Chapter 21 : ER (3)
Chapter 21 - ER (3)
[System: There is a recommended item.]
[Would you like to use the Potion of IPPA (Grade D)? Y/N]
What entered his field of vision was not the scenery of the Emergency Room, but a new notification window.
[Potion of IPPA (Grade D) — The user's senses are dramatically improved for a short period of time. (1,000P / Cannot be stacked)]
It was an item he wondered if he would ever have a use for while working as a psychiatrist.
Sihyeon immediately touched 'Y.'
Ding-dong!
[System: The effect of the Potion of IPPA is activated.]
[Time remaining — 2:59]
Whirr.
Along with the notification sound, a faint light began to swirl around Sihyeon’s fingertips.
‘Is this... improved senses?’
The sensation of air brushing between his fingers was as vivid as stroking the texture of paper. Even from the tube of the stethoscope he held in his left hand, he felt an elasticity that was clearly different from before.
Lub-dub— Lub-dub—
He began to hear the patient's heart sounds even without using the stethoscope.
Focusing a bit more, he could distinguish between the first heart sound (the sound of the atrioventricular valves closing) and the second heart sound (the sound of the aortic valve closing).
‘The second heart sound is faint. Is it because his blood pressure is low?’
[Time remaining — 2:39]
Time was ticking away even while he was marvelling at the effect of the potion.
‘First, let’s find where the blood is leaking.’
The important thing now was to find and specify the trauma site.
“I’m going to examine your abdomen again.”
Sihyeon asked for the patient’s understanding and began to examine him once more.
‘What is this?’
As he lifted the patient's gown, bluish bruises were revealed across the chest and upper abdomen.
These were things that were not visible at all until just a moment ago.
“Mr. Jeong Seong-hwan, when did these bruises appear?”
“Bruises? Where are there bruises?”
Both the patient and the guardian wore bewildered expressions.
‘How is this possible?’
It seemed the distinct bruises visible to Sihyeon were invisible to their eyes.
“Have you perhaps bumped into something or injured your chest recently?”
“I don't think so... Ah!”
The patient suddenly clapped his hands.
“I collapsed once the day before yesterday. I heard that people passing by were startled and performed CPR on me. I have no memory of it at all.”
“Ugh, that’s why you need to stop drinking so much. Did you black out from drinking again?”
“No! I didn't drink this week. I'm serious!”
“Really? What’s come over a man who drinks 366 days out of 365?”
The guardian had an incredulous look on her face.
‘A sudden change in consciousness in a patient who enjoys drinking...’
The conversation between the two piqued Sihyeon’s interest.
“Did you really not drink recently? Please tell me exactly. This is an important matter.”
“Of course! I haven't been drinking because I felt my body wasn't in good shape lately. Why would I lie?”
“…….”
“Fine. I had exactly one glass. Four days ago. I couldn't help it because of a team dinner with the staff...”
Seeing him confess, it seemed true that he had hardly consumed any alcohol recently.
‘If that’s the case...’
Sihyeon nodded slowly.
It felt like the puzzle pieces were falling into place belatedly.
……
Alcohol Withdrawal Syndrome.
A symptom that appears when a person who drinks every day suddenly stops or reduces their alcohol intake. Mild symptoms include hand tremors, insomnia, and anxiety, but in severe cases, the person may lose consciousness and suffer seizures.
The reason the patient did not remember getting injured was due to the seizure accompanied by loss of consciousness.
“Now that I hear you say it, this area does feel a bit stiff.”
The patient pointed toward his chest.
‘The location is a bit strange.’
Sihyeon tilted his head.
Generally, the location for chest compressions when performing CPR is the lower 1/2 of the sternum. However, in patient Jeong Seong-hwan’s case, the location was closer to the epigastrium and slightly shifted to the right.
“I’m going to examine you a bit more.”
Sihyeon immediately placed his left middle finger lightly on the patient's abdomen and began to tap the second knuckle of that finger with his right middle finger.
It was the exact examination technique he had learned in medical school.
While percussing the right abdominal wall while slightly changing the patient's posture, he felt a subtly dull sensation starting from a certain point.
‘Dullness? It’s too early for the liver to appear yet.’
Normally, it was a spot where a tympanic sound (the sound of gas distension, a ringing sound) should occur.
‘Is it ascites? Or hemorrhage?’
Even if it wasn't a large amount, there was a definite possibility that fluid was pooling in the patient's abdominal cavity.
“Mr. Jeong Seong-hwan, did you happen to have liver disease? Or ascites?”
“I’m not sure. They did say I had fatty liver.”
The patient’s reaction was that this was the first he’d heard of it.
‘Could it be?!’
Sihyeon carefully pressed the patient’s right upper quadrant.
