Chapter 18
The nurse confirmed the order and hurried off to fetch the portable EKG machine. I headed back toward the bed where the patient was lying.
Meanwhile, comments started rolling in on the blue interface.
Hippocrates' Descendant: Living one, do not jump to conclusions. Throat pain could be a musculoskeletal issue.
Yo (118.235): Wow, a sore throat, lmao. Yeah, it could be referred pain, but you have to check.
“Doctor! I brought the EKG!”
The nurse began attaching the electrodes with practiced hands.
The patient looked thoroughly frightened by the sudden commotion.
“Doctor... am I going to die? It's just a sore throat—why is everyone acting like this....”
“Sir, it's okay. We're just doing this as a precaution, so don't worry. Don't worry about anything, and just stay still for a moment.”
Then I said to the nurse,
“Just in case, please bring the crash cart over here ahead of time. We're only preparing it.”
Whiiiiiing—
The EKG machine began spitting out a long strip of paper.
Please, please let it be nothing.
Please let me be the idiot who was just overreacting.
But God did not hear my prayer.
The moment I took the EKG strip, my hand trembled slightly.
“Fuck...”
The curse slipped out on its own.
In leads II, III, and aVF, which show the inferior wall of the heart, the ST segments were rising like mountains. Classic findings of an inferior-wall infarction.
I shouted in a panic.
“Let's get one more lead, V4R!”
V4R.
A lead that checks the state of the right ventricle by placing an electrode on the right chest. In inferior infarctions, this is something you absolutely have to check.
A moment later, the additional EKG had my worst prediction laid bare.
The V4R lead also showed clear ST-segment elevation.
A right ventricular infarction accompanying an inferior-wall infarction.
This wasn't just a myocardial infarction. It meant the right ventricle, which acts as the heart's assist pump, was failing too.
If you carelessly use a vasodilator on a patient like this, blood pressure can plummet into the abyss and they can die of shock.
“Aspirin 300 mg, Plavix 600 mg—have the patient chew and swallow them right now.”
“Yes!”
“Give him oxygen at 2 liters through a nasal cannula! And nitroglycerin
(*Nitroglycerin, a representative vasodilator)
absolutely do not give it! His blood pressure will crash immediately! Instead, get another IV line and start normal saline
(*Normal Saline, saline solution)
500 cc wide open!”
Only after ordering the initial treatment could I finally catch my breath.
But anxiety quickly rushed back in. Had I missed anything? Was there more I needed to do in this situation?
I logged back into the gallery. I needed final confirmation.
Title: Did I do this right?
Author: Hell Joseon Slave 1
Inferior with RV infarction. MONA
(*Morphine, Oxygen, Nitroglycerin, Aspirin—the initial emergency drugs for ACS)
I took nitro out and loaded fluids. Now PCI
(*Percutaneous Coronary Intervention, a procedure to open blocked coronary arteries)
go in? Did I miss anything?
Posted.
Then I immediately pulled out my phone and opened the hospital contact list.
The cardiology on-call doctor. Cardiology, cardiology....
Just as I was scrolling through the contacts looking for him, at that very moment.
new comments began appearing in real time on the gallery window.
Cardiology Ghost: Good job. (sticker of a dumpling giving a thumbs-up)
Yo (118.235): The fluid loading was good. But did you check his heart sounds? Inferior-wall infarctions are prone to Complete AV Block
(*complete atrioventricular block)
so get ready in advance, yeah.
God of the Scalpel: Are the internal medicine guys done playing house? At that rate he'll go into cardiogenic shock. Better get ECMO
(*Extracorporeal Membrane Oxygenation, a device for extracorporeal oxygenation)
ready to spin it up and bring him up to the room? What are you going to do if he dies on the table?
Heart. Complete AV block. ECMO.
I still hadn't solved anything.
Get a grip, Han Hyeonjae, you bastard.
I cursed myself inwardly. There was no time to panic. I had to contact the person who could take this patient right now.
Cardiology.
[Cardiology Park Woo-young]
I swallowed once and pressed the call button.
Drrrrring
Drrrrring
Before two rings had even finished, the call connected abruptly.
Over the receiver, along with noisy chatter, a somewhat irritable voice shot out.
“Yeah, what is it?”
The clatter of trays could be heard over the voice.
It was the staff cafeteria.
'...Ah, so you're eating.'
I felt apologetic for a second, but another thought immediately flashed through my head.
'If he's in the cafeteria, he can sprint to the ER in three minutes. Maybe that's actually better?'
I forced aside the selfish thought and stated my identity and purpose as quickly and accurately as possible.
“Doctor! Hello! I'm Han Hyeonjae, first-year in emergency medicine. The reason I'm calling is that a 54-year-old male patient has been assessed as having a right ventricular infarction with an inferior-wall infarction, so I'm calli...”
