Chapter 60
Lee Minjae stood there, blankly.
Methemoglobinemia.
Cyanosis.
The paradox of oxygen saturation.
He must have been thinking of them in that order.
“Hah… shit….”
A curse burst from Lee Minjae’s mouth together with a hollow groan.
“ABGA! Draw an ABGA!”
Lee Minjae shouted almost like a scream as he pulled an arterial blood collection kit from the emergency cart.
“Hyeonjae, hold the kid’s arms and legs tight. If they move when I stick the artery, it’ll be a disaster.”
I nodded and held the child’s small body firmly still.
Lee Minjae wiped the skin with an alcohol swab, then picked up a heparinized syringe.
He inserted the needle and slowly pulled back the plunger.
Blood began to gush into the syringe.
I held my breath.
A normal arterial blood sample 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 let out a sigh at the sight of that brown blood.
“Ah….”
So this was it.
Irrefutable evidence.
The color of dying blood.
Lee Minjae pulled out the syringe and pressed gauze hard against the puncture site.
As Lee Minjae handed the syringe containing the sample to the nurse, he turned to the veteran nurse beside him.
“Nurse Jung, um... do we happen to have methylene blue in our ER medication stock?”
“Methylene blue...?”
Nurse Jung’s eyes widened.
“Well... it’s such a rare drug that we probably don’t have any. I’ll call the pharmacy team right away!”
Nurse Jung hurriedly picked up the phone.
Anxious time passed.
Methylene blue.
The only antidote for this disease, the one that turns methemoglobin back into normal hemoglobin.
If this hospital didn’t have that drug, this child would be....
“This won’t do.”
Lee Minjae bit his lip anxiously.
“I’ll call pediatrics first. They need to know about this situation too.”
Lee Minjae picked up the phone again and called the pediatrician on call.
“Yes, doctor on call for pediatrics. This is Lee Minjae, fourth-year emergency medicine resident.”
“...Yes. It’s a 24-month-old patient, and we’ve diagnosed methemoglobinemia. ...Yes, that’s right. There’s a history of baby food, and the arterial blood is chocolate-colored. So we’re about to give methylene blue now, but could you tell us about the pediatric dose or protocol...”
Lee Minjae listened to the voice on the other end for a moment, then frowned.
“Yes. Yes, understood. We’ll discuss it with the EM attending and proceed. Yes.”
Lee Minjae’s expression soured after he hung up.
“He said to consult with the attending and then give it. Well, from their point of view, that’s only natural. It makes no sense for a resident to decide diagnosis and treatment for a rare disease like this.”
He swallowed his curse and ran toward the resuscitation room door.
“Hyeonjae, stay right next to the kid and keep watching the vitals! I’m going to find the professor, get approval, and come right back!”
With that, Lee Minjae dashed out in a hurry, and only the child’s shallow breathing remained in the resuscitation room.
How much time had passed?
The station intercom rang.
It was the lab.
The nurse answered the phone and began writing the results on the chart.
Then the nurse held up the paper to me.
By calculation, the oxygen saturation was 73%, clearly showing that the child was in a state of hypoxia.
But the oxygen saturation measured by the machine was 85%.
One of them is lying.
And the liar was probably the 85% reading.
SpO2 85%.
SaO2 73%.
‘The machine is lying.’
A cunning disease that fools the machine’s eye.
Chocolate-colored blood flowing through the child’s veins.
Just then, Nurse Jung shouted in a frantic voice.
The call with the pharmacy team had just ended.
“Doctor! The main building pharmacy team has Proveblue injection
(* the methylene blue drug sold in Korea)
in stock! Thankfully, the expiration date is still plenty far off! We don’t have any in the ER!”
It was news of salvation.
I immediately turned and said to intern Choi Minseong, who had been watching all of this over my shoulder and not knowing what to do.
“Hey, intern! Minseong! You heard that!”
“Yes? Yes!”
“From now 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 all the way to the central pharmacy in the main building basement level 1! Don’t even think about catching the elevator! If you wait for the elevator at this hour, the kid will die! Run down the emergency stairs! Use every ounce of strength you’ve got in your whole life! Hurry! I’ll enter the order in the system under my name first!”
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.
“Quit nodding and just go.”
Right after Choi Minseong disappeared from view, Lee Minjae came running back into the resuscitation room, sweating profusely.
“Oh, the approval came through! The attending professor said to trust our diagnosis for now and proceed! If you write the order...”
“I already did! The intern has already left to get the medicine!”
At my answer, a faint smile spread across Lee Minjae’s face.
“Good! Nice instincts!”
Lee Minjae patted my shoulder once, then turned his gaze back to the patient’s parents.
“Hyeonjae, go explain it to them. You might as well have been the one to diagnose it.”
Somehow, it felt like these guys were all leaving the patient explanation to me.
Maybe it was just my imagination.
I nodded and walked over to the couple.
“Ma’am, sir. Let me explain again.”
I pulled over a chair and sat down.
“First, we found the cause. And fortunately, we also have the medicine to treat it here at our hospital.”
At that, the couple’s faces brightened a little.
“Your child has a very rare disease called methemoglobinemia.”
I began explaining the disease using the simplest words I could.
