient’s CT from earlier.
“It’s up.”
I stopped chatting and immediately grabbed the mouse.
The PD and the camera operator quickly crowded in behind me to capture the scene on the monitor.
Double-click.
The loading bar filled in an instant, and a black-and-white brain cross-section filled the screen.
There was no need to look closely… not at all.
“Ha….”
A sigh escaped me.
Around the right temporal lobe.
Right beneath the skull, a huge white mass was lodged there.
A textbook acute epidural hematoma.
I wasted no more time and picked up the receiver.
Time to call neurosurgery again.
Brrring-
[This is Neurosurgery.]
It was the resident I’d spoken to earlier.
His voice was full of tension, which in many ways stirred up complicated feelings.
“This is Han Hyeonjae from Emergency Medicine. The e-scooter patient’s CT just came up—did you see it?”
“I’m looking at it. This is… the amount…. The midline’s shifted like crazy too.”
“We should send him straight to the OR, right? His vitals are being held with mannitol for now, but we don’t know when he’ll crash.”
[The professor has already given the go-ahead. We need an emergency craniotomy. Anesthesia and the OR have both been called.]
Mm, got it.
[Where is the patient right now? Has he come back to the ER?]
The neurosurgery resident’s frantic voice came through.
“No. He should still be in the CT room. I figured we’d just waste time shuttling him back and forth.”
“Ah, then send him straight to the OR! Emergency operating room number 3!”
“We’ll get consent from the guardian and send him up as soon as they arrive.”
“Understood!”
Click.
I hung up, then immediately called the CT room on the in-house phone.
“CT room? Don’t send the e-scooter patient you just scanned back to the ER.”
“What? Then where should we send him?”
“Straight to the OR. Neurosurgery is coming down to receive him by the elevator. Push him over right now.”
“Understood.”
Only after hanging up did I let out a long breath.
The CT image on the station monitor still showed that dreadful white mass flashing on the screen, but in any case, this patient was now out of my hands.
From here on out, it was neurosurgery’s time.
“You can see it, right, PD?”
I pointed at the monitor with my finger.
“That huge white mass you see is all blood.”
“All of that is blood?”
“It’s blood that burst out when an artery ruptured and then clotted. Even at a glance, it’s way over 50 cc.”
With the mouse cursor, I pointed at the brain’s midline.
“And what’s even more serious is this. The midline that should normally be in the center of the brain is being shoved hard to the left by this clot, right? It’s shifted more than 1 cm.”
“Then… this is….”
“Yes. Brain herniation is happening right now. If we don’t open the skull and remove the blood immediately, this patient won’t make it through today.”
“Doctor.”
The PD asked cautiously.
“Will the surgery go well?”
As I turned off the monitor, I answered calmly.
“I don’t know. Still, the neurosurgeons are good at what they do. And more than anything….”
I looked at the empty bed.
“We caught it early and sent him on. Right after he vomited, we intubated him, lowered his ICP, got the CT, and rushed him straight to the OR. We did everything we could.”
Yeah, that’s that.
“Now we just have to trust and wait.”
The moment I finished speaking, someone shouted from far away toward me.
“Han, doctor! Chest pain patient!”
I reflexively turned around.
“Yep! I’m on my way!”
Exactly.
This is the ER.
***
The ER had already slipped into a brief lull.
I took a gulp of cold water to cool off.
The PD and the camera operator had also set their cameras down for a moment and were catching their breath; they looked a little miserable.
I wondered if they’d wanted to work this night shift, too.
“Hoo….”
I was sorting through the backlog of charts during that brief lull.
But the god of the ER always ignores my prayers.
Not that I know whether such a god even exists.
Brrring-brrring-
That ringing always has a weird frequency that spikes my heart rate.
The nurse sitting at the station picked up the receiver.
“Yes, this is the emergency room at Cheongjin University Hospital. Yes… yes….”
The nurse’s expression hardened in an instant.
The nurse scribbled furiously on the notepad, then hurriedly waved me over.
‘What’s going on.’
I set down the water bottle and walked over to the nurse.
The nurse briefly took the receiver away from the ear, then quickly briefed me while checking the notes.
“A man in his 60s. His chief complaints are abdominal pain and back pain, and they can feel a throbbing mass in his abdomen. BP is 80 over 50, pulse 120. He’s sweating cold and starting to lose consciousness. rAAA
(* ruptured abdominal aortic aneurysm)
suspected.”
“Oh, really…?”
My breath caught in my throat.
We need surgery. Right now.
I instinctively checked the operating room status board and the on-duty roster displayed on the monitor.
“Damn it….”
A curse slipped out on its own.
“Today’s vascular surgery on-call is… Professor Song Jiyeon.”
The status board had a red light reading [In Surgery].
‘The rAAA case transferred from Milyang is in there, and that was 30 minutes ago….’
Incision started 30 minutes ago.
rAAA surgery takes at least four to five hours.
There’s no way they can close the abdomen and come out right now.
‘Then what about the thoracic surgery team?’
Just in case, I checked the thoracic surgery schedule.
If vascular surgery was unavailable, we’d have to grab thoracic surgery instead.
[Cardiothoracic Surgery / OP / CABG]
‘CABG. We’re screwed.’
They’re in cardiac surgery.
Meaning they’ve got the heart-lung machine running and the chest open.
That’ll take at least six hours too.
Every surgical team in our hospital that can operate on the aorta is tied up in the OR.
We can’t accept this patient.
Even if we did, we couldn’t operate, so all we’d do is keep transfusing him in the ER until he dies.
“Please hand me the receiver.”
I took the receiver from the nurse with a heavy heart.
The PD pointed the camera at me again.
It’s the kind of sensational material that would make perfect TV, but I didn’t have time to care about that right now.
“Yes, this is the on-duty physician in the emergency room at Cheongjin University Hospital.”
“Yes, doctor! The patient’s BP is really unstable right now, and…]
The paramedic’s voice was shaking desperately.
“Sir, we’re unable to accept the patient right now. We can’t operate at the moment.”
[What? You can’t operate? At Cheongjin?]
“Right now the vascular surgery on-call doctor is already in surgery for an rAAA patient, and thoracic surgery is in the middle of heart surgery, so every surgeon capable of aortic surgery is completely tied up.”
I needed to get the information across as fast as possible.
“If you come here now, there’s no surgeon who can operate. Anesthesia is fully booked too. If you bring the patient here, he’ll die waiting. Our hospital can’t operate on him right now.”
[I see? Haa…]
A deep sigh from the paramedic.
That despair came through the receiver.
“I’m sorry, but I think you’ll have to look elsewhere. Please contact another hospital quickly. We don’t have time.”
[Understood. We’ll look for somewhere else.]
Click.
The call ended.
I set down the receiver and bit my lip.
“Hoo….”
It left a bitter taste.
I couldn’t help feeling helpless.
The PD asked cautiously.
“So just now, you refused because there wasn’t a doctor available to do the surgery?”
“Yes. It’s not like there isn’t anyone on duty. They only have one body, so they’re in the OR.”
I pointed at the status board.
The PD nodded and jotted something down in the notebook.
Then I went back to work.
I prescribed fever medicine to a patient with a cold, ordered an X-ray for an ankle sprain, and calmed down a drunk middle-aged man who was shouting.
The ordinary scene of the ER continued.
Time passed.
Five minutes.
Ten minutes.
And then.
So, if we’re being precise, about twelve minutes had passed since the first call.
Rrrring-
The second phone rang.