Chapter 96
“More precisely, we approached it as damage control rather than definitive treatment.”
I gripped the microphone in my hand a little tighter.
“As for your question about the role during that gap period, I’ll explain that in detail again in the conclusion of my presentation.”
I turned toward the audience without giving the questioner any more room to object.
‘Phew. I didn’t tremble.’
“All right, let’s continue the presentation.”
I stepped out from behind the stiff podium.
‘Worth it for all the TED talks I binged on YouTube yesterday. Walk like Steve Jobs. Naturally.’
I started making light gestures with my hand.
“This is the case we encountered.”
Click.
The slide changed.
[Slide 3: Case - Patient Presentation]
“The patient was a 54-year-old man…”
I recalled the horrific events of that day, which I had reviewed until late last night while checking the data.
“He arrived on foot, wearing construction work clothes, accompanied by a coworker acting as his guardian.”
I put emphasis on the word on foot.
“As you can see, there had been no advance call from the ambulance crew. He was, quite literally, a patient who walked straight through the emergency room doors.”
“The patient’s chief complaint was…”
Click.
A horrifying photo appeared on the screen.
It was a rusty piece of rebar, caked with dirt and cement, as if it had been photographed at a construction site.
A low groan rose from the audience.
“It was a penetrating abdominal injury caused by rusted rebar.”
Click.
The rebar photo slid to the corner, and the record from the time of arrival appeared.
[Initial vital signs: BP 60/palpable, HR 130/min, RR 30/min]
“The initial vital signs measured immediately on arrival showed BP 60, heart rate 130, and respiratory rate 30. By ATLS classification, this was clearly Class IV shock.”
I paused for a moment and looked over the hundreds of doctors seated in the audience.
“Yes, as everyone here knows, the survival probability of a patient like this is extremely low.”
Click.
Next slide.
[Slide 4: Case]
“We immediately moved the patient to the resuscitation room and performed a FAST ultrasound according to protocol.”
Click.
“That allowed us to confirm a massive hemoperitoneum.”
Click.
The next text appeared.
[MTP
(* Massive Transfusion Protocol)
activated, O-type Rh-negative blood transfusion started]
[No blood pressure response despite continued fluids and transfusions]
“We immediately activated MTP and began transfusing uncrossmatched O-negative packed red blood cells. However, despite forcing the fluids and blood in with pressure bags, the patient’s blood pressure did not respond at all and stayed around the 50 mmHg range.”
I steadied my breathing.
Now came the climax of the buildup.
“Now, in an emergency room, there’s one name that comes to mind first in a case like this. That is…”
Click.
Four huge letters were stamped in the center of the screen.
[Trauma Surgery]
“Exactly. Trauma surgery is the department that handles severe trauma patients. Naturally, we immediately called the trauma surgery team.”
I took one more step toward the edge of the stage.
“However, our hospital’s best trauma team, the team responsible for trauma care that day, could not care for this patient immediately.”
Pop.
A vivid red text box covered the screen.
[Trauma surgery team: arrival delayed by at least 15 minutes due to another emergency surgery]
The lecture hall began to murmur again.
For this patient, 15 minutes was no different from a death sentence.
“At least 15 minutes. Time this patient was not allowed to have.”
I looked back at the Aseong Hospital doctor who had been glaring at me.
“Then what options do we have?”
Click.
Time for slide 5.
[Slide 5: Emergency Medicine-Led Resuscitative Laparotomy]
The murmuring in the lecture hall once again fell into perfect silence.
“That’s right. An emergency resuscitative laparotomy.”
As the presentation reached its peak, my body began to tremble.
Stay calm.
You’ve run through this simulation many times already.
“We, the emergency medicine team, decided to perform an immediate laparotomy in the resuscitation room under emergency medicine leadership as the only and final means of preventing imminent death.”
Click.
[Midline incision performed]
[Massive intraperitoneal hemorrhage of approximately 4 L or more and Grade 4 splenic rupture confirmed]
“We made a midline incision from the xiphoid process to just above the pubic symphysis. Immediately after opening, the visually confirmed intraperitoneal bleeding was about 4 liters or more.”
Click.
The next slide appeared.
“We initially secured our view by suctioning out the blood pooled in the abdominal cavity…”
The conference hall began to murmur again.
“Here is how we identified the splenic rupture.”
A new title and diagram appeared on the screen.
[Four-quadrant packing]
“What you see on the screen is a simple anatomical diagram that divides the abdomen into four regions. Immediately after opening the abdomen, we confirmed bleeding so massive that it was impossible to secure a view. We immediately performed four-quadrant packing, the basic principle of damage-control techniques, packing the entire abdominal cavity with gauze and compressing it to induce temporary hemostasis.”
I pointed the laser pointer at the right side of the diagram.
