Chapter 123
By now, it was Monday of the following week.
Well, in the meantime I'd even forged a tearful camaraderie with the Scalpel God.
Anyway, I got through the weekend safely.
“Then I'll begin.”
M&M Conference.
Morbidity and Mortality Conference.
In other words, a place where we ruthlessly dissect and tear apart whether we missed anything and what went wrong that caused the patient to die.
And now, on the podium of that tribunal...
“Hhhk….”
I stand there.
The light from the projector shines on my face.
My eyes hurt.
In front of me sat the ER chief, the professors, Lee Minjae, and a few residents.
But the attendee I'm most on edge about today isn't them.
The woman sitting in the front row with her arms crossed, glaring at the screen.
The vascular surgery professor.
‘Professor Song Jiyeon….’
There were wildly opposite rumors about Professor Song's personality.
Some residents said she was an angel; others said she was a witch who tore your vessels apart.
The range was so wide I couldn't get a read on her.
But the aura she was giving off now seemed closer to the latter.
Scary.
I swallowed dryly and turned on the laser pointer.
“The patient was a 66-year-old man who came to another hospital with severe abdominal pain and back pain on the day of presentation.”
The slide changed. The patient's timeline spread out in brutal detail.
“At the time of the initial 119 call, our vascular and thoracic surgery teams were unavailable, so we told them we couldn't accept the patient. However, about 12 minutes later, we got a second call after another hospital also refused the transfer. The patient was clearly in shock, so although surgery was impossible, we judged that resuscitation and initial stabilization were urgent. Thus, on the second request, we decided to accept the patient. Therefore….”
Only my voice and the whirring of the beam projector's fan echoed through the conference room.
They should at least replace this projector.
“Immediately after arrival, the patient was moved to the resuscitation room, and his pulse was faint. We immediately activated the massive transfusion protocol….”
I briefed them on the brutal situation at the time.
From the decision-making process for REBOA, to the cardiac arrest, and the declaration of death.
“This is also mentioned in the Joint Trauma System Clinical Practice Guideline
(* U.S. military trauma system clinical practice guideline)
as well, where REBOA can be applied in non-traumatic vascular emergencies accompanied by hemorrhagic shock….”
I cited every paper and guideline I could to build a defense for the legitimacy of the Scalpel God's procedure.
“…The post-procedure exam results are as follows. There were no signs of limb ischemia, and no direct vascular injury from the procedure was observed.”
After the presentation ended, a brief silence fell.
“Questions, please.”
Small questions popped up here and there.
“I have a question about the timing of the vasopressors. Did you start them at the same time as the transfusion, or did you use them after seeing the response?”
“Was the MTP ratio followed exactly?”
I answered calmly.
Actually, this part wasn't an issue.
Because we followed the manual.
The real boss was someone else.
“Yes, well. I'm Song Jiyeon from vascular surgery.”
Professor Song Jiyeon took the microphone.
The air in the conference room dropped by about two degrees.
As expected, the rumors that she was the scary kind were….
“First, I want to apologize for not being able to receive the patient because our department's operating rooms were full. And thank you for trying your best to save the patient in the ER.”
Professor Song began dryly.
But it was only a courtesy remark to lead into her real point.
“Still, I think we need to talk about this part first.”
Professor Song's gaze sharpened.
“Yes. Please go ahead.”
“Looking at the chart, the ultrasound at the time records that the CFA
(* common femoral artery)
had collapsed and couldn't be seen. Is that correct?”
“Yes, that's correct. The pressure was so low the vessel was compressed.”
“Then why didn't you first consider surgically exposing the vessel?”
What?
“A blind attempt, if it fails, carries too much risk of permanently losing the chance because of a hematoma
(* hematoma)
forming. If you stick it once and it doesn't work, you can basically say goodbye to that leg. In an rAAA patient, losing one of the two femoral arteries is critical.”
Professor Song was right about everything she said.
I agree with most of what you pointed out. But at the time, we didn't have the equipment set up or enough staff.
I answered clearly.
“To perform the procedure, you need a surgical set and an assistant to help secure the field. But the resuscitation room staff were already stretched thin just handling the procedures, and the patient was in a PEA rhythm right before arrest. I judged we didn't even have time to cut and dissect. So I chose the fastest method: a blind attempt.”
“….”
Professor Song looked at me for a moment.
“Under the standard protocol, if a shock patient has no pulse, you cut in immediately and go straight in…. Of course, I understand there wasn't time….”
Professor Song said bitterly while twirling her pen.
“You got lucky getting in; this could also be seen as a mistake in technique selection.”
Fact bombardment.
Did the Scalpel God possess me and make it happen by luck? Or was it skill?
Anyway, it worked. If I'd tried the blind approach with my own skill, it would have failed 100 percent.
No, wait.
Maybe I'd still fail even if I used ultrasound.
“Still….”
Professor Song sighed and adjusted her glasses.
“You worked hard. Really. Honestly, it's not even surgery, and expecting that much from an ER resident—especially a second-year—is a bit much. It's just… I'm saying this because it's a shame. If only the surgical team had been there that day….”
There was deep regret in Professor Song's voice.
“I fully understand that as well.”
Then it happened.
“Professor. How about looking at it this way?”
Lee Minjae raised his hand and jumped in.
“Looking back at the situation, the patient's BMI was quite high. In that case, it would take a considerable amount of time. If you had tried to expose the vessel surgically and then the patient arrested, CPR would have shaken the field all over the place, making it even more dangerous. I think the bold blind attempt was the only way out.”
