Chapter 190
Episode 190 Every Patient Does ( ) (2)
“Why? Why all of a sudden?”
I had just finished issuing the standard orders and was about to send the patient to the radiology department. The Patient's assessment was finished, the orders for the Check had Gone Outside, and it was a very standard flow where we just needed to wait while administering pain medication.
However, for me to volunteered to go back and check on a Patient I had Just finished screening—What At all did that mean? To say it was out of curiosity or academic enthusiasm, her Expression was entirely too serious. Did it mean she found something bothersome in my briefing?
“No, that strange mark Doctor Han mentioned,” Baek Eunseo (Female) said without taking her Eyes off the Chart. “Didn't you take a closer look at it?”
“Ah... that?”
I rewound my memory for a Moment. That faint trace visible when I pulled up the Patient's Clothes?
‘It was definitely hard to see because of the hair, though.’
It was a fact that the faint shape was difficult to recognize because it was obscured by the so-called belly hair and the contours of the Skin. Was it better to Check again? The Patient had answered rather bluntly that it was just a skin disease he usually suffered from. Since the Patient said so, I wondered if a Doctor really needed to go as far as bringing out a magnifying glass to be suspicious, so I had Just brushed it off lightly...
‘A mark on a diagonal.’
Should I have focused more on what appeared faint due to the hair? While pressing down with an alcohol swab? If you press down on the hair with an alcohol swab to make it adhere to the Skin, you can observe the color changes or boundaries of the epidermis hidden underneath much more clearly.
‘Is there a skin disease that appears diagonally, diagonally, diagonally?’
I tried to mobilize all the dermatological knowledge I knew. If it were shingles, it would form a band along the ganglion, but it is usually unilateral and accompanied by blisters and extreme pain. The bruise on that Patient Just now didn't have blisters, and he said his whole Abdomen hurt, not that only that specific area was burning. Psoriasis or eczema? There's no way something like that would appear perfectly diagonally.
While I was rolling my Head, Baek Eunseo (Female) continued speaking with a calm Voice.
“The shape you mentioned is a bit uncomfortable. Of course, based on the Patient's statement, there was no accident, so it is also true that the probability of Trauma is low, However...”
“Trauma.”
I mumbled that word Outside my Mouth without realizing it.
“Right.”
What if the diagonal trace crossing from the lower left navel toward the upper right flank, or in the opposite direction, was not a skin disease? If so, it is the result of powerful physical Pressure applied from the outside.
‘Especially since that sign occurs during a car accident.’
When a Car brakes suddenly or collides, the passenger's Body is thrown forward by inertia. At this Moment, the safety line, the Safety Belt, strongly compresses the sternum, pelvis, and lower Abdomen to hold the Body back. A clear subcutaneous hemorrhage left on the Skin due to Tremendous impact and friction. It Just looks like a bruise, but the presence of this mark means there was a deceleration impact strong enough for the Belt to dig into the Skin, and the probability of the Intestine underneath being crushed and bursting or tearing rises exponentially.
However.
‘That Patient said he didn't have one, even when I asked specifically about a car accident.’
He said he had Just stayed at home. Is there a reason for a Patient to lie to a Doctor? Unless they are an insurance fraudster, there is no reason to hide the fact of a car accident when they have crawled into the Emergency Room screaming that they are dying of pain. Unless, of course, it involves a crime like drunk driving or unlicensed driving.
‘I should have just taken a picture and asked the gallery later.’
After taking a Picture of the affected area and posting Just one line like [Is this a skin disease? Or Trauma?] on the Void Gallery, the spirits of each department who claim to be the best would have poured out dozens of differential diagnoses. With that dreadful Collective Intelligence of the spirits, the answer would have come out in a Minute. Why did I make a Judgment alone and leave, abandoning such a Good cheat key? Probably because I judged it as a Mild and easy case.
Even so, the fortunate thing was...
“But a CT will probably go out anyway,” I said, placing my Hand back on the Mouse. “Since gas isn't passing, it looks like an obstruction. So as soon as the X-ray comes out, the CT will probably go straight in...”
