Chapter 45
Just then.
“Han Hyeon-jae!”
A frantic voice called from behind.
It was Choi Su-min.
Seeing me standing there, pale-faced and in a daze, clutching the station phone, Choi Su-min must have realized something had happened.
“What’s going on? Why do you look like that? Who are you talking to?”
Choi Su-min approached me with a worried look.
I silently held up one hand while still clutching the receiver.
‘Just a moment.’
Then, without making a sound, I carefully shaped three syllables with my lips, putting every last ounce of my fear and urgency into them.
T. T. P.
I saw Choi Su-min’s eyes go from confusion to shock.
Of course, anyone would have understood the hellish weight those three letters carried.
Just then, with a loud clatter, a sheet of paper slid out of the fax machine in the corner of the station.
It was a test result.
Still holding the phone, I snatched the paper from the machine and spread it out in front of Choi Su-min.
The red handwriting scrawled by the lab staff at the bottom of the result sheet stood out clearly.
[Schistocytes: 3+ observed, suspect TMA, especially TTP]
(* Schistocytes 3+ observed, suspect TMA, especially TTP.)
Choi Su-min didn’t ask anything else.
“Dr. Jeong! Move patient B-9 to a bed in Area A right now! Reconnect the vital sign monitor, and check blood pressure every 15 minutes—no, every 5 minutes! Keep monitoring consciousness, and for urine output, put in a Foley
(*Foley catheter)
catheter and start checking!”
At that order, the entire station sprang into action.
The nurses ran around busily, preparing to move the patient.
In the center of that chaos, Choi Su-min picked up another phone.
MICU
(*medical ICU)
“Hello? This is Choi Su-min, third-year EM resident. We have a patient in the ER right now suspected of TTP. Could you pull a bed in the ICU immediately?”
“Yes, TTP. Thrombotic thrombocytopenic purpura. I think we need to start plasma exchange right away. If we want to save the patient, we have to move them now. Please, as quickly as possible.”
I turned my attention to the crisis in front of me, leaving that battle to play out behind my back.
Jin Se-hee was already pouring out orders to me over the phone.
[...Start high-dose IV steroids right away, contact the blood bank and tell them to secure at least 20 units of fresh frozen plasma for plasmapheresis in advance. Also contact nephrology in advance and have the plasmapheresis machine and staff ready. I’ll be coming down right now.]
“Yes, doctor, understood.”
The call ended.
I put down the receiver and looked at Choi Su-min, who had just finished speaking with the ICU.
“The fellow says she’s coming down now.”
“I know. I heard.”
War had begun.
“Solu-Medrol
(* an injectable steroid with anti-inflammatory and immunosuppressive effects)
1-gram loading dose, and call the blood bank again—request an emergency release of at least 20 units, up to 30 units of FFP right now. Call nephrology again and ask them to prepare plasmapheresis
(* plasma exchange)
right away! Quickly, quickly!”
The station was complete pandemonium.
The nurses were running everywhere, and the phones were ringing nonstop.
That complacent assumption that it was ITP.
My own ignorance in thinking I could just give steroids and wait.
If it weren’t for the gallery’s crazy ghosts, I’d probably be writing this patient’s death certificate by now.
“Han Se-hee! Pull yourself together!”
At Choi Su-min’s shout, I snapped back to my senses.
There was no time for self-reproach.
I had to make up for my mistake.
“Go to the patient right now and explain it again. Explain how serious this situation is. Has the guardian arrived?”
“No, not yet.”
“Then call them right now and tell them to come. And tell the patient that they’re going to the ICU right now. Tell them we’ll do everything we can—go and pass that along.”
I took heavy steps toward the bed where the patient had just been moved in Area A.
The patient was anxiously staring at the ceiling, their face even paler than before.
They must have had some vague idea why everything around them had suddenly become so hectic.
“Patient.”
I briefly ran a hand over my face.
“The situation has... become a lot more serious than we initially thought.”
My voice was stiff and rigid.
There was no time to explain everything in detail, and no room to reassure them.
