Chapter 54
The polite applause that followed the speaker's final “Thank you” filled the seminar room.
I clapped a few times without any feeling.
At last, it was over.
The senior professor serving as moderator took the microphone.
“Yes. Then we’ll have five minutes for Q&A. If anyone has a question, please raise your hand.”
“Ah... um, I listened carefully to the presentation. I’m Lee Hyun-woo from Ajou University Hospital. What I’d like to ask is about the patient’s average length of stay and the follow-up period after discharge...”
Hmm, should I point out this presentation?
Back in My Day: Hell Slave. Now.
Hell Joseon Slave 1: What do you mean, now?
Cardiology Wraith: Hurry, go go. Become the conference troublemaker, hell slave.
Hematoma Is Hell: Smash that bogus diagnosis to pieces! There is no mercy in academia!
“Uh... exactly how am I supposed to ask? Tell me that much, would you. It’s not like I can suddenly leap up onto the podium and say, ‘Hey! You’re wrong!’!”
At my desperate question, the gallery’s mad masters began issuing very specific and vicious operational instructions as if they’d been waiting for this.
Cardiology Wraith: You have to ask it in the form of a question. Never make a definitive statement. You have to keep the stance all the way through: not ‘You’re wrong,’ but ‘I’m just a nobody and don’t really know, but I was wondering if there might be that possibility, so I’d like to ask the esteemed presenter about it.’
Hippocrates’ Descendant: That’s right! Put on the mask of academic humility and beat the other person down!
Cardiology Wraith: Say it like this: ‘Looking at the echocardiogram you showed earlier, unlike the textbook findings of takotsubo cardiomyopathy, the myocardium at the apex seems to be abnormally thickened. I’d like to ask for the presenter’s esteemed opinion on whether you considered another disease that should be differentiated here—apical hypertrophic cardiomyopathy, worsened under stress.’
Damn perfect.
“Hey, let’s actually go now. This is boring.”
Kim Ji-hoon grabbed my arm and pulled.
“No, I have a question.”
“What?”
Ignoring Kim Ji-hoon’s horrified expression, I shot my right hand up.
The moderator professor’s gaze, having just seated the previous questioner and now looking for the next person, met mine.
“Are you crazy? Why are you doing this? Hey, put your hand down!”
Kim Ji-hoon, panicking beside me, tried to drag my arm down, but it was already too late.
“Yes, the doctor with glasses there. Please state your affiliation and name before asking your question.”
“Ah, yes. Hello. I’m Han Hyeon-jae, a first-year in the Emergency Medicine Department at Busan Cheongjin Medical Center.”
Several professors’ eyes lit up with interest at my introduction.
“Excellent presentation. Before my question, could you show slide 12, the echocardiogram you showed earlier, once more?”
A subtle hint of embarrassment flitted across the faces of both the moderator and the presenter at my request.
But there was no reason to refuse.
My question still had no intent behind it. I was only asking to see the image again.
The presenter operated the laptop and displayed the problematic image on the screen.
The air in the seminar room subtly changed.
That was the moment a first-year resident singled out a specific slide and asked to see it again.
I felt that change with my whole body.
What stood out most was how the gazes of several professors in the front row changed.
Two or three gray-haired senior professors who had just moments ago been hesitating to raise their hands with bored expressions.
The look on those professors’ faces said, “Oh? Look at this guy?”
Damn. If you stare like that, I can’t handle the pressure.
If you keep watching me with that much pressure, my heart will start shaking too.
I screamed inside.
The presenter clicked the mouse a few times and then took the microphone.
“Yes. One moment... here is slide 12, as requested.”
“Ah, yes. Thank you, doctor.”
I adjusted the trembling microphone with my shaking hand.
My heart was pounding.
Whew.
Calm down, calm down.
“Thank you again for the excellent presentation, doctor. Since I’m a junior resident still in training, I may have missed something basic, so to help me understand, I’d like to ask one thing.”
I lowered myself as much as I could.
That was Cardiology Wraith’s teaching.
“First of all, what I’d like to ask is whether you happened to separately measure the thickness of the apical myocardium during diastole.”
