Chapter 129
“Is the ETA up yet?
“Yes, doctor.
I checked the clock.
The second hand was ticking briskly.
“Earlier they said the 119 ETA for the dyspnea patient was four minutes, so... three minutes have already passed.”
They were about to arrive.
“Should we go wait outside?”
Just as I was about to get up.
Bzzzz-
As if it had been listening in on me, the ER automatic door swung open with a loud clatter.
At the same time, an urgent shout rang out.
“Patient incoming! Please move!”
“...Guess there’s no need to go out after all.”
I gave a bitter smile and immediately turned back toward the bed.
Thud-thud-thud.
The paramedics came in pushing the cart at an unusual speed.
Behind them, first-year Baek Eun-seo was right on their heels, taking the handoff.
“24-year-old female. She’s had a high fever since this morning, and 30 minutes ago her mental status started worsening and she complained of shortness of breath. Current temperature is 39.2 degrees. BP is 100 over 60, pulse 130, respiratory rate 35. Oxygen saturation is 98%."
Her vitals were a mess.
Seriously ill.
“Right away, uh... we’ll take her into A-4! Give 10 liters through an oxygen mask!”
At Baek Eun-seo’s hesitation-free order, the stretcher turned into the A zone.
Swishhh.
The curtain was drawn, and the medical staff transferred the patient onto the bed.
“One, two, three!”
Thud.
The patient was soaked in cold sweat, staring into space and gasping for breath.
Baek Eun-seo scanned the patient’s condition and gave orders.
“Get two 18-gauge lines in and run 1 liter of normal saline wide open. Hook up the monitor right away.”
The force in her voice definitely didn’t feel like that of a mere first-year.
‘...Eun-seo seems to have picked up a little experience now.’
She didn’t panic at the unstable vitals and went straight for fluid resuscitation.
Very appropriate.
She’s still only a first-year, but there’s a reason Lee Minjae calls Baek Eun-seo a smart backup.
Baek Eun-seo auscultated the patient’s chest and glanced back at me.
“Doctor, sepsis
(* sepsis)
seems likely, right?”
Her eyes were already screaming that it was sepsis.
High fever, tachycardia, tachypnea, altered consciousness.
Because she already met the qSOFA criteria for sepsis.
“We need to take a look first.”
I stepped back and answered calmly.
“But her consciousness is fluctuating, her temperature is high, and her respiratory rate is elevated. Clinically it’s strongly suspicious. Still, we need to check the history too. Has the guardian arrived?”
“They’re handling registration outside right now.”
“Okay. Send out the basic labs and two sets of blood cultures, and get a urine test too. Lactate
(* lactic acid)
levels are important, so ABGA
(* arterial blood gas analysis)
right away.”
“Yes!”
The area around the bed was bustling with activity.
Blood was drawn, fluids were going in, and a physical exam was underway.
I folded my arms, looked down at the patient, and ran through the possibilities in my head.
‘Sepsis in a young woman.
A case that’s common when it’s common, and rare when it’s rare.
Elderly patients fall into sepsis from pneumonia or a urinary tract infection like it’s nothing, but a healthy 24-year-old suddenly going right up to the brink of shock?
‘Let’s first consider the possibility that it’s not sepsis.’
The first rule of emergency medicine.
Not everything you see is all there is.
Could it be drug intoxication?
Maybe an overdose of sleeping pills or antidepressants?
Serotonin syndrome can cause high fever and altered consciousness.
But a respiratory rate of 35 is a bit atypical.
If a young diabetic patient had skipped insulin? It could look like dyspnea, and consciousness can cloud over too.
If there’s a concurrent infection, she could have a fever as well.
That would show up right away on the ABGA and blood glucose test.
Could it be a thyroid disorder?
Or myocarditis?
‘I need to think this through...’
I studied the patient’s neck closely.
No obvious thyroid enlargement.
Auscultation showed no wheezing, only coarse breath sounds.
Then back to square one.
‘What about sepsis?’
That was still the most likely.
If so, where was the source of infection?
‘Pyelonephritis, the undisputed number one cause of sepsis in young women?
Respiratory rate is 35.
Pneumonia would be a possibility too.
Then was it simple pneumonia progressing into septic shock?
Her consciousness is drooping and she’s running a fever.
Was her neck stiff? No, it wasn’t, so meningitis gets quietly dropped from the candidate list.
‘Hmm...’
The numbers on the monitor were jumping around.
What is this, some kind of traditional dance?
[BP 90/50]
Even with fluids going in, her blood pressure didn’t rise—it actually dipped a little, which made me pretty uneasy.
It’s shock.
Septic shock.
Her blood vessels are dilating, and her blood pressure is crashing.
Now it’s a race against time.
If I spend an hour or two waiting for CT and bloodwork results to find the cause, I’ll miss the golden window.
‘Hmm, right.’
The answer is already decided.
Diagnosis can wait.
First I need to keep the patient alive before I can diagnose her.
‘For now, before the tests come back, I’ll give broad-spectrum antibiotics preemptively.’
I called Baek Eun-seo.
“Eun-seo.”
“Yes!”
“Let’s run the bundle. Don’t wait for lab results—mix a third-generation cephalosporin and vancomycin right away. Once the fluids are in, get ready to start norepinephrine.”
