Chapter 60
Lee Minjae stood there, staring blankly.
Methemoglobinemia.
Cyanosis.
The oxygen saturation paradox.
Those words must have flashed through his mind in that order.
“Ha… shit….”
A hollow groan escaped Lee Minjae, followed by a curse.
“ABGA! Let’s get an ABGA!”
Lee Minjae shouted almost at the top of his lungs as he pulled an arterial blood-gas draw kit from the emergency cart.
“Hyeonjae, hold the baby’s limbs tight. It’ll be a disaster if the child moves while I’m puncturing the artery.”
I nodded and held the child’s tiny body firmly in place.
Lee Minjae wiped the skin with an alcohol swab, then picked up a heparinized syringe.
He inserted the needle and slowly pulled the plunger back.
Blood began surging up into the syringe.
I held my breath.
Normal arterial blood should have been a bright, vivid scarlet, full of oxygen.
But the blood filling the syringe was not scarlet.
It was a grotesque, ominous dark brown.
Lee Minjae and I both groaned at the sight of that brown blood.
“Ah….”
This was it.
Irrefutable proof.
The color of dying blood.
Lee Minjae removed the syringe and pressed firmly on the puncture site with gauze.
As Lee Minjae handed the syringe containing the specimen to a nurse, he turned toward the senior nurse beside him.
“Nurse Jung, um… do we have any methylene blue in our ER medication stock?”
“Methylene blue…?”
Nurse Jung’s eyes widened.
“I’m not sure… It’s such a rare drug, so we probably don’t have any. I’ll call the pharmacy department right away!”
Nurse Jung urgently picked up the phone.
An anxious stretch of time passed.
Methylene blue.
The only antidote for this illness, capable of turning methemoglobin back into normal hemoglobin.
If this hospital didn’t have that drug, this child would….
“This won’t do.”
Lee Minjae nervously bit his lip.
“I’ll call pediatrics first. They need to know about this situation too.”
Lee Minjae picked up the phone again and contacted the pediatric on-call doctor.
“Yes, is this the pediatric on-call doctor? This is Lee Minjae, a fourth-year emergency medicine resident.”
“…Yes. Yes, a 24-month-old patient, and we’ve diagnosed methemoglobinemia. …Yes, that’s right. There’s a history of eating baby food, and the arterial blood is chocolate-colored. So we’re about to administer methylene blue, and I wanted to ask about the pediatric dosage or protocol….”
Lee Minjae listened to the voice on the other end for a moment, then furrowed his brow.
“Yes. Yes, understood. I’ll discuss it with the EM attending and proceed. Yes.”
Lee Minjae’s expression was grim after he hung up.
“They said to administer it after discussing it with the attending. Well, that’s only natural from their perspective. It makes no sense for a resident to decide on the diagnosis and treatment of some rare disease like this.”
He bit back a curse and ran toward the resuscitation room door.
“Hyeonjae, stick right by the baby and keep watching the vitals! I’ll find the attending, get confirmation, and come right back!”
After Lee Minjae hurried out, only the child’s shallow breathing remained in the resuscitation room.
How much time had passed?
The station intercom rang.
It was the lab.
A nurse answered the phone and began writing the details down in the chart.
Then the nurse held the paper out toward me.
The calculated oxygen saturation was 73%, clearly showing that the child was hypoxic.
But the oxygen saturation measured by the machine was 85%.
One of the two was lying.
And the liar had to be the 85% reading.
SpO2 85%.
SaO2 73%.
‘The machine is lying.’
A cunning disease that fooled the machine’s eyes.
Chocolate-colored blood flowing through the child’s vessels.
Just then, Nurse Jung called out urgently.
She had just finished speaking with the pharmacy department.
“Doctor! The main building pharmacy says they have Proveblue injection
(* the methylene blue medication sold in Korea)
in stock! Luckily, it has plenty of time left before its expiration date! The ER doesn’t have any!”
It was news of salvation.
I immediately turned and spoke to Intern Choi Minseong, who had been watching the whole situation without knowing what to do.
“Hey, intern! Minseong! You heard that, right!”
“Yes? Yes!”
“From this moment on, you have to become the fastest person in our hospital!”
I hurriedly pulled a piece of paper from my pocket and scribbled on it.
“Take this and sprint to the central pharmacy on the main building’s basement level one! Don’t even think about waiting for the elevator! If you wait for an elevator at this hour, the kid could die! Run through the emergency stairs! Use every ounce of strength you have! Hurry! I’ll put the order into the system under my name for now!”
I pressed the prescription into Choi Minseong’s hand.
Choi Minseong stood there blankly for a moment, then realized how serious the situation was and nodded with a solemn expression.
Don’t waste time nodding—get moving.
Immediately after Choi Minseong disappeared from view, Lee Minjae came sprinting back into the resuscitation room, drenched in sweat.
“Hey, we got confirmation! The attending professor said to trust our diagnosis and proceed! You can put in the order—”
“Already done! The intern has gone to get the medicine!”
A faint smile spread across Lee Minjae’s face at my answer.
“Good! Nice thinking!”
Lee Minjae gave my shoulder a single pat, then turned his gaze toward the patient’s parents.
“Hyeonjae, go explain it to them. You practically made the diagnosis.”
Why did I feel like every one of these guys kept leaving the patient explanations to me?
Was it just my imagination?
I nodded and approached the couple.
“Ma’am, sir. Let me explain again.”
I pulled over a chair and sat down.
“We’ve found the cause. And fortunately, our hospital has the medicine needed to treat it.”
At those words, the couple’s expressions eased a little.
“Your child has a very rare illness called methemoglobinemia.”
I began explaining the disease, choosing the simplest words I could.
