Chapter 43
It wasn't a bruise severe enough to suggest a major injury.
Just a faint bruise that commonly appears when you bump into the corner of furniture or something.
A trivial mark I would normally have brushed off.
But today, for some reason, that bruise started bothering me.
Before I knew it, I had stopped and peered into the curtain.
“Patient.”
At my voice, both the nurse and the patient looked at me.
“You have a little bruising on your arm. Did you bump into something?”
The patient looked down at her arm, as if she hadn't even realized there was a bruise there.
“Huh? There is. When did that happen….”
The patient frowned and tried to remember.
“Maybe I bumped it against my desk while working late yesterday... I don't really remember...”
The answer was vague.
Whether she truly couldn't remember or just didn't think it was a big deal.
But that uncertainty left a tiny, nagging ember in my mind.
I couldn't explain the reason.
It just... felt wrong.
A young woman who had been up for several nights and was exhausted.
A throbbing migraine.
And bruises she herself didn't even know about.
Taken separately, they were all common symptoms and signs that meant nothing in particular.
‘...Could I just let this go?’
There was a 99 percent chance this was nothing.
But the remaining 1 percent.
An ER doctor is a job that must always bet everything on that 1 percent chance.
I hesitated for a moment.
‘...Something feels wrong.’
In the end, I decided to follow that unexplainable unease inside me.
I turned to the nurse and said.
“Doctor, I'm sorry, but before we give the shot, I'd like to draw blood first. CBC
(*Complete Blood Count)
Please add just that one test. And hold the ketorolac for now.”
At my sudden order, the nurse's eyes widened slightly, but she nodded soon after.
The patient looked like she was thinking, ‘A blood test too...?’, but obediently held out her arm.
Leaving that behind, I returned to the station.
Yeah. It'll probably be nothing.
I was just being too sensitive.
Was this the aftereffect of that crazy incident?
Telling myself that, I started focusing on the backlog again.
Time passed, and the memory of that young designer patient faded into the noise of the other ER patients.
About forty minutes later, perhaps.
One of the interns came over to me carrying a stack of charts.
“Doctor, the labs for the 28-year-old headache patient in Bed 9 of Zone B just came back....”
Something about the intern's voice felt off.
“Everything else is fine, but the platelets... they're 38,000.”
I stopped typing.
Then I slowly looked up.
“What?”
“The platelet count came back at 38,000. The normal range starts at 150,000... Could it be a lab error? Was the sample sent wrong, or is it a machine error? Should we rerun the test?”
What the intern said was reasonable.
A number this absurdly low is usually more likely to be a lab error.
…Gasp?
I drew in a short breath.
I forced myself to stay calm and said to the intern.
“Yeah, rerun it. Looks like the specimen was sent to the wrong place. Draw it again into another tube, and this time take the specimen to the lab yourself and have them confirm it.”
My voice was strangely calm.
But a cold sweat was running down my spine.
Please.
Please let it be a lab error.
I stared blankly at the spot where the intern had disappeared.
38,000.
That number kept circling ominously in my head.
I went to the corner of the station and leaned my head against the wall, starting my own round of worrying.
First, calm down.
The patient is a 28-year-old woman.
Chief complaint: headache.
Migraine.
That's what she said.
I thought so too.
But the platelet count is 38,000.
Does a migraine eat platelets?
Damn, that's nonsense.
Then my first diagnosis was wrong.
This headache isn't just a migraine.
Then what are the possibilities?
The differential diagnosis list I'd memorized by heart flashed through my mind like a series of snapshots.
Causes of thrombocytopenia.
First, the scariest possibility was a blood cancer like leukemia.
A case in which cancer cells take over the bone marrow and prevent it from producing normal blood cells.
But the patient's other blood counts were normal.
White blood cells and red blood cells alike.
Then maybe I can lower the possibility of cancer a little for now.
Next?
Medication.
Certain medications can destroy platelets.
But the patient said she hadn't taken any recent medications. Her past history was clean too.
Liver cirrhosis or splenomegaly?
Even if the liver is unhealthy or the spleen is enlarged, platelets can be destroyed.
But in a young woman?
And with no other symptoms?
The odds were low.
Then what's left...
‘An autoimmune disease.’
A faint possibility surfaced in my mind.
