Chapter 23
The ER, a couple of hours before shift change, was in chaos. Traces of all the incidents and accidents that had erupted through the night were everywhere.
My eyes were completely sunken, and the charts that needed processing were piled up at the station like Mount Everest.
I kept tapping away at the keyboard with dead eyes. My fingers moved mechanically, but my brain had stopped working long ago.
If someone looked at me right now, they'd probably think I was a robot.
Beep. Current-bot here.
That was when it happened.
“Doctor! Chest pain
(*Chest Pain, chest pain)
A patient just came in! I think you need to see him right away!”
The nurse at the triage desk called out to me in a sharper voice than usual.
Beep.
My frozen brain was forcibly rebooted.
I shot up from my chair and headed in the direction the nurse was pointing.
***
A man was sitting in a wheelchair right in front of the triage desk.
Usually I'd see them after triage. Is it that urgent?
The man, who looked to be in his mid-fifties, was pale to the point of gray, and cold sweat glistened on his forehead and the bridge of his nose.
Looking lower, he was clutching the center of his chest with his left hand and gasping for breath.
And his expression looked extremely grave too.
I'm fucked. For real.
I stepped up to the man and asked in the calmest voice I could manage.
“Sir, are you alert enough to answer? Since when has it been hurting, and where exactly does it hurt?”
“About… an hour ago….”
He managed to continue.
“Suddenly… it feels like someone is… squeezing the middle of my chest… like I'm being crushed by some heavy rock….”
It was similar to the classic pain pattern of a myocardial infarction.
“Does the pain radiate anywhere else?”
“Yes… into my left shoulder… and my arm… with a tingling sensation….”
Radiating pain. That was the clincher.
I opened his chart and quickly checked his history.
Hypertension, diabetes, and a pack-a-day smoking history of more than fifteen years.
He had all the worst possible conditions for heart trouble.
The most lethal differential diagnoses flashed through my mind.
Acute coronary syndrome, aortic dissection, pulmonary embolism.
The moment I missed one of those three, this man would be a cold corpse within hours, right in front of me.
The only silver lining was that all the circumstantial evidence pointed to a single culprit.
'If I miss this, someone dies. Not me—the patient.'
Cold sweat ran down my spine.
It took less than a minute to make the diagnosis.
But every second from here on would determine the rest of this patient's life.
“Doctor! Move this patient to Area A right away! Hook him up to the monitor immediately and get IV access first! We'll place two 18-gauge lines, one in each arm! And bring the EKG over here right now! We're doing it immediately! Have him chew 300 mg of aspirin!”
The most important thing right now was the EKG.
Then I grabbed the shoulder of the nearest intern.
“Find any senior doctor right now! Check where they are and call them over! ACS
(*Acute Coronary Syndrome)
is strongly suspected! They need to come immediately! Hurry!”
Last time with the myocardial infarction, I was so overwhelmed that I pulled off a one-man show, but in a situation like this, it was reassuring to have a senior around.
Of course, I considered logging into the gallery, but then I decided against it.
This was textbook, plain and simple, and the tests would all be done according to protocol anyway.
Besides, I didn't want the patient to think I was some weirdo suddenly staring off into space.
The nurses started moving briskly. The intern ran around the hallway with his phone, trying to find where the seniors were. Someone else was hauling over the EKG machine.
I stayed close beside the patient and checked his vital signs.
Blood pressure 145/90, pulse 95.
He was hanging in there for now.
But it wouldn't be strange if he crashed at any moment.
I took the patient's hand. It was damp and cold with sweat.
“Sir, it's okay. We're going to do everything we can from here on out. Please hang in there just a little longer.”
My voice was shaking.
At that moment, the EKG machine came rumbling to a stop beside the bed.
“EKG's here!”
At the nurse's shout, the sound of wheels rolling behind me stopped.
The nurse lifted the patient's shirt and started attaching electrodes to his chest.
That brief moment while waiting for the strip to print felt like an eternity.
My head was filled with horrifying waveforms of electrical signals suggesting a myocardial infarction.
Whirrrr- szzzt zzzzzzt-
The machine finally spat out a long strip of paper written in the language of the heart.
Before it was even finished printing, I snatched the paper up as if to tear it apart.
And then.
“……”
What?
I looked at the strip again, this time much more slowly and carefully.
Sinus rhythm. 95 beats per minute.
The intervals of every wave were regular, and the shapes of the P wave, QRS complex, and T wave were all perfectly normal.
There was no sign anywhere of the ST-segment elevation or depression I had been frantically searching for.
Just... a completely normal EKG.