“Inside our blood are friends called hemoglobin that deliver oxygen. But because of a certain ingredient in the food your child ate today, some of those friends suddenly went on strike. They look fine on the outside, but they can no longer carry the most important thing of all—oxygen. Since oxygen can’t be delivered throughout the body, cyanosis, or bluish lips, has appeared.”
I paused to catch my breath, then explained the most important part.
“This illness usually occurs only very rarely in very young babies under six months old, whose ability to secrete stomach acid is still immature. It’s extremely rare in a child over two years old.”
I took the child’s father’s hand.
“So this is absolutely not your fault as parents. Normally, children this age don’t develop this even if they eat spinach or carrots. You were simply extremely unlucky. Please don’t blame yourselves.”
Tears finally spilled from the mother’s eyes.
“The antidote will be here soon. Once we give this medicine, it will repair the damaged hemoglobin and allow it to deliver oxygen again. After the injection, you’ll see your child’s blue lips gradually return to their normal color.”
Finally, I added a little advice about what to do going forward.
“Of course, your child will need to be admitted. Their body may simply be unusually sensitive to that ingredient. Just in case, from now on, it would be best not to give them too much of nitrate-rich vegetables like spinach or carrots at once, but to divide them into smaller portions.”
When I finished explaining, the couple repeatedly bowed their heads and thanked me.
I accepted their thanks with a bitter smile.
***
After Choi Minseong disappeared toward the emergency stairs, another agonizing stretch of waiting began in the resuscitation room.
Lee Minjae and I silently looked back and forth between the child’s lips and the numbers on the monitor.
We had done everything we could.
The diagnosis?
Made.
The treatment plan?
Set.
The antidote?
On its way somewhere in this hospital right now.
But that short interval felt unbearably long.
To ease my anxiety even a little, I opened the Gallery window again.
==========
Title: An intern went to get methylene blue.
Author: HellJoseonSlave1
They say the main building pharmacy has it in stock. Proveblue injection 0.5%, apparently. They had some, so I sent the intern sprinting. We’re about to administer it.
==========
ㅇㅇ (210.94) : Oh, looks like they had methylene blue? Your hospital is pretty good at managing its emergency medication stock, huh?
BackInMyDay : Wow, your hospital is great. I once saw a methemoglobinemia patient exactly like yours, but our hospital didn’t have any in stock. I called every nearby university hospital pharmacy, but in the end, they all said they didn’t have any either.
HematomaIsHell : Right. It’s a really rare drug. Most hospitals don’t keep it stocked unless they’re large hospitals. Lucky you had some.
…So it really is a rare drug.
As I read the comments, I realized once again how precariously I was walking a tightrope.
If we hadn’t had the medicine, this child would….
Wait, this wasn’t the time to think about that.
The most important and fundamental question rose to the forefront of my mind.
‘So how much of this medicine do I give?’
I vaguely remembered the adult dosage.
But this was a two-year-old.
Injecting the wrong dosage into this tiny body, which weighed less than 15 kilograms, would be like injecting poison.
HellJoseonSlave1 : But how exactly am I supposed to calculate and enter the order for this? I’m confused about the pediatric dosage. I felt awkward asking the chief, so I thought I’d ask you guys first. The child weighs 12 kg.
As if he had been waiting for my honest question, a savior appeared.
ㄴ PediatricsGhost77 : You’re only asking that now?! 1–2 mg per kilogram! Since the patient weighs 12 kg, starting at 12 mg is the safest! But you said the medicine you have is 0.5%, right? That means it contains 5 mg per mL, so draw up 2.4 mL, dilute it in normal saline, and administer it very slowly over at least five minutes.
From the calculation to the infusion rate and precautions.
As expected of PediatricsGhost.
Now I was certain.
ㄴ HeirOfHippocrates : Living one, what PediatricsGhost says is correct, but medication dosages for children must always be handled with extreme caution. Your chief is probably overwhelmed too, so make sure you call the pediatric on-call doctor again and have them double-check the dosage.
ㄴ HellJoseonSlave1 : ㅇㅋㅇㅋ 알았다. 고맙다.
I immediately picked up the phone and contacted the pediatric on-call doctor.
“Yes, this is Han Hyeonjae from emergency medicine. I’m calling to double-check the dosage for administering methylene blue to a pediatric patient with methemoglobinemia….”
When I gave the dosage I had calculated—or rather, copied—the pediatrician sounded surprised for a moment, but soon confirmed that my calculation was correct.
How much time had passed?
“Huff… huff… I got it!”
The resuscitation room door opened, and Choi Minseong came running in looking like a walking corpse.
Choi Minseong was carefully clutching a small glass ampoule.
“Good work, Minseong! Really, good work!”
Lee Minjae patted the intern on the back.
The nurse connected a syringe to the child’s IV line and began injecting the medicine very slowly.
Everyone held their breath.
One minute. Two minutes. Three minutes.
Nothing changed.
The child’s lips were still blue.
My heart began beating anxiously again.
Was the diagnosis wrong?
Was the medicine not working?
Then, it happened.
A very faint pink hue began spreading from the tips of the child’s blue lips.
Color returned to the pale cheeks.
The child’s shallow, irregular breathing began to grow deep and even.
Lee Minjae ran a hand through his hair.
Relieved smiles spread across the nurses’ faces.
A short while later, a transport team from the pediatric intensive care unit came down to transfer the patient.
The child had now fully regained a normal complexion and was moved onto a transport bed.
I stood blankly at the resuscitation room door, watching.
The child’s parents bowed toward me.
I could only awkwardly bow back.
Only after their figures disappeared beyond the elevator could I finally let out a sigh.
“Hah.”
I saved the child.