A disease where the immune system makes a mistake, treats our own platelets as enemies, and attacks them indiscriminately until they're destroyed.
The kind of disease that makes the platelet count alone drop sharply.
Idiopathic thrombocytopenic purpura. ITP.
It felt like every piece fit.
Yeah, for now, this was the most reasonable suspicion.
I couldn't keep worrying over it by myself anymore.
I looked around.
Just then, third-year Choi Soo-min was finishing charting on another patient.
I walked over to Choi Soo-min and reported it in the calmest voice I could manage.
“Doctor Choi Soo-min. I'm reporting on the 28-year-old female headache patient in Bed 9 of Zone B.”
“Oh, that migraine patient? She's still in pain even after the meds?”
“No, that's not it... I noticed some bruising on her arm, so just in case I ordered a CBC, and it came back with a platelet count of 38,000. The repeat test is already underway.”
At my words, Choi Soo-min's expression hardened instantly.
Choi Soo-min immediately grabbed the mouse and opened the patient's chart.
“38,000? What about the other counts?”
“White blood cells and hemoglobin are both normal.”
“Hmm...”
Choi Soo-min rested a chin on a hand and stared at the monitor. The same differential diagnosis list was probably unfolding in their head too.
“Doctor, I think ITP is the most likely possibility, since there are no other findings at all.”
Choi Soo-min nodded at my cautious opinion.
“I think so too. It's far too textbook to consider other possibilities. Let's look at the repeat result first. If it comes back the same...”
Before long, the intern came running back to me with a look that was almost tearful.
In the intern's hands was the freshly printed result slip.
“Doctor, here's the repeat result... 35,000.”
The inevitable had come.
It wasn't a lab error.
Choi Soo-min took the result slip and let out a deep sigh.
“Haa... Hyun-jae, go explain it to the patient yourself. Tell her she needs to be admitted.”
“Me?”
“Yes. You found the case, didn't you? Go explain it calmly, in a way she can understand. Explain it well.”
I swallowed hard. I had to tell a patient who wanted a painkiller shot and to go home that a serious autoimmune disease was suspected and that she needed to be admitted for a thorough examination.
I made heavy steps back toward the patient's bed.
When I pulled the curtain aside, the patient was looking at her smartphone while receiving an IV drip. I dragged a chair over and sat beside her bed.
“Patient, I need to tell you something for a moment. You may be very surprised, but please listen calmly. Your headache doesn't seem to be a simple migraine like we first thought.”
Slowly, choosing the simplest words I could, I began to explain.
“Have you ever heard of platelets?”
“Platelets?”
“They're the cells that rush to a wound first when our body is injured and bleeding starts, and they play a very important role in sealing the wound and stopping the bleeding. Think of them as the body's repair crew.”
I paused to catch my breath.
“A normal person has about 150,000 to 400,000 of these platelets in their blood. But when we just checked your blood, your platelet count came back at 38,000.”
The patient's eyes widened.
“What? Is that very low?”
“Yes. It's extremely low. Even a minor bump can make blood vessels burst, and with too few platelets to stop it, bruises can form easily.”
“Then why am I...”
“The disease we're most strongly suspecting right now is idiopathic thrombocytopenic purpura, or ITP.”
I tried to explain it with an analogy the patient could understand.
“It's a difficult name, but I'll explain it simply. Normally, our immune system is supposed to attack only harmful bacteria or viruses from outside. But sometimes it gets confused and attacks our body's normal cells as if they were enemies. That's called an autoimmune disease. In your case, it looks like your immune system is mistaking our own platelets for enemies and repeatedly destroying them.”
The longer I explained, the paler the patient's face became.
“Right now, your life isn't in immediate danger. Please don't worry too much. But if the platelet count is this low, very dangerous situations can occur. For example, if even a tiny blood vessel in the brain bursts, it could lead to a brain hemorrhage. And I can't completely rule out the possibility that the headache you're having is also a warning sign of that.”
The patient's eyes trembled with fear.
“So you won't be able to go home today.”
I said firmly.
“You need to be admitted right now. We'll admit you to the hospital and run additional detailed tests to confirm whether this really is ITP or whether there's another cause. At the same time, we'll start treatment to calm your immune system a little so it stops destroying your platelets.”
That was the end of the explanation.
The patient stared blankly into space without saying a word.