Before I could even finish, a loud chair-scraping sound burst from the receiver, followed by a shout.
“What?!?! Infarction?!?! Got it!!!!”
…Click.
The call was cut off.
“?”
I stood there blankly for a moment, holding the phone with the call-ended screen on it.
What the hell is wrong with that lunatic?
What did he mean by got it? Was he coming or not?
What kind of doctor hangs up without even asking about the patient's condition?
Two seconds later my phone started ringing like crazy. The caller was the same number from just now, Park Woo-young from cardiology.
I reflexively hit the answer button.
“Hello?”
“Ah, sorry! Sorry! Hey, I forgot to ask something important!”
A hurried voice came through the receiver, along with rough breathing that sounded like he was sprinting down the hallway at full speed.
“What's the patient's condition? Give me the basics! I'm running over there right now, so I'll listen while I move!”
'Well, I guess if he says infarction, you'd throw down your spoon and run over here.'
Swallowing a bitter laugh, I mobilized every bit of knowledge the ghosts had drilled into me yesterday and all the judgments I'd just made, and began my report.
“Yes, doctor. Let me report. A 54-year-old male patient came in around noon today with severe sore throat as his chief complaint. He was initially classified as KTAS level 5 under suspected cold symptoms, but because the severity of the pain he reported and the exam findings were so far apart, I proceeded with testing while keeping a possible cardiac issue in mind.”
“Sore throat? Not chest pain?”
“Yes, that's right. He is mainly complaining of a burning pain radiating to the jaw and neck.”
“Got it, keep going. Vitals?”
The breathing on the other end grew even rougher.
“Current vitals are blood pressure 90 over 60, pulse 55, respiratory rate 22, oxygen saturation 98%. Compared to when he arrived, the blood pressure and pulse are gradually dropping.”
“EKG?”
“On the 12-lead EKG just done, there is clear ST-segment elevation of about 3 mm in leads II, III, and aVF, and reciprocal change
(*reciprocal changes)
showing ST-segment depression in leads I and aVL. In the right-sided EKG done to rule out right ventricular infarction, the V4R lead also showed a 2 mm elevation, so at present I judged this to be a right ventricular infarction accompanying an inferior-wall infarction.”
“So what was the initial treatment?”
“Immediately after confirming the EKG, the patient was alert, so I had him chew and take aspirin 300 mg and Plavix 600 mg. He is currently on 2 liters of oxygen via nasal cannula. RV infarction
(*Right Ventricular Infarction, right ventricular infarction)
is present, so I did not administer nitroglycerin, and I am currently loading 500 cc of normal saline to maintain blood pressure. We're still waiting on the cardiac marker results.”
I even added the advice the gallery ghosts had given me.
As naturally as if it were my own judgment.
“And, doctor, keeping in mind the possibility of bradycardia and AV block that can accompany an inferior-wall infarction, we've already attached defibrillator pads to the patient and are preparing for any possible emergency.”
My report was complete.
From the other end of the line, I could hear nothing but rough breathing. Had I gone too far? Was I acting too knowledgeable for a first-year?
At last, Park Woo-young from cardiology, still panting, spoke.
“…Hey.”
“Yes, doctor.”
“For an EM first-year, your call is really clean. You're almost there. Just wait a bit.”
…Fuck.
Damn, I just said all of that without stuttering once.
Just as I was about to start feeling proud of myself, another comment that chilled my spine came to mind.
'Are the internal medicine guys done playing house? At that rate he'll go into cardiogenic shock. Better get ECMO ready and Cath lab
(*Cardiac Catheterization laboratory, cardiac catheterization suite)
up? What are you going to do if he dies on the table?'
That's right. For a patient whose right ventricle is this damaged and whose blood pressure is hanging by a thread, nobody knows what might happen during the procedure.
The heart could stop completely, or he could fall into uncontrollable shock. The last line of defense in a case like that. A machine that takes over the functions of the heart and lungs.
ECMO.
And that was thoracic surgery territory.
Without realizing it, I cut him off in a panic.
“Ah, uh, doctor from cardiology!”
“Yeah, what is it?”
The rough breathing was still coming through the receiver.
“I'm sorry, but I think we need to prepare for both cardiogenic shock and cardiac arrest. Right now, can I contact thoracic surgery as well about possible VA ECMO
(*a type of ECMO)
backup? May I put in the call?”
A brief silence fell on the other end of the line.
A first-year emergency medicine resident had just declared to a cardiology fellow that he would need to contact thoracic surgery and hang up for a moment.
A lowly first-year, at that.
Normally, in a situation like this, it would be the cardiologist who is ultimately responsible for the patient and performing the procedure who should make the call and request it.
But you never know. From what I can tell, this guy isn't in his right mind either.
“Uh... yeah, do that! And if they wonder why it's a first-year, drop my name!”
Okay.
Success.