Could It Be a Heart Condition? (2)

I looked at the patient. His face was still pale with pain.

Could he be faking it? That was an act?

All of that—the cold sweat, the shallow rapid breathing, and even the faint tremor at his fingertips?

If that was acting, then that patient needed to head straight to Chungmuro and audition.

No.

One ember still burning in my head whispered.

Something's here.

Yeah, fuck.

If one shot doesn't do it, then a second, a third, a fourth wouldn't hurt.

Myocardial infarction is a dynamic disease.

He might look fine now, but ten minutes from now his heart could start screaming.

So I decided to keep following up with EKGs every 20 minutes.

At the same time, I stared into space and opened the gallery window in my head.

Title: [HELP] Chest pain patient, but all tests are normal. Yet he keeps saying it hurts.

Author: HellJoseonSlave1

Man in his 50s, classic ACS-suspect chest pain. But the 20-minute follow-up EKGs, X-ray, basic labs, and troponin are all normal. The patient is still sweating and rolling around in pain. What am I missing? Or should I just discharge him?

It was while I was posting my desperate question.

Just then, Yoo Seonghun, who happened to be walking by, glanced over my shoulder at the monitor and clicked his tongue.

"Still hanging on to that patient? Following up with EKGs and watching him? Hm. Yeah, I guess it is kind of fishy."

His voice carried equal parts sympathy and mockery.

"But I think…"

The very moment Yoo Seonghun opened his mouth.

The first comment appeared in the blue interface in my vision.

Cardiology Ghost: Idiot. What kind of ACS has normal troponin? It's unstable angina. The EKG can come back normal.

And that voice overlapped perfectly with Yoo Seonghun's voice behind me.

"…You can't rule out unstable angina either. It's not to the point where we need to call Cardiology and rush into an urgent procedure right this second, but…."

Fuck.

I got goosebumps.

Yoo Seonghun immediately started issuing new orders.

"First, follow up troponin every 3 hours, and start a heparin infusion

(*Heparin Infusion, a treatment that continuously or intermittently infuses the anticoagulant heparin through a vein)

…Ah, no. If the chest pain keeps going, let's give sublingual nitroglycerin

(*a medicine that dissolves under the tongue)

and see how he does. We'll have to keep watching him."

I hurriedly entered the medication orders as instructed.

"But it might not be angina."

"Huh?"

Even the ghosts are saying it's angina?

You said it looks like angina yourself?

Suddenly?

"Look at the time that's passed. The patient had chest pain an hour before he came to the hospital, and it's already been almost two hours since he arrived. If unstable angina had lasted that long and been that severe, then at the very least troponin should've risen even a little, or he should've already had an MI

(*myocardial infarction)

by now. Something's… off."

I looked at the clock on the wall at the station and let out an "Ah…" groan.

Yoo Seonghun was right. Time. A variable that explained everything while also sending everything into a maze.

***

And as time passed, our last remaining hope disappeared.

The troponin we checked again was still perfectly fine. Completely normal.

I couldn't even go home. I just sat there like a madman, waiting to see what would happen to this patient.

In the end, I logged back into the gallery. This time with a pleading heart.

Title: It's not angina either. So what the hell is it now.

Author: HellJoseonSlave1

Cardiology Ghost, it wasn't that after all ㅠ The 3-hour follow-up troponin is normal too. The patient still says it hurts. What the hell am I supposed to do now? Should I call psychiatry and have them look for somatic symptom disorder?

The comments came from an unexpected place. A new nickname I'd never seen before.

DigestiveIsImportant: Have you considered esophageal spasm? If it's not malingering, that's a very strong possibility. Take a shot of ketorolac for the hell of it and prescribe a GI cocktail

(*a mixture of medications used to relieve indigestion symptoms)

and give it to him. It'll get dramatically better.

I went blank after reading that comment. Esophageal spasm?

"What the hell is a GI cocktail, you nerd…"

I searched my phone for the unfamiliar term for the first time in my life.

Gastrointestinal cocktail…

No, that's something American doctors use, you fucking bastard.

We don't give medications in that combination.

This is the Republic of Korea. If we prescribed some no-name cocktail like that, HIRA would be calling us immediately.

But…

Esophageal spasm can actually cause symptoms almost identical to heart disease.

And right in front of me was a mysterious chest pain patient whose cardiac tests were all normal.

Nothing to lose.

I couldn't make that cocktail, but I could try using its principle.

A drug that relaxes severe esophageal spasms.

I entered a new order with the feeling of grabbing the last straw: a powerful antispasmodic, Tiropa injection.

Right. If it's not the heart, then let's beat up the esophagus instead.

Please, let something stick.

I told the nurse to prepare the injection, almost completely giving up.

Please let this medicine work. Please let that patient just be a terrible case of esophageal spasm.

Even if I end up being a total idiot who put on this whole show over the last few hours, please just don't let that patient have a fatal illness.

The nurse connected the syringe to the patient's IV line and slowly began injecting the medication. I watched anxiously.

That was when it happened.

Far off, I could see Park Wooyoung from Cardiology finishing another consult and about to leave the ER.

In that moment, I caught him and started explaining the patient's history.

Since he's a heart specialist, maybe he'd be able to tell me something.

"…Could this still be a heart disease, doctor? Am I missing something?"

Park Wooyoung answered without even a second of hesitation.

"Just indigestion, isn't it?"

He gave my shoulder a light tap and passed by, leaving behind a single "Good work."

Indigestion.

…Was it?

I turned my gaze back to the patient.

***

About two or three minutes after the injection had gone in,

a miracle happened.

