Chapter 56
We took heavy steps and walked into the crowd waiting for us.
Like the miracle of Moses, the people parted to make way for us.
Damn. This is so stressful.
All eyes were fixed on Kim Ji-hoon and me.
“They’re here.”
“Is that Mr. Han Hyeon-jae?”
“He’s much younger than I expected.”
“Of course. He’s only a first-year.”
I forced myself to look calm and stood in front of the poster with my name on it.
Kim Ji-hoon stood in front of his poster in a near half-delirious state.
“The patient’s final diagnosis was right coronary artery occlusion, but could you explain the relationship with the sore throat symptoms in a little more detail?”
“Yes. The right coronary artery is an important vessel that supplies blood to the inferior wall of the heart and the right ventricle. Ischemic pain in this area often radiates to the neck, jaw, and back. This happens because the pathways of the vagus and sympathetic nerves that innervate the heart and neck partially overlap in the thoracic spinal ganglia, leading to this phenomenon...”
I fluently recited the contents of the paper I had memorized all night as if they were my own knowledge.
It was the model answer I had prepared in advance, reviewed dozens of times by the ghosts. The doctor who asked the question nodded as if satisfied.
The mood at the start wasn’t bad.
The questions were within the expected range, and I answered them accurately.
At this rate, it looked like I’d get through it safely.
Just then, Professor Kim Hyeok-jae of Oseong Seoul Hospital, who had been watching me closely in the seminar room earlier, raised his hand.
“Dr. Han, I enjoyed your presentation. It’s a very interesting case. But I have one question.”
Thump—what is it?
“In a case like yours, under an extreme physical stress like myocardial infarction, ischemic injury can rarely occur in other organs as well. In particular, in patients with underlying vascular disease, did you consider the possibility that nonocclusive mesenteric ischemia caused by reduced cardiac output could manifest as atypical pharyngolaryngeal discomfort? If those two had come together, what would have been the key clinical clue for differentiating them in the emergency room?”
Silence fell.
…Mesenteric… what?
My brain came to a complete stop.
NOMI?
Nonocclusive mesenteric ischemia?
Of course, I had seen it in a book.
But I had never once imagined I’d be asked to differentiate that in a myocardial infarction patient who came in with a sore throat.
This isn’t a question a first-year can answer, professor.
I couldn’t say anything and just mouthed words silently.
Cold sweat ran down my spine.
“Uh…”
I barely squeezed out a voice.
“Um… may I think about it for a moment before answering?”
And so I declared surrender in the face of the worst crisis of my medical career.
Gallery, gallery. Please.
A murmur spread through the room.
“What is he looking at? The air?”
“What’s wrong with him? Did he suddenly lag?”
“Hmm, I’ve heard geniuses are a bit weird somehow, but I guess it was true.”
Hell Joseon Slave 1 : Hey!! That professor from Oseong Hospital is asking some weird shit right now!! He’s saying a myocardial infarction patient can have mesenteric ischemia or whatever along with it—what kind of bullshit is that!!! Tell me the differentiation point, now!!!! I’m giving you 10 seconds!!!!! If you don’t tell me, I’m just declaring suicide and bolting right here!!!!!
At my desperate threat, the gallery started moving in a hurry.
Back in My Day : You crazy bastard, calm down! NOMI! That’s a really fucked-up disease!
God of the Scalpel : The differentiating points are the abdominal exam and the lactate level!
Cardiology Wraith : If it were mesenteric ischemia, the abdomen wouldn’t just hurt—it would hurt like hell! There’d be abdominal distension, rebound tenderness when pressed, or the bowel would be rotting away and causing metabolic acidosis, sending the lactate level through the roof! Your patient’s abdomen was fine, and the lactate on the labs was normal, right? Tell him that!
“Ah, yes. I’ll answer.”
At my calm voice, the murmuring around me died down again.
“I sincerely appreciate your question, professor. In a severe stress situation such as acute myocardial infarction, the possibility of accompanying nonocclusive mesenteric ischemia is certainly an important differential to consider. Especially if the patient were elderly or had underlying vascular disease, that would be even more so.”
Phew, let’s calm down.
My voice gradually began to tremble.
“However, in the case of the patient I managed, the abdominal physical exam performed at presentation showed no signs of peritoneal irritation such as abdominal distension, focal tenderness, or rebound tenderness. In addition, the initial blood tests did not show any significant elevation in lactate levels suggestive of metabolic acidosis.”
Now it was time for the conclusion.
“If the two conditions had manifested simultaneously, I think it is highly likely that the rise in cardiac enzyme levels would have been accompanied by a sharp increase in lactate levels due to intestinal ischemia. Therefore, based on the patient’s clinical symptoms and test results at the time, I tentatively judged the possibility of NOMI to be low.”
When I finished speaking, silence fell once again.
Professor Kim Hyeok-jae burst into a hearty laugh, looking very satisfied with my answer.
“Haha! This kid’s a real gem, a real gem! A first-year at this level? It can’t even compare to when we were in training!”