“It looks like a much more urgent, much more dangerous disease than we first thought. It’s not simply a matter of the bleeding not stopping.... Right now, countless tiny clots are forming in the tiny blood vessels inside your body. And those clots are attacking very important organs like your brain and kidneys.”
The patient’s eyes widened.
“Please call your guardian right away and ask them to come. We’re going to move you to the medical ICU immediately. To save you, we need to start a treatment called plasma exchange, which exchanges out the plasma in your blood. From here on out, it’s truly a race against time.”
I couldn’t go on any further, and met the patient’s trembling eyes.
A wave of guilt and remorse washed over me.
The road back to the station after uttering words that were basically a death sentence for the patient.
I came to a stop for a moment.
In all this chaos, was there anything I was overlooking?
Rationally, the things I needed to do were sorted out, but deep inside, unease was still churning.
In the end, I opened that forbidden window once again.
HellJoseonSlave1 : I’m starting steroid infusion and preparing plasmapheresis right now. The platelets are in the 30,000s, but just in case, should I prepare a platelet transfusion too?
My question seemed utterly common-sense.
If platelets are low, wouldn’t it make sense to give platelets?
But the moment that question went up, the gallery was once again engulfed in a blaze of rage.
HemeOncIsHell : That insane bastard has really decided to keep killing the patient until the very end!!!
BackInMyDay : How in the world did a moron like that become a doctor? Every professor who let that bastard graduate from med school should be ashamed of themselves. He doesn’t even know the basic pathophysiology of TTP.
CardiologyGhost : Hey!!!!!!!!!!! Transfusing platelets into a TTP patient is exactly the same as pouring oil on a burning house, you crazy bastard!!!!!!!!!!
HemeOncIsHell : You mean you’re going to add more kindling to the clot factory? Right now, platelets are clumping like mad inside the patient’s body and making clots, and if you add new platelets on top of that, what do you think will happen?
HemeOncIsHell : Even bigger, even more numerous, and even stronger clots will form and completely block the patient’s brain vessels! Absolutely! Under no circumstances should you transfuse platelets unless the patient is dying from massive bleeding!
HemeOncIsHell : (an emoji of a dumpling spontaneously combusting)
Ah....
Just then.
“I’m from hematology-oncology!”
A sharp voice came from the ER entrance.
It was Jin Se-hee, the heme-onc fellow.
“Where is the patient?”
“Oh, she’s been moved over to Area A.”
“Please lead me there.”
Jin Se-hee didn’t give me even a moment to breathe.
I began briefing her almost mechanically, overwhelmed by her crushing presence.
“28-year-old female patient, strongly suspected TTP. Chief complaint on arrival was headache, platelet count 35,000, and schistocytes 3+ confirmed on PBS. LDH and bilirubin are elevated, and renal function is still within the normal range. High-dose steroid infusion has already been started, and FFP 20 units plus plasmapheresis is being prepared. The patient’s consciousness is still clear and vitals are stable.”
While listening to my report, Jin Se-hee just nodded silently.
“Good job.”
She said it briefly.
“For an EM first-year resident to handle the initial response this well, that’s excellent. Skipping the second-year and calling me directly was a great call too. Really good judgment.”
I was dumbstruck by the praise.
I thought I’d be getting chewed out.
“From here on out, I’ll take over.”
She said that and headed toward the patient.
Jin Se-hee’s back looked unbelievably reassuring and dependable, like an elite special-forces operative who had just parachuted into the battlefield at the very last second, when the whole unit was on the brink of collapse.
Wow, so this is what an internal medicine doctor is like.
Damn, that’s cool as hell.
Oops, even thinking that is forbidden.
If I said that out loud, I’d be terrified of the snide remarks I’d hear from Lee Min-jae.
Jin Se-hee checked the patient’s condition directly and started firing off orders like a storm.
“Get a C-line
(* central venous catheter)
ready right away. Since we’ll need to insert a dual-lumen catheter into the femoral vein for plasmapheresis, bring the kit. Keep checking blood pressure, and if it looks like it’s about to drop, get norepinephrine
(*vasopressor)
ready too.”
All the responsibility shifted from my shoulders to Jin Se-hee’s.
Only then could I finally let out a long sigh.