Chapter 83
11 p.m.
Phones rang all around, and monitor alarms screamed.
Nurses hurried back and forth, and interns paced anxiously.
I was already half out of my mind, wrestling with the pile of charts coming in.
My fingers tapped the keyboard mechanically, but my brain had long since switched to power-saving mode.
That was when it happened.
A triage note popped up with a ding.
“Uh... what kind of patient is this...?”
And then, before I had time to take in the situation, the stretcher cart pulled in by the EMT rolled toward me.
On it lay a man who looked to be in his mid-fifties, clutching his stomach.
He wore a crumpled but still expensive-looking suit, and a gold watch gleamed from beneath his sleeve.
I stood up.
“What brings you in?”
I moved beside the stretcher and asked in the most businesslike voice I could.
“Doctor! My stomach! It feels like my stomach is twisting apart!”
With a groan that made it hard to tell whether he was exaggerating or serious, the man pointed to his lower right abdomen.
“Ever since last night I felt like my digestion was off, and this morning it started stabbing, and now it feels like someone is stabbing me with a knife! I’ve thrown up a few times too!”
As I listened, I rapidly ran through my differential diagnosis in my head.
Right lower abdominal pain, tenderness, vomiting, low-grade fever...
This was basically a textbook question.
Classic appendicitis symptoms.
I put on latex gloves and began examining his abdomen.
“This is where it hurts, right? I’ll press here.”
I gently pressed with my finger on McBurney’s point, the expected location of the appendix between the navel and the right pelvic bone.
“Ah!”
The man screamed.
Tenderness was positive.
“I’m letting go now.”
I quickly lifted my finger away.
“Aah! It hurts more when you let go!”
Rebound tenderness was also positive.
I performed a few more tests as well.
Rovsing’s sign, where pressing on the lower left abdomen causes pain in the lower right abdomen, and the psoas and obturator signs, where pain is triggered when the right leg is raised or rotated inward.
All were positive.
Everything pointed to appendicitis exactly as the textbook said.
The diagnosis was now about 90 percent certain.
All that was left was to check inflammatory markers with blood tests and confirm the swollen appendix on imaging, either CT or ultrasound.
I was about to order routine labs and an abdominal CT.
Just then, the man slapped my hand away.
“Hey, doctor! Why are you dawdling like that?”
He pointed at his stomach and said in a voice full of irritation.
“Can’t you tell at a glance? We need to get a CT first, quickly!”
I stared at him in disbelief.
“Sir, first we need to do blood tests...”
“What blood test, for heaven’s sake!”
The man cut me off. With a very learned expression, he began lecturing me on medicine.
“Do you know how much medical information I’ve been digging through since last night without even sleeping? I typed in all my symptoms, and this might not even be something like appendicitis!”
With a very serious face, the man began presenting his research findings.
“From what I found, this could be diverticulitis, or maybe that thing... early Crohn’s disease, the one a lot of young people get? Right lower abdominal pain doesn’t automatically mean appendicitis! Doctor, you should study a little more too!”
I was speechless.
Diverticulitis usually causes pain in the lower left abdomen, and Crohn’s disease’s main symptoms are chronic diarrhea and weight loss.
I could only admire the man’s perfect misdiagnosis.
“So there’s no time to draw blood or anything! Let’s get a CT first, doctor! That’s how we’ll find the exact cause!”
I pressed hard at my temple.
I swallowed a deep sigh.
Ah, here we go.
Step 1 of the coping method.
First, begin the conversation by acknowledging the patient’s knowledge.
“Sir, you must have studied a lot overnight. Right lower abdominal pain isn’t always appendicitis, of course. We can certainly consider diverticulitis or Crohn’s disease as possibilities. That’s a good point.”
My soulless praise spread a smile across the man’s face that seemed to say, ‘I do know a thing or two, don’t I?’
The first step was a success, at least.
Now, on to the main point.
“Sir, there are a few things we need to check before we do the CT.”
I tried to keep my tone as kind and logical as possible.
“First of all, drawing blood takes a lot less time than going for a CT. The results come back in about 30 minutes too. As for the CT, there are a lot of emergency patients queued up ahead of you, so you’d have to wait a bit.”
A time attack. One of the most effective strategies in the ER.
“And once we draw blood, we can get exact numbers for things like how severe the inflammation is inside your body and how high your white blood cell count is. Those results help us judge how urgent your condition is right now, and what exactly we need to confirm with the CT. They’re a big help in setting the direction of the diagnosis.”
I looked at the man with bright eyes.
“Whether it’s appendicitis, diverticulitis, or Crohn’s disease, if it’s an inflammatory disease there will definitely be abnormal findings in the blood test. Checking that first is the proper order. Will you trust me and follow my lead? Please?”