At that lavish praise, the other professors around nodded in agreement.
I bowed awkwardly amid the torrent of praise.
“Oh, you’re too kind. Thank you.”
“I’m not joking. If you ever get interested in critical care subspecialty training or a fellowship later on, be sure to contact us. Oseong is the best in this field, haha!”
“Thank you.”
With that reply, the attention on me subsided.
A few residents threw some light questions at me after that, but nothing serious.
I parroted the model answers I had prepared in advance.
When the questions about me ended, one of the professors who had been interrogating me, Professor Park Ju-seong of Seoul Catholic Sacred Heart Hospital, turned his gaze to the side.
“Who is this? Poster number P-116… Kim Ji-hoon? Cheongjin Medical Center. Oh, a colleague?”
Professor Park scanned Kim Ji-hoon’s poster with an interested look.
The poster topic was ‘A Case of Rhabdomyolysis Caused by Excessive CrossFit.’
It was a plain, educational case that you could see very commonly in the emergency room these days.
‘Oh, Ji-hoon. Sorry.’
Because of my flashy(?) debut, the judges’ standards had already been driven insanely high.
The professors might now be expecting that every first-year from Cheongjin Medical Center is a lunatic like me.
But Kim Ji-hoon was just an ordinary, diligent first-year.
Sure enough, Professor Park opened his mouth.
“Dr. Kim Ji-hoon. I enjoyed your presentation. The patient’s CK
(*Creatine kinase)
levels were over 100,000, which was very impressive. In severe rhabdomyolysis like this, the most concerning complication is, of course, acute kidney injury.”
What on earth was he going to ask?
“Here’s my question. To prevent myoglobin from the patient’s urine from clogging the renal tubules, urine alkalinization therapy is often performed along with fluid therapy. What’s your view on the controversy over whether this urine alkalinization therapy is actually effective in improving patient outcomes?”
Fuck.
I cursed inwardly.
That is not the level of question you can ask a first-year emergency medicine resident.
Go ask a nephrologist, you old man.
Why the hell are you asking Ji-hoon that?
Kim Ji-hoon’s face went pale.
Kim Ji-hoon sweated coldly from his forehead as he desperately racked his brain.
“Uh… yes… um… professor…”
Kim Ji-hoon started stumbling over his words.
“For rhabdomyolysis patients, um, uh, first of all, it’s most important to aggressively administer a sufficient amount of fluids to secure urine output.”
That’s the first page of the textbook.
“And… um, urine alkalinization can also… um, maybe help… prevent kidney damage…”
Kim Ji-hoon’s voice grew smaller and smaller, and his gaze drifted anxiously to the floor.
Professor Park asked no more questions.
He simply gave a faint, brief nod and moved on to another poster.
***
And just like that, all the attention drained away, leaving only Kim Ji-hoon and me in front of the poster.
Poor guy…
Kim Ji-hoon called out to me.
“Hyeon-jae.”
“What.”
“Am I… am I an idiot?”
I couldn’t bring myself to answer right away.
“Hmm…”
What should I even say?
Would it be comforting to say, ‘No, you’re not an idiot’?
And saying, ‘Yeah, you’re an idiot,’ would just make me a bastard.
“If it were you… you could have answered it, right? That question the professor asked.”
“…No?”
I shrugged as much as I could and put on a face that said I knew nothing.
“I don’t know either, man.”
Kim Ji-hoon’s eyes went round at my answer.
Boing.
“Huh? You don’t know either? Really?”
“I don’t know, man.”
I lightly smacked Kim Ji-hoon on the shoulder.
“I only went all-in on my paper topic, that myocardial infarction that came in with a sore throat. I memorized everything—every question that could come up and every expected answer. But rhabdomyolysis? The usefulness of urine alkalinization? How would I know that? That’s not my field.”
At my shameless acting, the shadow that had been hanging over Kim Ji-hoon’s face slowly began to lift.
“Wow… you crazy bastard.”
A swear laced with awe burst from Kim Ji-hoon’s mouth.
“Just how hard had you prepared that you could answer those professors instantly without even blinking? I thought my heart was going to burst. You’re a total nutcase.”
“Tsk.”
I slapped Kim Ji-hoon hard on the back.
“That’s why you should’ve prepared properly in advance, buddy.”
Kim Ji-hoon had no rebuttal to my words.
He just looked at me with a gaze that said, ‘That bastard is really ruthless.’
Sorry, Ji-hoon.
This is the only way we survive together.
I can’t exactly tell him that ghosts live in the gallery I frequent.
It was then that an awkward but warm camaraderie began to blossom between us.
“Oh, how did it go? There were so many people earlier!”
Professor Cheon Eun-jeong, who had come back from watching the other presentations, was waving and walking over to us from far away.
“I got utterly crushed, professor.”
And Kim Ji-hoon, loyal to the end, gave all the credit to me.
“Hyeon-jae carried everything by himself.”
“Oh, really?”
Professor Cheon looked at me with a very satisfied expression, as if she had expected that.
I could only smile awkwardly and scratch the back of my head.