Chapter 44
I finished explaining the hospitalization to the patient and returned to the station with a heavy heart.
ITP. Idiopathic thrombocytopenic purpura.
A disease where the immune system loses its mind for a moment and destroys its own platelets.
Of course it was a serious disease, but among blood disorders it was relatively common and one of the kinder ones, since treatment starts with steroids.
Yeah, that had to be it.
If it wasn't a test error, ITP was the most likely possibility.
Especially in young women.
Every sign pointed to that.
I tried to reassure myself like that.
But the unexplained unease lodged in one corner of my heart wouldn't go away.
In the end, unable to shake off that anxiety, I summoned the all-purpose tutors in my head.
Let's just do one final check.
If even those crazy ghosts say it's ITP, then I can hand the patient over to hematology-oncology with complete peace of mind.
==============
Title: 28/F, headache, bruising, platelets 38k. ITP?
Author: HellJoseonSlave1
The repeat test came back like this too, so is it okay to treat this as ITP with steroids? Anything else to consider?
==============
It was an utterly ordinary question.
But the moment I posted it, the gallery turned into a hellish free-for-all.
Heme-Onc Is Hell : You crazy bastard, are you fucking trying to die?!!!!!!!!!!!!
...Huh?
I blinked in disbelief. Did I ask something wrong?
Heme-Onc Is Hell : ITP? What the hell are you on about, you quack! Why did the patient come in saying they're in pain? Huh? Because they have a headache! They said their head hurts! But the platelets are destroyed! Can't your brain even interpret what that means, you dumbass!
That was the beginning. Ghosts from every specialty lunged at me and started tearing into me.
Back in My Day : Tsk, tsk. Kids these days really don't have the basics down. Headache, thrombocytopenia, bruising. Even if you see just those three things, sirens should be going off in your head! And you still say something stupid like ITP after seeing this!
Cardiology Ghost : Hey, when your patient's labs came back, did you check the LDH
(*
lactate dehydrogenase)
and bilirubin levels? Any signs of hemolytic anemia? How about kidney function? Are the renal numbers okay?
Heme-Onc Is Hell : Didn't you send out a peripheral blood smear? Aren't you ruling out TTP?? While you're prescribing steroids and standing around with your hands behind your back, the patient's clots are getting so bad it's basically a party, and they'll just go straight to the underworld! You crazy bastard, are you trying to die!!
TTP.
Thrombotic Thrombocytopenic Purpura.
Thrombotic thrombocytopenic purpura.
Ah.
Ah, right.
How could I have forgotten this? How could I not even think of it?
TTP. A disease where blood clots form like crazy for no reason in all the tiny blood vessels throughout the body.
As the clots form, they consume all the platelets, so the platelet count plummets, and the red blood cells forced through those narrow vessels get shredded to pieces, causing hemolytic anemia.
And those clots block the vessels leading to the brain, heart, kidneys, and the body's most important organs, slowly destroying them.
If the diagnosis is delayed even a little, it's one of hematology's worst emergency diseases, with a mortality rate that approaches 90%.
The symptoms of that disease.
Thrombocytopenia. Microangiopathic hemolytic anemia. Neurologic symptoms. Renal failure. And fever.
My patient…
…headache. …thrombocytopenia. …bruising.
I felt the blood in my entire body turn cold as I sank into the station chair.
While I was reassuring myself that it was one of the more benign diseases, clots may already have been forming in the patient's cerebral vessels.
Heme-Onc Is Hell : Get a PBS
(* peripheral blood smear)
slide prepared and check for schistocytes
(* fragmented red cells)
first, you moron! If it's TTP, we're fucked, bastard!!!!!! Run!!!!!
That last comment snapped me back to my senses.
There was no time to beat myself up right now.
I shot up from my seat and grabbed the intercom as if I were screaming.
Extension 7111.
Press.
Press.
Press.
Press.
“Yes, hello, this is the central lab…
“Lab, right? The repeat test for the 28-year-old female patient in ER B section, bed 9, just came back! Patient chart number 1397131—please, right now, make a peripheral blood smear slide from that sample and look at it under the microscope! I don't need anything else, just tell me whether there are schistocytes or not as fast as possible! It's urgent! STAT! STAT!”
“Huh?
“I'm asking you to run a peripheral blood smear for patient chart number 1397131! It's urgent!”
“Y-yes.”
My voice was trembling with fear.
I hung up the receiver and covered my face with trembling hands.
Please.
Please, don't let it be.
Please don't let there be shattered red blood cells.
***
I was huddled in a corner of the station, pointlessly refreshing the EMR window.