The patient's contorted brow gradually began to smooth out.

His rough breathing gradually became steadier.

The patient slowly loosened the hand clutching his chest and stared blankly into space.

"Uh…?"

The patient took one big breath as if he couldn't believe it.

"Doctor… it doesn't hurt."

Chest pain gone.

…

I couldn't say anything for a moment.

That goddamn chest pain had vanished like a lie with one shot.

It wasn't a heart problem.

With a hollow laugh, I dragged a chair over beside the patient and sat down.

"Patient, did you maybe eat something yesterday?"

At my question, the man scratched his head as if he'd only just come to his senses and answered.

"Yesterday… I had quite a big meal."

"Yes, what did you eat?"

"Well… I had that mala xiangguo that's popular these days… and I drank a lot of baijiu with a friend. About three bottles…."

Mala xiangguo. Baijiu.

A fantastic combination to start with.

No way he drank all three bottles by himself.

"And then I came home and, before bed, my stomach felt a little sour… so I ate a bulgogi burger set from the fridge to sober up and went to sleep."

I pressed hard on my temple.

Greasy mala xiangguo, strong baijiu, and then cold cola and a hamburger.

That would clog a drain, never mind an esophagus.

"Did you maybe work out or anything yesterday?"

"Ah! I went to the gym yesterday!"

The man's face brightened.

"Come to think of it, my chest felt a little tight! I had bench-pressed heavier than usual!"

Confirmed.

All the puzzle pieces fell into place.

Then muscle pain and stomach cramps…

Reflux esophagitis and esophageal spasm caused by greasy, irritating food and alcohol.

And chest muscle pain from overdoing chest exercises.

Those two things created a fantastic synergy and produced symptoms that were exactly the same as acute myocardial infarction.

I got him outpatient appointments with Gastroenterology and Orthopedics, then wrote the prescription.

And only after watching him for another hour and confirming the pain had completely disappeared did I finally discharge him.

The patient left while bowing over and over, saying, "Doctor, you saved my life! A big hospital really is different!" I gave him an awkward smile.

…

With a hollow laugh, I went back to the station. And the moment I sat down, I opened the gallery window to report the end of this ridiculous episode.

Title: Hey, that chest pain patient from earlier was just indigestion lol

Author: HellJoseonSlave1

He was some middle-aged guy who slammed mala xiangguo, chased it with baijiu, then used a hamburger to sober up before hitting the bench press. One shot of Tiropa and he was fine enough to walk out. Guess it wasn't anything serious lol. From now on, if it's atypical, I guess I should suspect GI first too. Cardiology Ghost was wrong this time lol

As I hit the post button, I thought, 'This should leave those ghosts a little deflated too.'

But contrary to my expectations, the gallery's reaction was cold.

Cardiology Ghost: What the hell did you just say?

The first comment already sounded ominous.

BackInMyDay: This case really wasn't that big a deal lol, but what? You're going to suspect what first from now on?

Cardiology Ghost: You first-year scrub. Do you have any idea how scary unstable angina is? “This case really wasn't that big a deal lol,” my ass. You just got lucky and landed on esophageal spasm. If it had really been angina, that patient would've gone home on the stomach medicine you prescribed and died on the pavement on the way back. So now you're going to rule out GI first?

I was left speechless by the fury filling the screen.

No, what exactly did I do so wrong? It ended up not being that. The test results were normal too.

Before my indignation could even fade, Cardiology Ghost's comment kept going.

Cardiology Ghost: I'll show you how ignorant you are. Here's the problem. Forty-five-year-old man, smoker. The day after drinking, he wakes up at dawn with a strange tight feeling in his chest, feels better after 30 minutes, and goes back to sleep. In the morning he's fine, so he goes to work, but the same pain comes back in the afternoon and he comes to the ER. By the time he arrives, the pain is gone. EKG normal, troponin normal. What are you going to do with this patient? Answer me.

…What the hell is this.

I frowned. No pain and all the tests are normal?

ㄴ HellJoseonSlave1 : If there are no symptoms and the tests are normal, wouldn't you just reassure him, set up an outpatient cardiology appointment for a more detailed workup, and discharge him?

The moment my reply went up, the gallery exploded again.

Cardiology Ghost: Hahahahahahahahaha, you're just handing out murder licenses like crazy!

GodOfScalpel: (no idea what this is)

Cardiology Ghost: Variant angina

(

*A special kind of angina that's very difficult to diagnose.)

You dumbass! Don't you know coronary artery spasm? Admit him right now, put him on 24-hour monitoring, do a provocation test

(*a test that intentionally induces coronary artery spasm for diagnosis.)

or do a CAG

(*coronary angiography)

and confirm it, then use a calcium channel blocker! You're sending him home? That patient is going to die of a heart attack in his sleep tomorrow morning!

My mind went blank.

Ah.

ㄴ HellJoseonSlave1 : No, how the hell was I supposed to know that? I'm not a cardiology specialist.

BackInMyDay: If you didn't know, you should've asked lol

ORGhost3: That's what we're here for.

RespiratoryGhost: If you're confused, uneasy, or just plain fucked, ask us no matter what.

Cardiology Ghost: (an emoji of a frog character clenching its fist)

I couldn't say anything back.

ㄴ HellJoseonSlave1 : Ugh, fine, I get it

I barely managed to post a single line in reply.

Once I closed the gallery window, a crushing wave of fatigue washed over me.

…

I muttered to myself while staring at the empty beds in Zone A.

I've still got a hell of a lot to learn.

…Still, it's a relief.

Because it wasn't heart disease.