“Ouch!”
A scream burst out reflexively. He had simply missed it because of the severe chest pain, but there was also severe pain when his abdomen was pressed.
‘The abdominal wall is tense!’
So-called abdominal guarding. It was a state where the abdominal muscles were unconsciously tensed to protect the abdominal organs.
‘To think I almost missed this...’
Organ damage due to incorrect chest compressions. While the patient briefly lost consciousness due to alcohol withdrawal, the people around him began CPR without knowing the cause.
Deep compressions at 100 times per minute. If you press the correct point, it can make a stopped heart beat again, but if done incorrectly, it was no different from beating the abdomen.
A situation where liver damage and resulting intra-abdominal hemorrhage were suspected. Sihyeon headed straight for the station.
……
“Are you done seeing the patient? How is he?”
“Psychiatrically, there are no special symptoms. But he’s complaining of abdominal pain?”
Sihyeon observed Chae Yi-jin’s reaction while feigning ignorance.
“Abdominal pain... not chest pain?”
As expected, Chae Yi-jin’s reaction was one of surprise.
“Yes, it was in a spot slightly shifted to the right of the epigastrium.”
“It’s not typical, but there are cases where patients occasionally complain of abdominal pain in angina or myocardial infarction. Wouldn't it be right to view it that way?”
Chae Yi-jin seemed to think little of the patient’s abdominal pain.
“Still, how about doing an abdominal CT scan...”
“By whose authority are you ordering a CT?”
Right then, someone cut Sihyeon off from behind.
“Our department will handle that on our own. I’d appreciate it if you would only worry about psychiatric matters, Doctor. How was the patient?”
Internal Medicine third-year Nam Hye-mi asked irritably.
“It appears there was a recent alcohol withdrawal seizure. The patient reported experiencing a loss of consciousness.”
“Loss of... consciousness?”
Nam Hye-mi’s eyes widened at the fact she hadn't managed to grasp.
“I understand that’s a part easily overlooked unless a very meticulous history is taken... I was amazed that you didn't miss it even in such an emergency and requested a consultation!”
On the other hand, Sihyeon put on an expression of sincere admiration.
“Weren't you concerned about that part as well, which is why you requested the consult?”
Nam Hye-mi, who had cleared her brain and requested the consult without a single thought, simply gaped like a fish, her expression saying, ‘Me? I did?’
“T-That’s a given for an internal medicine doctor. So, why are you insisting on a CT? What’s the rationale?”
“First, there was tenderness in the upper abdomen. Based on the history, trauma is suspected, and upon examination, there appeared to be a small amount of fluid collection (a state where fluid has pooled).”
Sihyeon began pouring out the findings he had just gathered from his examination.
“You want me to trust your physical (physical exam)? His belly isn't even noticeably swollen; how on earth did you find a small amount of ascites? Do you have an ultrasound probe attached to your finger or something?”
Nam Hye-mi reacted as if she were appalled.
“It’s a situation where hemorrhage is suspected rather than ascites,” Sihyeon corrected her.
‘What is with this guy?’
She had called him to get a formal psychiatry consultation note because she heard the patient drank a lot, but he gave the impression that he had suddenly performed an intense internal medicine exam.
“I don't know if it's ascites or bleeding, but if you're so determined to put in an order for an abdominal CT, do it under your own name. I don't want to hear complaints about over-treatment for no reason.”
“Yes, I will do that.”
She thought he would back down appropriately after that, but Sihyeon immediately sat at the station PC and began entering the additional prescription.
— Contrast-Enhanced Abdominal CT [EMERGENCY]
‘Is he ignoring me right now?’
She was a third-year resident. No matter the department, wasn't she his senior by two years in medical school?
Nam Hye-mi was seething inside, but because of the words she had already spoken, she couldn't say anything more and simply avoided the spot.
“Dr. Chae Yi-jin, could you check the CT images when they come up later? I’ll ask the radiology resident on duty for the reading.”
Taking advantage of Nam Hye-mi’s brief absence, Sihyeon asked Chae Yi-jin to check the images and then left the Emergency Room.
……
20 minutes later.
‘What is this? Liver laceration and Hemoperitoneum (blood in the peritoneal cavity)??’
Chae Yi-jin could not take her eyes off the CT images that had just been uploaded.
‘Dr. Cheon Si-hyeon was right.’
The patient was in a state of ongoing hemorrhage due to abdominal trauma. While monitoring whether the unstable angina would progress to a myocardial infarction was important, the patient’s life would be in danger if the bleeding wasn't stopped.
‘At this rate, a medical accident...’
To make matters worse, they were currently pouring in antithrombotic agents to prevent the heart vessels from clogging. These drugs could make the abdominal bleeding even more severe.