I saw other patients, did charting, even dozed off, but all my nerves were fixed on one phone call from the lab.
A minute felt like an hour in hell. My head was filled with every worst-case scenario.
‘That bruise and headache are way too suspicious. If it's really TTP….’
That was when it happened.
Rrrrring!
The station phone rang out sharply.
It felt like that one ringtone drowned out every other sound in the ER.
I almost reflexively grabbed the receiver.
My heart was pounding like crazy. Please. Please say it's not.
“Yes, this is the emergency medicine department.”
My voice was trembling without my realizing it.
“There!! The patient in ER B section, bed 9! The 28-year-old female patient! The peripheral blood smear results are out!!!!”
I swallowed hard at the frantic shout.
“There are numerous schistocytes visible on the slide, and it looks like Grade 3+ or higher! Plus, severe thrombocytopenia with giant platelets is obvious, and Polychromasia
(* polychromatophilic red cells)
findings are also clear! This is TTP or HUS
(* hemolytic uremic syndrome)
and fits the thrombotic microangiopathy picture perfectly! You need to check this fast…!”
I'm fucked.
My worst fear.
No, the gallery ghosts' prophecy had come true.
They said there were lots of shattered red blood cells. Grade 3+. It was basically a scene of red blood cell corpses lying around.
The bone marrow, seeing the platelets and red blood cells dying off, was sending raw recruits—platelets and red cells that hadn't even been properly trained—into the battlefield after just a one-week crash-course boot camp.
Whether it was TTP or HUS didn't really matter.
Either way, they're both the same goddamn kind of thrombotic microangiopathy that will kill the patient if you don't treat them right away.
Besides, it was more in line with TTP anyway.
I hung up before she even finished speaking.
There wasn't even time to panic.
From here on out, every minute and second was directly tied to the patient's life.
“Internal medicine! Internal medicine, fuck!”
I sprang up from the chair and ran like a madman toward the whiteboard in the center of the station.
The nurses around me looked at me in surprise, but I couldn't see anything.
All I could see were the densely written names and contact numbers.
Hematology-Oncology.
Heme-Onc.
Who's on heme-onc call.
I traced down the whiteboard with trembling fingers.
[On-call Internal Medicine (Hematology-Oncology)]
- Primary call (Internal Medicine R2 Kim Ji-eun)
- Secondary call (Hematology-Oncology Fellow Jin Se-hee)
There were two names.
Kim Ji-eun. Jin Se-hee.
Wait. Call the primary first? Or the secondary?
Reason and instinct were clashing fiercely in my head.
By procedure, I should obviously call second-year Kim Ji-eun, the primary call, first.
A lowly first-year passing over a second-year and calling the fellow directly would be no different from a suicidal act against hospital etiquette.
Kim Ji-eun would be furious, and fellow Jin Se-hee might chew me out with, 'Where did this random first-year crawl out from to call me directly?'
But...
But this isn't the time to worry about hierarchy.
How much would second-year Kim Ji-eun know about TTP?
In the end, Kim Ji-eun would probably get flustered by the patient and end up calling the senior fellow again.
Of course, that's just my guess.
That process would waste at least ten minutes.
And during those ten minutes, clots would be blocking the patient's brain, heart, and kidney vessels, destroying the organs.
“Still, this is something a heme-onc doctor should handle.”
I made up my mind. Even if my hospital life got fucked, first save the patient.
My hospital life was already fucked anyway.
I wasn't scared anymore.
“Second call!”
I pulled out my phone and frantically punched in the number for heme-onc fellow Jin Se-hee from the on-call roster. Right before pressing the call button, I took a moment to catch my breath.
Huu… ha… fuck… fuck…
The fingertips of my hand were ice-cold.
Every word I was about to say would determine the course of a person's life.
Rrrring-
Rrrring-
Two rings later, the call connected.
A slightly tired female voice came from the other end of the receiver.
[Yes, this is Jin Se-hee from Hematology-Oncology.]
“Hello, Dr. Jin Se-hee. This is Han Hyeon-jae, a first-year in emergency medicine. I'm calling urgently about a patient who came into the ER.”
I continued, forcing myself to breathe evenly so my voice wouldn't shake.
“She's a 28-year-old female patient. Her chief complaint was headache, but her blood test showed a platelet count of 35,000. And on the peripheral blood smear we just did... numerous schistocytes were observed, Grade 3+ schistocytes. TTP is strongly suspected, so I contacted you directly instead of the second-year. I'm sorry.”
After my report ended, a one-second silence fell over the receiver.
[…Wait. What? Schistocytes 3+ and platelets at 35,000? TTP?]
Her voice had snapped fully alert in an instant.