“Yes, got it!”
It’s a game of probabilities.
And my gut says bacteria are throwing a party somewhere inside this patient’s body.
“Her SpO2 is okay at 98% right now, but her respiratory rate is 35, so there’s too much going on. If this goes septic shock anyway, her mental status drops further and her respiratory muscles tire out, then we’ll have to scramble to intubate—so I’m debating whether we should do it proactively here and now.”
SpO2 98%.
By the numbers alone, it’s normal.
That means the lungs’ ability to take in oxygen itself is still fine.
But the patient’s chest was heaving as if it might burst any second, and she was panting so hard that the accessory muscles in her neck were bulging.
She’s holding on for now, but can she keep that respiratory rate up an hour from now? Two hours from now?
The moment she tires out and her breathing stops, hell will truly break loose.
“Right? That’s what I’m worried about too. If lactate builds up, she’ll pant even harder to compensate, but if we put her to sleep now, we’ll break that compensatory mechanism..."
Baek Eun-seo agreed, biting her lip.
It’s a dilemma.
Sedate her and I’m afraid we’ll cut off compensation and drop her blood pressure; don’t sedate her and I’m afraid the patient will exhaust herself.
“Looks like APN
(* pyelonephritis)
or pneumonia is at the stage of turning into sepsis... let’s decide after looking at the blood gas results.”
Tap. Tap-tap-tap.
Then light footsteps came from afar.
“Doctor! The ABGA results are in!”
By then an intern had... um... the name tag’s hard to read.
Anyway, a sharp-looking intern with glasses came running over, waving the results sheet.
“Thanks.”
I held out my hand and snatched the sheet.
In the ER, an ABGA is the fastest and most accurate report card for a patient’s condition.
Because this single sheet contains the patient’s biochemical status.
It’s the answer key to how severe the sepsis is, what caused the shock, and why she’s breathing like that.
And so I unfolded the paper.
[ABGA Result]
“...Hmm.”
I frowned.
The numbers were way off the mark from what I’d expected.
What on earth is this?
[pH 7.45 / pCO2 10 / HCO3 12]
For a moment I thought I’d misread the numbers.
Only after rubbing my eyes and looking at the sheet again did I realize it was the correct one.
“pH is 7.45? Slightly alkaline? No, it’s practically at the edge of normal?”
Strange.
Usually when septic shock hits, oxygen delivery to the tissues fails and lactate builds up.
Lactate is an acidic substance.
In other words, there should be metabolic acidosis...
“It’s sepsis, so she should have metabolic acidosis and be breathing hard to compensate.”
The algorithm in my head started creaking.
Once the body becomes acidic, it compensates to survive.
So the patient pants and hyperventilates.
Because the body has become acidic, it breathes like mad to blow off carbon dioxide and restore balance in order to survive.
That’s the typical hyperventilation mechanism in sepsis patients.
Even with all that compensation, it can’t fully overcome the underlying metabolic acidosis, so by the book the pH usually stays acidic.
Of course, in the early stage of sepsis, hyperventilation can do its job and go down in a blaze of glory(?), leaving things slightly alkaline, but given this patient’s vitals, septic shock is suspected, so that one’s out too.
‘But this... something just doesn’t add up.’
The pH is 7.45.
It’s normal.
It’s even leaning toward the alkaline side.
Bicarbonate is 12.
Normal is around 24, so it’s been cut in half.
That part fits.
Acid has built up in the body, and the buffering system has been drained trying to compensate.
There is definitely metabolic acidosis.
But the pCO2 is 10.
Normal is 40—how did it drop all the way to 10?
‘A mixed acid-base disorder...? Why the hell are the numbers like this? Is respiratory alkalosis the main issue?’
Why are the numbers weird?
I mean, in a typical sepsis patient, pH should be low, pCO2 should be moderately low, and HCO3 should be low too.
But this woman is breathing so hard that her blood is tipping toward alkalinity.
Could there be something directly hitting the brain’s respiratory center, rather than bacteria or inflammation?
Central fever?
Encephalitis?
Pulmonary embolism?
‘Okay, early sepsis can cause hyperventilation and alkalosis. But does the carbon dioxide partial pressure really drop all the way to 10?’
“Hmm...”
My mind was getting tangled up.
I had a bad feeling this might not be something I could solve by just assuming ordinary septic shock and slamming in antibiotics and fluids.
If the diagnosis is wrong, the treatment direction is wrong too.
‘It’s been a while since my head felt this dizzy. I need to ask someone.’
I’d probably have to summon the human calculators—the old-timer and the nephrology ghost—and beg them to decipher this damn ABGA.
For now, my judgment is that it’s not sepsis.
No, even if it is sepsis, something else is mixed in.
I was going over the test results one by one before asking anything else.
Huh?
‘The lactate level...
Just as I was pinching my brow and almost reaching a conclusion.
“Doctor. This might be...”
The first-year Baek Eun-seo, who had been looking over the results sheet with me, spoke up.
And, at the same time.
“Looks like it isn’t sepsis?”
“It’s not sepsis.”
“…?”
I turned my head blankly and looked at Baek Eun-seo.
‘What the hell. Why are you stealing my line?’