A state where gas is not discharged and a heavy tenderness across the entire Abdomen. Whether it's a paralytic ileus caused by constipation or a traumatic ileus where the Intestine ruptures due to a seatbelt injury, causing Blood to pool and the Intestine to rot, in the End, the only way to Check the exact condition inside the Abdomen with your own Eyes is to take an abdominal CT using contrast media.
I clicked the Mouse as it was.
Click.
The Blood test and X-ray prescriptions were transmitted.
“Is that so?” Baek Eunseo (Female) nodded her Head. “Then if we're going to take a CT anyway...”
“It doesn't matter if that trace is traumatic.”
Whether the bruise mark is a skin disease, a Safety Belt mark, or a mark from being hit by someone with a Baseball bat, the immediate sequence of treatment does not change. Take an X-ray, confirm that the Intestine is swollen, and then run a contrast CT to confirm whether the Intestine has burst or is blocked. If intestinal perforation or bleeding due to a car accident is confirmed, we can Call general surgery then and open the Abdomen.
“True,” Baek Eunseo (Female) replied with a bright Expression, as if agreeing with my logic.
The prescription had Already Gone Outside, and Now all that was left was to wait for the Patient to return from the radiology department.
“...”
I quietly stared at the Monitor where the transmission completion Window was displayed. My Head understood it perfectly, but What is this unpleasant sensation crawling up slowly from the tip of my sternum? The Patient's statement that somehow doesn't add up. The ambiguous tenderness spread across the entire Abdomen. The Symptom of gas not coming out. And the diagonal bruise mark that was hidden by hair, which he insisted was a skin disease.
“But let's go see him.”
“Pardon?”
Baek Eunseo (Female), who was about to sit in her Seat after agreeing, turned back to me with surprised Eyes. It was a gaze carrying the meaning of why go back to the Patient when we're going to take a CT anyway.
I stretched my arms out as far as I could.
“It feels uncomfortable.”
To an Emergency Room Doctor, discomfort is soon a reason to act. I got up from my Chair and Started to move my steps.
It was then.
Ding~
A cheerful notification Sound grabbed my ankle. I reflexively looked at the Monitor. The PACS System notification window was flashing.
[X-ray : Chest PA / Abdomen Erect & Supine Uploaded]
“...The X-ray is up.”
Having lifted my Buttocks to go touch his Abdomen, I stopped in an awkward posture.
“Oh, If so, it might be better to just look at the Image. You did the physical examination earlier, and making a Judgment with an objective Picture seems much better.”
“Yes. We should do that.”
I sat back on the Chair and brought up the Image.
Click.
First, the chest X-ray.
“Chest PA... nothing special. Lungs are clean, no free Air under the Diaphragm.”
It wasn't pneumonia, and there was no finding of Air floating upward due to a ruptured Intestine. Heart size was also normal. If so, the problem is the Abdomen. I clicked the abdominal X-ray window.
Click.
The Moment the black and white Picture appeared on the Monitor, groans escaped from my mouth and Baek Eunseo (Female)'s at the same time.
“Ah...”
“Ah...”
The small intestines, full of gas, were swollen and tangled together. The folds of the Intestine were clearly visible. It is a typical pattern that appears when the small intestine expands. On the other hand, in the large intestine or rectum area, which is the edge of the Picture, black gas shading was barely visible.
‘The small intestine is swollen and there are folds... but there's nothing in the large intestine or rectum area.’
I brought up the erect Picture. In the Picture taken while standing, AFL, where Air and Fluid separate to form layers, was stacked layer upon layer like stairs.
“The AFL is also distinct. Hmm.”
The Diagnosis was clear.
“It's an SBO.”
The small intestine was blocked. Food and gas that could not go down filled the small intestine, increasing the Pressure. This explains the reason Why the Patient said his whole Abdomen hurt and Why he said gas was not coming out.
“Yes, should I Call general surgery?” Baek Eunseo (Female) placed her Hand on the call phone as if she had been waiting.