“The upper right quadrant, that is, the region where the liver is located, and the lower right quadrant were both fine. Even after removing the packs, no additional bleeding was observed.”
I moved the pointer to the upper left quadrant.
The audience’s gaze followed the red dot in unison.
“But the moment we removed the pack from the upper left quadrant, where the spleen is located…”
The memory of that day came back vividly.
The horrifying moment when blood surged up again.
“We confirmed that uncontrolled arterial blood was gushing out.”
I looked straight at the face of the Aseong Hospital doctor who had been glaring at me.
“We immediately confirmed the splenic rupture and repacked the area to completely control the bleeding, and only then could we finally wait for the surgical team.”
Pop.
[Slide 6: Case - Surgical Treatment and Course]
[Door to OR?]
“After the initial damage-control packing in the emergency room, the patient was transferred in a temporarily stabilized condition to the emergency operating room in the emergency medical center building. Upon arrival, the waiting trauma surgery team immediately performed a splenectomy…”
Now it was time to show why I had stood here.
[Slide 7: Patient Prognosis]
[Discharged without neurological complications after ICU and ward treatment]
A photo of a man filled the screen.
He was a middle-aged man dressed in neat everyday clothes.
“This photo was taken seven months after the accident and shows the patient as he is now. I attached it with the patient’s consent, with his face blurred.”
I could feel the tension that had filled the lecture hall melt away at the sight of this one photo.
Murmuring started again, but this time it was admiration and relief, not shock.
“As you can see, he’s in remarkably good shape.”
I smiled as I recalled the rough conversation Professor Kang and the patient had that day.
“They even traded jokes.”
Click.
The touching photo disappeared.
I adjusted my grip on the presenter.
That’s the end of the heartwarming part.
A new slide appeared.
[Slide 8]
[The Role of an Emergency Medicine Doctor: How Far Does It Go?]
I could feel the air in the lecture hall grow cold again.
“Delay in surgical intervention….”
I began reciting the logic I had memorized perfectly while slowly scanning the audience.
“This is not uncommon in medical reality, both in Korea and abroad. In particular, it is an even more serious problem in secondary hospitals that are not regional emergency medical centers like ours, or in local hospitals where surgeons are not on duty 24 hours a day.”
I nodded.
“The patient we were dealing with was in no condition to wait 15 minutes for a surgeon to arrive.”
I paused and posed a question to the audience.
“Then should an emergency medicine doctor remain only in that passive role of stabilizing the patient and handing them off?”
I met the eyes of the Aseong Hospital doctor who had thrown a provocative question at me earlier.
The screen flashed.
[Shouldn’t we bridge this treatment gap to save the patient?]
The lecture hall was silent enough that not even a breath could be heard.
I immediately brought up the next slide.
[Slide 9]
Half of the screen showed the cover of an unfamiliar paper.
[Paper Screenshot: Case Report…]
I pointed the laser pointer at the English title of the paper.
“This case involved a 19-year-old woman with blunt cardiac rupture.”
The professors seated in the front row frowned.
“At the time, Niigata University Sado Hospital, which was responsible for this patient, was in a situation where immediate intervention by a surgeon was impossible.”
“And so.”
I put force into the next sentence.
“An emergency medicine physician performed an emergency thoracotomy directly in the emergency department resuscitation room and directly repaired the ruptured left ventricle.”
“Wow…”
“Crazy…”
The murmurs rolled in like waves.
“They sewed up a heart in the ER.”
“And it was an EM doctor.”
I confirmed the reaction and brought up the next slide.
Pop.
[Result: Patient survived with favorable neurological outcome]
“The patient survived. Not only did he survive, he survived with a favorable neurological outcome.”
I highlighted the paper’s conclusion section.
[Conclusion: …continuous education systems and guideline consensus are needed so that regional emergency medicine physicians can perform surgical procedures.]
“This was a paper published in the Journal of the Japanese Society of Emergency Medicine just four years ago.”
I asked the audience.
“This paper from the neighboring country poses the provocative question, ‘Should emergency medicine doctors become temporary surgeons?’ and concludes, ‘Yes. If necessary, we need to build an education system.’”
I pressed the presenter button.
The final slide.
[Slide 10: Conclusion and Proposal]
“This is the conclusion.”
I drew in a breath.
“I dare to propose that more proactive training in REBOA and selective damage-control techniques like the one we used, along with interdisciplinary discussion, may be necessary in emergency medicine residency training.”
The screen turned black.
The presentation was over.
I plugged the microphone into the stand and bowed 90 degrees to the audience.
“That is all. Thank you.”
…
Silence.
The chairman fell silent.
There was no applause or murmuring.
The hundreds of doctors who had listened to such an arrogantly delivered presentation stared blankly at the black PPT screen.