Chapter 17
A few days passed.
The gallery ghosts' mandatory study sessions were held without fail on every one of my days off.
My days off were no longer days off.
But strangely enough, after going through that hell, hospital life became just a tiny bit easier.
Of course, it was still fucking awful. That was an unchanging truth.
But at least I no longer trembled before every situation like I used to. In my head, a bare minimum framework had now taken shape, however faintly.
Of course, that framework did not reduce the total amount of bullshit in my hospital life.
“Hey, doctor! I’m telling you, my heart feels like it’s about to burst! Shouldn’t you be checking a heart ultrasound instead of whatever that ECG thing is? The son of Mr. Kim next door said his chest hurt like that too, got an ultrasound, and went straight into some stent procedure or whatever!”
Today’s first villain was a man in his fifties.
He had come to the ER this morning complaining of heartburn after drinking heavily the night before.
He had classic reflux esophagitis symptoms, and the ECG was clean.
But he firmly believed he had to be a patient with acute myocardial infarction, dying any second now.
“Sir, the ECG doesn’t show any findings suggesting an acute myocardial infarction. For now, let’s get you an injection and observe….”
“I heard doctors these days don’t listen to patients even with an ear! I looked everything up online! Symptoms like mine are highly likely to be atypical myocardial infarction!”
I pressed hard on my temples.
The internet medical doctor, huh. Guys like that always end up not coming to the hospital when they’re really sick, saying, “The internet said it was fine,” and then they miss the golden hour.
After a long back-and-forth, only after I showed him the lab report proving his cardiac enzyme levels were normal did he reluctantly accept the shot. Then, thirty minutes later, he strolled out belching, looking perfectly fine.
Once I had driven off one troublemaker, an enemy from within took the stage.
Nam Juhyeon, a second-year emergency medicine resident.
Nam Juhyeon, the second-year resident, was especially sharp today. Since morning he had been chewing out an intern as if he were about to eat him alive, and that anger finally turned toward me.
“Han Hyeonjae.”
“Yes, doctor.”
“Who ordered a CT for patient B-21?”
“Ah, I did. She’s an 80-year-old woman, and after falling she kept complaining of headache and dizziness, so I was trying to rule out a possible intracranial hemorrhage….”
“Who gave you permission?”
“No, just now you said that for elderly patients in Zone B, if they fell, we should lower the threshold for CT and actively scan them even if the symptoms are vague….”
“When did I ever say to just order it however you want? You should report to me, consult with me, and then place the order under my name! Who the hell are you to just go around ordering brain CTs? If they get radiation exposure and sue us saying it caused cancer, are you going to take responsibility?”
I was at a loss for words.
‘Fuck, you told me to place the order, you bastard.’
My inner self was hurling foul-mouthed abuse, but in reality I could only bow my head.
Patients who fall get CTs routinely anyway, damn it.
That guy just wanted to tear into somebody today. And I happened to be the easy target. That’s the nature of this fucking hospital.
“I’m sorry. I’ll be sure to report it first next time.”
“There won’t be a next time.”
Nam Juhyeon snapped coldly and went his own way.
I flipped the bird at empty air, then went back to my seat.
Damn. Today was especially fucking awful.
***
It wasn’t all bad, though. The ER was hell, but it was also full of the most fascinating sights in the world.
A college student had been brought in after dislocating his shoulder while playing basketball. His right shoulder was slumped at a grotesque angle at a glance. An orthopedic surgery second-year resident was called down.
“Aaaagh! It hurts! I feel like I’m going to die!”
“Hang in there a little. Relax your muscles and breathe out with a hoo~.”
OS
(*Orthopedic Surgery, orthopedics)
The second-year resident had the patient lie face down on the bed, then let his arm hang down off the bed. He then attached a 5-kg weight to the wrist.
It was a method of waiting for the muscles to relax and then using gravity to reduce it naturally.
I watched every movement with interest from beside him. That was what a real procedure looked like.
About ten minutes later, when the OS second-year gently rotated the patient’s arm, a dull thunk sounded and the shoulder slid back into place.
“Uh... huh? It doesn’t hurt!”
The face of the patient who had been screaming that he was dying just moments ago brightened.
I let out a small exclamation without realizing it. How many shoulders would you have to put back in to develop hands like that?
***
1 p.m.
After the morning-long war finally ended, lunchtime at last arrived.
Kim Jihoon tapped my shoulder.
“Hey, we should go eat.”
“Oh, yeah.”
I stood up, rolling my stiff neck.
Before heading to the cafeteria, I habitually swept through the entire patient list on the EMR screen from top to bottom once.
By now it had become almost reflexive: checking who the new patients were, whether the test results for patients I’d seen were back, and whether there were any unusual findings.
The scroll wheel spun rapidly.
Colds, gastroenteritis, simple contusions, drunks... a peaceful-looking list.
I was about to turn my body away from the screen without thinking.
Right then.
My eyes froze on one line on the monitor.
Huh?
Wait a second.
Kim Jihoon urged me.
“What are you doing? Aren’t you coming?”
I stopped scrolling and moved the mouse cursor to that patient's chart.
“Hey, Han Hyeonjae!”
“You go ahead first. I need to check something. I’ll be there later.”
Every nerve in my body was screaming.
That patient.
Something.
Something was very wrong.
I swallowed dryly and moved the mouse cursor to open that patient's chart.