“That's a retrospective argument….”
Today, I became certain.
Lee Minjae is a fucking lunatic.
How could he stand there and say something like that without even blinking in front of a professor from another department?
So, as the medical debate between Professor Song and Lee Minjae began, I stood on the podium, listening blankly to their discussion.
In this place where all the 'what ifs' kept coming up, I suddenly remembered what happened after I fainted and got home.
I mean the post I uploaded to stir up the discussion and sort things out as soon as I woke up.
[Dead Medic Gallery]
=========================
Q. What was the real cause?
Written by : Hell Joseon Slave
We put in REBOA and poured in blood, so why didn't he come back?
Was it put in too late?
Or was the balloon position wrong?
Or was it already useless because the vessels had already burst?
=========================
While I was reviewing it, there was one comment that stood out in particular.
[Comments]
Scalpel God : Hell Slave, let's study.
ㄴ Hell Joseon Slave1 : You okay? Didn't it mess with your head?
ㄴ Scalpel God : I'm not some low-rank scrub like you, so I'm fine. You should be the one pulling yourself together.
And the Scalpel God had casually left behind a single line that pulled the nail out of my chest.
ㄴ Scalpel God : I guarantee that no surgeon, no matter who you brought in, could have saved him in that resuscitation room at that time.
…
The debate in the conference room was still hot.
“Still, we have to stick to protocol.”
“We need to consider the special circumstances of emergency situations.”
But I no longer felt those words as pain.
Because that crazy surgical ghost had told me it wasn't my fault.
‘How should I put it… it feels weird.’
I lowered my head slightly and repeated it to myself.
‘Thanks, Scalpel God.’
And just like that, after the brief debate ended, Lee Minjae suddenly raised his hand and attacked me.
“During the procedure, the patient went into a PEA arrest. Right? Normally, when an rAAA ruptures and causes arrest, it means the intravascular blood volume has already been depleted, but in that situation, would inflating the balloon meaningfully raise the coronary perfusion pressure?”
All eyes in the room turned to Lee Minjae.
“With no blood, does blocking it with a balloon really get the blood moving? Wouldn't it be better to open the chest with an emergency thoracotomy, manually clamp the descending aorta, and do cardiac massage? Textbook-wise, that's the more certain method.”
“Dr. Lee Minjae. You know that too, don't you.”
Lee Minjae stared at me as if asking what the hell I was talking about.
“In our hospital's resuscitation room, there has only ever been one case since opening where an ER doctor surgically opened a patient, and you know who did that one case.”
“….”
Lee Minjae's expression twisted strangely.
“Ahem.”
Lee Minjae cleared his throat and looked away.
He was acknowledging that we didn't have the equipment, the manpower, or the time to do an RT.
Then it happened.
“Doctor! I have an opinion!”
A clear, bright, and extremely tactless voice rang out from somewhere.
“If, in the situation you mentioned earlier, we had used a high dose of epinephrine while simultaneously giving rapid infusion of fluids, wouldn't that have helped maintain perfusion pressure a little more? In the literature….”
I narrowed my eyes and searched for the source of the voice.
It was first-year resident Baek Eun-seo, enthusiastically typing away on a laptop in the corner.
‘…When did that one get here?’
Apparently, our ER has three lunatics after all.
And they're evenly spread across the years, too.
The enthusiastic first-year Baek Eun-seo, fellow Lee Minjae, a few surgery residents, and one vascular surgery professor.
The M&M conference, attended by Professor Song and the two professors from our department, came to a rough close with Baek Eun-seo's never-ending Q&A.
The conclusion was basically….
[The REBOA itself was chosen as an appropriate procedure.]
Rather, the fact that a second-year resident attempted it was encouraging! Something like that.
[The patient's death was due to irreversible hemodynamic collapse caused by delayed transport, and by the time he arrived at the hospital the state was already irreversible.]
[There is a need to discuss improvements to the on-call system and backup structure for emergency vascular surgery.]
That kind of thing.
In the end, it was basically an official stamp certifying that it wasn't my fault.
Once the meeting was over, people began leaving one by one.
I was gathering my things to leave the conference room when Professor Song from vascular surgery tapped my shoulder.
“Dr. Han.”
“Yes, Professor.”
Professor Song looked at me with eyes that had softened a little.
“You worked hard. And I'm sorry.”
“Ah….”
“If only the surgery team had been there, you wouldn't have had such a hard time. I'll make sure something like this doesn't happen next time.”
She gave a short wave of her hand and disappeared like the wind.
That brief apology strangely resonated in my chest.
For some reason, I stood there in the empty conference room for a long time, feeling a bitterness I couldn't explain.
The patient was gone, and the system was imperfect.
But we keep reflecting and apologizing like this.
And then, looking ahead to next time, we move a little farther forward.
That's just how a hospital works.
I was standing there blankly, lost in that lingering afterglow, when…
“Uh… excuse me. Who are you?”
A strange voice came from behind me.
“Huh?”
I jumped and turned around to find a trauma surgery fellow and a crowd of residents standing at the door.
And on top of that, they were staring at me with expressions that said, 'What the hell is this bastard doing, standing there blocking the way?'
“We're scheduled for trauma center grand rounds. The room is reserved.”
“I'm sorry!”
I hurriedly grabbed my bag and fled the conference room as if running away.
“Thank you for your hard work!”
I heard the door close behind me.
The embarrassment came rushing in.
Of course, thanks to that, the heavy bitterness was unexpectedly cleared away quite neatly.
Still, getting sentimental is a luxury.
Let's get back to work.