It was an EKG so clean it could have been printed in a textbook.
“What the hell is this?”
The cry in my heart escaped before I could stop it.
“Are you sure the leads were attached properly, doctor?”
My voice came out a little sharp.
Oh, sorry.
“Huh? Of course. I checked it several times.”
The nurse's voice was laced with bewilderment.
Just then, fourth-year Yoo Seonghun strode into Area A.
“I heard there was some commotion. Is this the patient?”
I wordlessly handed the EKG strip to Yoo Seonghun.
Yoo Seonghun took the strip and alternated his gaze between the sweating, groaning patient and the spotless EKG.
One look at the patient.
One look at the EKG.
Another look at the patient.
One look at the EKG.
One look at the ceiling.
One look at my eyes.
What are you looking at my eyes for?
His brow furrowed slightly.
“The EKG is clean... but the patient's presentation is textbook.”
Those muttered words oddly made me feel a faint sense of relief.
Right, I wasn't the only one who thought something was off.
“For now, Hyeonjae. Let's get a portable X-ray and repeat the EKG every 20 minutes.”
***
Ten minutes later.
The portable X-ray was done. The image was sent immediately to PACS
(*Picture Archiving and Communication System, medical imaging storage and transmission system)
and Seonghun and I stood in front of the station monitor to check the patient's chest X-ray.
What we were looking for was obvious.
Fluid in the lungs, air in the lungs, an abnormally enlarged heart, or, in the worst case, signs that the aorta had torn and the mediastinum had widened.
But the patient's chest on the monitor looked far too peaceful.
Both lungs were clear, and the heart's size and shape were normal too.
The aortic contour was smooth too. There wasn't a single clue anywhere as to why this patient should be in such agony.
Seonghun's expression grew colder and colder.
“Isn't this just musculoskeletal pain? Maybe a cracked rib. Or maybe he's faking it.”
“But the pain pattern he's describing is too classic. The pressure, the radiating pain...”
“I know. I know, but the test results say otherwise.”
Seonghun's voice was tinged with skepticism.
My mind was getting tangled too.
Had I gotten ahead of myself? Was I making too much of a fuss? Had the patient's act completely fooled my textbook knowledge?
***
Forty minutes later.
The patient was still yelling that he was in pain, and we kept waiting with no end in sight.
The EKGs taken at 20-minute intervals were normal too.
The ER had started bustling again, and even while seeing different patients, Seonghun and I had all our attention fixed on the blood test results.
At last, an alert popped up on the EMR screen.
[Blood test results arrived]
Feeling sweat collect in the hand gripping the mouse, I clicked the results. Seonghun also came up behind me and looked at the monitor with me.
CBC: normal.
Chemistry: normal.
CRP: normal.
D-dimer: normal.
Everything, every number, was maddeningly normal.
No inflammation, no electrolyte imbalance, and no trace of a clot suggesting pulmonary embolism.
Seonghun let out a deep sigh.
“See? I told you it's just a sprain or something. Give him ibuprofen
(*Ibuprofen, anti-inflammatory pain reliever)
or a pill, and if he still says it hurts, send him to neurology or orthopedics outpatient and discharge him.”
No.
It wasn't over yet.
“Doctor, wait a moment. There's still... one last test left. Would it be okay to discharge him after checking that too?”
“...Ah, right. We should see all the test results before discharging him.”
So we decided to wait a little longer.
***
1 hour and 25 minutes after arrival.
The last line of defense.
The final verdict on whether this was a heart problem when everything else was normal.
Cardiac enzyme levels.
Among them, the most sensitive and specific troponin level had to rise if the heart muscle had been damaged even a tiny bit.
The emergency lab called. With trembling hands, I picked up the receiver.
“Yes, this is Han Hyeonjae from Emergency Medicine.”
“The troponin result for patient A-2 is in.”
My heart sank with a thud.
“S-so... what was the result?”
The lab staff member on the other end of the line recited the number in a flat voice.
“Troponin I, less than 0.04. It's normal.”
Click.
I set down the receiver.
EKG normal, X-ray normal, blood tests normal, and even the final line of defense of cardiac enzymes was perfectly normal.
All the evidence was telling me my diagnosis was wrong.
Seonghun gave my shoulder a light pat and went off to see another patient, wearing a look that said, See? I told you so.
I was left alone.
Fuck. What the hell.
Then why is this patient hurting? Was all this commotion I caused over the past hour just my imagination?
What the hell is this, anyway?
Have I gone crazy?
No, what the hell is this!!
Then let's think about what options are left.
...The gallery.