[Patient: Park Jinsu (M/54)] [Arrival time: 12:10] [KTAS(*Korean Triage and Acuity Scale, Korean emergency patient classification. Level 5 is the lowest) : Level 5] [Chief complaint: Sore throat]
So far, nothing was wrong.
A 54-year-old man. He came in with a sore throat. KTAS level 5.
This was a case the ER saw all the time. Dozens like him were shoved in every day like a conveyor belt.
I scrolled down to check the initial chart. The author was my classmate, Jo Suyeon.
[Initial chart]
3 days ago, he started having a sore throat and took over-the-counter cold medicine, but there was no improvement. Since this morning, the pain had worsened to the point that he said it was hard to talk or swallow saliva.
Vital signs: BP 130/80, HR 88, RR 20, BT 36.8℃, SpO2 99%
Pharynx & Larynx: no erythema, no swelling, no exudate. Tonsils symmetric, not enlarged. Uvula midline. (*Pharynx and larynx: no redness, swelling, or exudate. Tonsils are symmetric and not enlarged. Uvula is midline.)
[Assessment & Plan]
R/O) Acute pharyngitis, Common cold (*Differential: acute pharyngitis, common cold)
Plan) IV fluid hydration & Symptomatic control (*IV fluids and symptomatic treatment)
From the perspective of a first-year resident, Jo Suyeon’s charting was perfect.
It was textbook and flawless.
She had performed every physical exam needed for the patient’s chief complaint without missing anything, and based on the results, had arrived at the most reasonable presumed diagnosis.
And then she had started the most basic treatment that matched it.
The most standard play possible for a KTAS level 5 patient suspected of simple acute pharyngitis.
And yet.
Damn it, and yet.
The warning lights in my head were going off like crazy.
The larynx is clear?
It wasn’t that the charting was wrong. Jo Suyeon had probably written exactly what she saw.
The patient’s throat, medically speaking, had absolutely nothing wrong with it. No redness, no swelling, no pus. Everything looked clean.
But he was saying his throat hurt like hell?
That made no sense.
This wasn’t just a mild scratchy throat from a cold. The pain was bad enough that he could barely talk or swallow saliva.
At this level of pain, the throat should be blazing red and swollen, or there should be a huge abscess on the tonsils, or at the very least there should be white pus on it.
But there was none. Nothing.
There was a huge gap between the objective findings and the patient's subjective complaints.
I scanned the chart again from top to bottom. The vital signs were stable. He didn’t even have a fever.
If it were pharyngitis caused by a viral or bacterial infection, there would usually be at least a slight fever.
Could it... not be a cold?
Then where was this horrific pain coming from? If it wasn’t a problem with the throat itself?
...Could this be referred pain?
My heart sank.
Referred pain.
Pain felt in a place other than where the source actually is.
The human nervous system is intricately tangled, so the brain often gets confused about where pain is coming from.
And the most terrifying, most lethal condition that can cause referred pain to the throat—the kind an ER doctor has to be able to rule out in their sleep—is….
Fuck.
Wait.
The puzzle pieces in my head began snapping into place.
A 54-year-old man. Middle-aged. An age where the risk of cardiovascular disease rises sharply.
He’d taken cold medicine, but there was no improvement. Of course there wasn’t.
Because the cause wasn’t a cold.
Throat pain. An atypical referred pain pattern of myocardial infarction, radiating to the jaw, shoulder, or back.
Right?
Without realizing it, I licked my dry lips. Jo Suyeon wasn’t wrong. Just by looking at the patient’s symptoms and KTAS level, anyone would have thought the same. This was a hidden trap.
Right?
If my guess was right, that patient was lying on a bed in a corner of the ER right now, getting IV fluids while his heart muscle slowly rotted away.
Not a KTAS level 5 patient, but a KTAS level 1 patient who needed monitoring and an IV line right away.
I shot to my feet. I needed an ECG right now.
I also needed to check cardiac enzyme levels.
But before that, I needed to confirm it. If I was wrong, I’d be the idiot making a scene over a perfectly normal cold patient.
I started typing while walking toward the patient.
I’d better post this on the gallery first, then order the tests.
Title: [Urgent] Sore throat patient—does this look right?
Author: HellJoseonSlave1
50s/M. Chief complaint: severe sore throat, no improvement even after taking cold medicine. But on exam, the larynx and pharynx are clear. No fever either. Is this ACS
(*Acute Coronary Syndrome, acute coronary syndrome)
an atypical presentation? I think it might be.
The instant I mentally hit post, I reached the front of the B-28 bed where the patient lay.
The patient had started breaking out in a cold sweat and was letting out faint groans while staring at the ceiling.
As I approached, the patient slowly opened his eyes.
“Doctor, it feels like my throat is burning....”
Burning pain.
It was one of the classic chest-pain patterns of myocardial infarction. It was showing up in his throat right now.
I made up my mind.
“Sir, please wait a moment. I need to do one important test.”
I ran to the nearest computer.
My fingers trembled slightly as I logged into the EMR.
“Doctor! For patient B-28, Park Jinsu, I’ll get an ECG right away! Please bring the portable machine over here immediately, and at the same time, cardiac markers including cardiac enzymes
(*Blood test set to check for myocardial damage)
I’ll send the lab order right away!”
At my urgent shout, the sleepy air in the station before lunch froze for an instant.
“Huh? B-28 patient? The cold patient...?”
The nurse looked at me with a puzzled expression.
“It might not be a cold. Hurry.”