The man closed his mouth as if at a loss for words for a moment.
He still looked displeased, but with the explanation that bloodwork would be faster and the plausible medical basis for checking inflammation markers, he seemed unable to find any more reason to keep being stubborn.
“Ahem...!”
The man gave an unnecessary cough, then reluctantly held out his arm.
“Fine! But draw it quickly! Don’t dawdle!”
I let out a sigh of relief inside.
Phew, at least he was reasonable.
“Nurse Jung!”
The nurse looked up.
“Room B-10, routine labs and CRP please! Could you draw blood?”
“Ah, yes!”
Nurse Jung smoothly wheeled the blood-draw cart into the treatment room.
I didn’t forget the courtesy line to soothe the man’s remaining anxiety.
“I already have my own suspicions from your symptoms, so we’re going to go ahead and get an abdominal CT right away. While the blood test results are coming back, we’ll prepare the CT in advance. So don’t worry too much.”
At my words, the man’s face finally softened a little.
I quietly returned to the station.
***
The internet guy’s blood test results and CT scan took some time to come through.
In the meantime, the emergency room doors opened and closed without pause.
“Uuugh... blood... blood...”
As a glorious remnant of a dawn drinking binge, a college student who had fallen after drinking and split open a 10 cm gash in his forehead was brought in, supported by his friends.
The wound was deep, and the bleeding was heavy.
With drunk rambling as background music, I performed local anesthesia with lidocaine, cleaned the filthy wound, and then carefully stitched it up with nylon sutures.
The college student’s desperate plea to leave as little scar as possible was already being drowned and mashed into mush by the anesthesia and alcohol.
Sorry, buddy, this isn’t plastic surgery.
“My whole body is itching... swelling up... and breathing is...”
A beekeeper whose whole body had swollen up like hives after being stung by bees also came rushing in, in a state just short of anaphylactic shock.
I secured his airway first, gave an intramuscular epinephrine injection, and pumped him full of steroids and antihistamines.
Only after I confirmed that the wheezing had gradually eased could I finally breathe a sigh of relief.
After frantically handling three or four more patients like that, several dozen minutes had already flown by.
The man was fading completely from my mind.
Just then, a small notification window popped up at the lower right of the EMR screen.
At last, the internet guy’s CT images and lab results appeared.
I clicked the mouse and opened the images.
Abdominal CT.
As expected, it was appendicitis.
But...
It was in far worse condition than I had thought.
A normal appendix should be about the thickness of one finger, but this man’s appendix was swollen to more than 1.5 cm, almost as thick as a thumb.
The wall had thickened, and the surrounding fatty tissue had turned murky from inflammation.
Fat stranding... check.
There was even an appendicolith, a little stone-like mass, lodged at the end of the appendix.
And the most important part.
Part of the appendix wall looked faintly discontinuous, and there appeared to be a small amount of air and dirty fluid pooled around it.
‘...Perforation
(* perforation)
suspected.’
I swallowed dryly.
It was a ticking time bomb.
I needed to check the blood results too.
White blood cell count over 18,000.
CRP
(* C-reactive protein)
level over 15.
The inflammatory markers were high enough to pierce the sky.
Every piece of evidence pointed to one conclusion: if he didn’t go to surgery right now, he was screwed.
I stood up.
When I pulled back the curtain, the man was still lying in bed and groaning.
“Sir, your test results are in.”
I wheeled in a mobile monitor and brought the CT images up in front of him.
“This is a cross-sectional CT image of your abdomen. Over here in the lower right abdomen, you can see this swollen area. This is the appendix attached to the end of the cecum—what people commonly call the appendix.”
I pointed with my finger at the appendix swollen with inflammation.
“It’s swollen to more than twice its normal size, and the surrounding inflammation is very severe. If you look here, you can even see signs that the tip has ruptured a little, letting out pus and air.”
The patient grimaced and looked back and forth between my face and the monitor.
“Your condition is much more serious than we expected. If you don’t get emergency surgery right away, the inflammation could spread throughout your abdomen and progress to sepsis, and you could end up in a truly dangerous situation. You need emergency surgery immediately.”
“Surgery...?”
The man repeated it in disbelief.
Then anger and distrust rose on his face.
The man jerked his upper body upright and shouted.
“Surgery? Here? What are you talking about!”
He glared at me as if I were a fraud.
“If I need surgery, send me to Seoul! Now! You know Oseong Hospital, right? I’m a VIP there! I’m going to Oseong Hospital!”
He shouted, pointing at his stomach.
“I’m not getting surgery at some backwater hospital in Busan like this! Call an ambulance right now! I’m going to Seoul!”