“Inside our blood are little workers called hemoglobin who deliver oxygen. But because of a certain substance in the meal the child ate today, some of those workers suddenly went on strike. They may look fine on the outside, but they can no longer carry the most important thing, oxygen. So oxygen isn’t being delivered throughout the body, and that’s why cyanosis appeared, with the lips turning blue.”
I took a breath and explained the most important part.
“This disease usually occurs only very occasionally in very young babies under six months old, whose stomach acid production is still immature. For it to appear in a child past two years old is truly rare.”
I took the child’s father’s hand.
“So it is absolutely not the parents’ fault. Usually, children this age don’t get this from eating spinach or carrots. It was just incredibly bad luck. Please don’t blame yourselves.”
Tears finally spilled from the mother’s eyes.
“The antidote will be here soon. Once this medicine goes in, it will fix the hemoglobin that was broken and make it able to deliver oxygen again. After the injection, you’ll see the child’s blue lips gradually return to their original color.”
I added a few lifestyle precautions at the end.
“Of course, the child will have to be admitted. Their body may be unusually sensitive to that substance. From now on, just in case, please don’t give too much of nitrate-rich vegetables like spinach or carrots at once. It’s better to give them in smaller portions.”
When I finished speaking, the couple kept bowing and thanking me.
I accepted their thanks with a bitter smile.
***
After Choi Minseong disappeared toward the emergency stairs, the resuscitation room once again fell into a terrible waiting period.
Lee Minjae and I said nothing, only alternating our gazes between the child’s lips and the numbers on the monitor.
We’d done everything we could.
The diagnosis?
Made.
The treatment plan?
Set.
The antidote?
It was already racing toward somewhere in this hospital.
But that short time felt unbelievably long.
To ease my anxiety even a little, I opened the Gallery window once more.
==========
Title: Intern Went to Get Methylene Blue.
Author: Hell Joseon Slave 1
The main building pharmacy team says they have stock. It’s Proveblue injection 0.5%, so I sent the intern sprinting there. It’s about to be administered.
==========
ㅇㅇ (210.94) : Oh, looks like they had methylene blue? Your hospital’s emergency medication stock management is pretty good?
BackInMyDay : Wow, your hospital is great. I once saw the exact same methemoglobinemia patient as you, but back then our hospital was out of stock, so I called every pharmacy team at nearby university hospitals and still ended up being told none of them had it.
HematomaIsHell : Right. It really is a rare drug. Most places don’t keep it unless they’re a major hospital. Lucky you had it.
...So it really is a rare drug.
Reading the comments, I realized once again just how precariously I was walking a tightrope right now.
If the drug hadn’t been available, this child would have....
Wait, this isn’t the time to be thinking that.
The most important and fundamental question came to mind.
‘So how much of this drug am I supposed to give?’
I vaguely remembered the adult dose.
But this was a two-year-old child.
Injecting the wrong dose into this small body, one that weighed less than 15 kilos, would be like injecting poison.
HellJoseonSlave1 : But how exactly am I supposed to calculate the order for this? I’m confused about pediatric dosing. I feel weird asking the chief, so I’m asking you guys first. 12 kg.
As if they had been waiting for my honest question, a savior stepped in.
ㄴ PediatricGhost77 : You’re asking that now?! 1 to 2 mg per kg! Since the patient weighs 12 kg, starting with 12 mg is safest! But you said the drug you have is 0.5%, right? Then there’s 5 mg in 1 ml, so draw up 2.4 ml and dilute it in normal saline, then give it very slowly over at least 5 minutes.
From the calculation process to the infusion speed and the precautions.
As expected of the pediatric ghost.
Absolutely reliable.
ㄴ HeirOfHippocrates : O living one, the pediatric ghost’s words are probably correct, but children’s medication doses must always be handled with extreme caution. Your chief is probably swamped too, so be sure to call the pediatrician on call once more and double-check the dose.
ㄴ HellJoseonSlave1 : Okay, okay. Got it. Thanks.
I immediately picked up the phone and contacted the pediatrician on call.
“Yes, this is Han Hyeonjae from emergency medicine. I’m calling to double-check the dosage for giving methylene blue to a child with methemoglobinemia...”“
When I told the pediatrician the dose I had calculated, or rather copied, the doctor on the other end sounded briefly surprised, then confirmed that my calculation was correct.
How long had passed?
“Huff... huff... I brought it!”
The resuscitation room door flew open, and Choi Minseong ran in looking almost corpse-like.
In his hands, he carefully held a small glass ampoule.
“Good work, Minseong! You really did great!”
Lee Minjae patted the intern on the back.
Then 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.
There was no change.
The child’s lips were still blue.
My heart started pounding anxiously again.
Was the diagnosis wrong?
Was the medicine not working?
That was when it happened.
A very pale pink began to spread from the ends of the child’s deep blue lips.
Color returned to the child’s pale cheeks.
The shallow, irregular breathing began to deepen and even out.
Lee Minjae ran a hand through his hair.
Relieved smiles spread across the nurses’ faces too.
A little later, the transport team came down from the pediatric ICU to move the patient.
The child was moved onto the transport stretcher, now completely back to a normal color.
I stared blankly at the scene from the resuscitation room door.
The child’s parents bowed to me.
I could only awkwardly bow back.
Only after their figures disappeared beyond the elevator could I finally let out a breath.
Ha.
We saved him.