I stared at her blankly.
“...Don't you have work to do? Why are you trying so hard to look after my Patient...”
You have your own patients too. However, Baek Eunseo (Female) replied energetically.
“If I've finished all my work, I'll take it as meaning I can make the Call instead.”
“Ha, wow.”
When did she change like that? Now she has completely become a sly old fox.
“Right, please do. I'll put in the CT order.”
I clicked my tongue and moved the Mouse. An X-ray Only allows us to know the fact that it is blocked, but we cannot know the reason Why it is blocked or whether the Intestine is rotting away. A CT is essential for an accurate Cause identification and a Decision on whether Surgery is needed.
I ordered an emergency contrast abdominal CT. In the meantime, Baek Eunseo (Female) finished her phone call with the general surgery On-duty doctor, hung up the Handset, ran over to my Side, and reported.
“For now, since it's a simple obstruction with no history of Surgery, they said to admit him and observe.”
“Hmm...”
It was the expected response. Textbook-wise, in the case of an intestinal obstruction without a past surgical history, the principle is conservative treatment—inserting a nasogastric tube to decompress, Fasting, and giving IV fluid while waiting, as it often resolves on its own. Unless there is a finding of strangulated obstruction that requires opening the Abdomen immediately, meaning a Situation where the Intestine is twisted and Blood cannot flow.
“Because it does resolve on its own sometimes. But the Patient's condition looked bad.” I muttered, leaning my chin on my hand.
That Cold Sweat from earlier. And the pale complexion.
“They said they think it'll be fine if we use pain medication. They said the pain will decrease once the nasogastric tube is put in and decompressed.”
“Really...”
Am I reacting too sensitively?
It was then.
Ding.
Another notification Sound rang. This Time it was the Lab.
“Oh, the Lab results are up.” Baek Eunseo (Female) pointed at the Monitor.
‘When did Time pass like this.’
I opened the results window.
Click.
[WBC 13,000] [CRP 2.5]
“Right, the inflammation levels are rising...”
If there is an intestinal obstruction, inflammation levels naturally rise. A white blood cell count of 13,000 is high, but it's not at the level of sepsis. I scrolled down quickly. Just in case it might be pancreatitis.
[Amylase 65 / Lipase 42]
“The pancreas is normal, and...”
It was the Moment I skimmed through the electrolyte levels and was about to check the liver figures and Kidney figures at the very End. My Gaze locked onto one Spot.
[AST 145 / ALT 112]
“...”
I stopped breathing for a Moment.
“Uh. Shit.”
Profanity popped out of my mouth without me realizing it. Baek Eunseo (Female) also opened her Eyes wide, looking surprised.
“Why is the liver like this?”
The normal level is below 40. But it had jumped well over 100. Because he drank a lot of Alcohol? Fatty liver? No, it's different from the pattern of a patient with chronic liver disease. It is acute. It means something is destroying liver cells at this very Moment.
‘Liver figures jumping in a simple intestinal obstruction?’
Is it ischemic hepatitis caused by a Shock where Blood doesn't go to the liver? No, the Blood pressure earlier was 130 over 80, which was perfectly normal. If so, drug poisoning? Or...
“Did necrosis progress after an internal hernia?”
If the Intestine slips into a hole somewhere inside the Abdomen, and Blood doesn't flow and it starts to rot, inflammatory substances can spread throughout the Body, causing liver figures to rise as a premonition of multiple Organ failure.
However.
‘It's too fast for that, though?’
The Patient said he had been hurting since Dawn Today. If the Intestine had rotted to the point where the liver figures hit triple digits in half a Day, the Patient's Blood pressure should be dropping and he should be burning with a Fever by Now.
‘Then, in the End, is it Trauma?’
I'll ask those bastards in the gallery about that later. First, the important thing. This is not a Patient to just watch.
“Eunseo.”
“Yes.”
Baek Eunseo (Female) answered immediately, as if she also detected the seriousness of the Situation.
“Call general surgery again.”