Thickness.
The moment I stressed that word, I saw one professor in the front row curl the corner of his mouth faintly.
I went on.
“Textbook-wise, if this were stress-induced myocardial stunning, the muscle in that area should stretch and become thinner than normal, but when I looked at the image earlier...”
I paused briefly and pointed at the screen.
“From what I could see, the muscle at the apex looked thicker than the rest of the heart...”
I added the magic sentence that would package all of this aggression as nothing more than an innocent question.
“...Of course, it may have been my inexperience that made me see it wrong.”
That was the magic sentence.
In other words, it was the same as beating the other person up as hard as you could and then saying, “Oh, I learned something!”
When I finished speaking, a one-second silence fell over the seminar room.
Then, breaking that silence, murmuring surged in from all around like waves.
“Thickness?”
“Huh? Come to think of it, yeah?”
“Look at that image again. It’s real. Why is the apical part so thick?”
People began whispering.
Low exclamations of “Ah!” burst out here and there.
The truth that had just a moment ago been invisible to the eye began to emerge.
The presenter on the podium had gone completely pale, glancing back and forth between the screen and me, unable to say a word.
Hmm, had his mind gone blank?
“Diastolic thickness?”
The presenter’s mouth opened and closed a few times before a voice finally squeezed out of his throat.
“Uh... um... uh... so...”
“Ah... well... because it was the textbook apical ballooning
“(* apical ballooning)
finding of takotsubo cardiomyopathy, we didn’t separately measure the myocardial thickness.”
That answer made the air in the seminar room turn cold once more.
‘Because it was typical, we didn’t check.’
It was the most dangerous and arrogant thing a doctor could say.
“Ah, I see. Thank you for the detailed answer despite how busy you are. Then may I additionally ask whether the initial ECG had any findings strongly suggestive of hypertrophic cardiomyopathy, such as giant T-wave inversions in the chest leads from V2 to V4?”
Giant T-wave inversions.
The moment that word came out of my mouth, one of the front-row professors’ eyes flashed.
“Uh... um... uh...”
The blood drained completely from the presenter’s face.
“Ah, I was going to ask that.”
“There was T-wave inversion. But was it deep?”
Murmuring exploded all around.
The moderator grabbed the microphone.
“Presenter, just a moment. Please bring up the ECG slide again.”
With an almost-crying face, the presenter fumbled with trembling hands and brought the initial ECG image up on the screen.
The moderator stood up from his seat and pointed to a part of the screen with a laser pointer.
V3 and V4 leads.
In those leads, exactly as I had pointed out, sharply inverted T waves with deep notches were clearly visible.
“The T wave is... inverted. The depth... it looks like it easily goes beyond 10 mm.”
The moderator switched off the laser pointer and turned his head toward me.
“The first-year doctor Han Hyeon-jae from Busan Cheongjin Medical Center who asked that question—do you perhaps have any additional comments or anything else you’d like to ask about this finding?”
Every gaze in the seminar room turned back to me.
I readjusted the microphone.
The murmuring from here and there came clearly to my ears.
“Apical HCM?
“(* Apical hypertrophic cardiomyopathy)
”
“He figured that out in one shot as an EM first-year?”
“Aseong Hospital is old news now. They came to give a presentation and missed something that basic.”
“Tsk tsk, he really put his advisor’s face in the mud.”
“Did the advisor professor not even review it properly? He just let that through?”
I tried my best not to pay attention to the voices drifting in from all around and, following Cardiology Wraith’s advice as closely as possible, began to offer my own pointed advice.
“Ah, yes. In my brief opinion, this case seems more likely to be an acute exacerbation of apical hypertrophic cardiomyopathy than takotsubo cardiomyopathy. If Apical HCM is correct, the patient is always at risk of sudden death. Therefore, you should contact the patient as soon as possible and have them return to the hospital for a thorough evaluation, including cardiac MRI, though...”
The moment my words ended, heavy silence settled over the seminar room.
I tried my best not to pay attention to the voices drifting in from all around and, following Cardiology Wraith’s advice as closely as possible, began to offer my own pointed advice.