“Yawn. Did the CT from psychiatry come up?”
Returning to the Emergency Room after a long while, knowing nothing, Nam Hye-mi asked indifferently.
“How is it? Nothing much, right? As I thought...”
“Yes, it’s right here.”
Chae Yi-jin brought up patient Jeong Seong-hwan’s abdominal CT images on the monitor.
In the next moment, an earthquake erupted in Nam Hye-mi’s pupils.
“This... I need to noti the professor. Or should I? Should I contact the Hepato-Biliary-Pancreatic Surgery (the surgical sub-specialty for the liver, biliary tract, and pancreas) resident on duty first?”
She, too, had never seen a patient with heart disease and a liver laceration at the same time until now.
“Dr. Chae Yi-jin. This patient’s abdominal CT... our Internal Medicine department prescribed it. Understood? The abdominal exam was also done by our department.”
“Pardon? But the abdominal CT order was placed earlier by the psychiatry doctor...”
“Other departments can’t see psychiatric records anyway. As for the order... right! Just say it was accidentally placed from a PC that was logged in with Dr. Cheon Si-hyeon’s ID. If the professor finds out about this later, we’ll be in trouble. Got it?”
Even in the midst of her panic, Nam Hye-mi’s mind was working excessively well to avoid disciplinary action.
“Is this the patient?”
While Nam Hye-mi was panicking while looking at the CT images, someone approached from behind and asked.
[Trauma Surgery Professor Gang Baek-hyeok]
“Yes, this is the liver laceration patient I mentioned earlier.”
The resident standing next to Gang Baek-hyeok answered.
[Surgery Resident Yu Geun-ung]
“Professor, hello.”
Nam Hye-mi and Chae Yi-jin stood up simultaneously and bowed toward Gang Baek-hyeok.
“You’re working hard seeing a difficult patient. Dr. Chae Yi-jin, is it manageable?”
“Yes, Professor. The senior residents are helping me a lot.”
Gang Baek-hyeok, after hearing Chae Yi-jin’s answer, looked at Nam Hye-mi and said,
“Dr. Nam, please take good care of her.”
“Yes, Professor,” Nam Hye-mi answered with a gentle smile. It was a look 180 degrees different from when she was hounding Chae Yi-jin.
“I’ll discuss this patient directly with Professor Kim.”
“Pardon? Ah, thank you, Professor.”
Since it was the dawn hours, she had been reluctant to call the on-duty professor, but to think the professors would settle the coordination among themselves. Nam Hye-mi cheered inwardly.
‘But why?’
However, something was strange. As soon as the abdominal CT results were confirmed, and even before she could call the surgical resident on duty, the on-duty professor of that department had appeared.
“Did you contact GS (General Surgery) first?”
“No. I also just confirmed the test results.”
Chae Yi-jin was equally bewildered.
……
The parking lot in front of the Emergency Medical Center.
“Regarding that patient, Professor Gang Baek-hyeok spoke directly with Professor Kim Jin-hong of Cardiology. They decided to start with emergency surgery first and then immediately follow up with a PCI (Percutaneous Coronary Intervention).”
“I’m sorry for calling you so late.”
Sihyeon and Yu Geun-ung were sitting on a bench, having a conversation.
“Don't be sorry. I was awake anyway because there was another emergency surgery scheduled.”
Yu Geun-ung said as he gulped down vending machine coffee.
“But how did you know Professor Gang Baek-hyeok would go straight to the ER? Even I didn't expect that.”
“It’s a unique case. Ischemic heart disease and intra-abdominal hemorrhage at the same time... Doesn't Professor Gang love that kind of thing?”
“Is that so?”
Yu Geun-ung tilted his head.
“It’s already time to go into surgery. Good luck! Hang in there for the rest of your duty!”
Yu Geun-ung glanced at his watch and hurriedly went to prepare for surgery.
Ding-dong!
[System: Patient Jeong Seong-hwan’s treatment progress increases!]
[Treatment Progress 21 -> 44/100 | Until Discharge: 14 days 4 hours 21 minutes 18 seconds]
[Survival Probability 51%]
A welcome notification window. The survival probability was now over half.
‘Perhaps this time...’
A satisfied smile spread across Sihyeon’s face.
— I hope you don't overdo it. Every change comes with a price.
Choi Se-young’s warning had vanished from his mind before he knew it.
Many things had changed.
But whether in the past or the present, Sihyeon’s role was incredibly clear.
‘It’s my job. Something I must never avoid.’
In the next moment, a familiar notification sound rang out again.
Ding-dong!
[System: The user’s will resonates with the system.]
[A new function is being activated!]
Flash.
The empty parking lot where Sihyeon stood was suddenly engulfed in a bright light.