Chapter 194

Episode 194 I am? A Detective (2)

Mes of the God (Male): Busted, boo. Acting like a know-it-all and turning out to be a quack.

ㄴ Latte is Mine: Boo, take off your fixed nickname. Just demote him to Ghost77.

ㄴ Pediatric Ghost: No, fuck, I’m in the neonatology subspecialty! ㅠㅠㅠㅠㅠㅠ

Inside the translucent window floating in the void, authoritative ghosts were having a keyboard battle like neighborhood elementary schoolers.

'The Pediatric Ghost is flustered? This is unexpected.'

Watching the highly anticipated Pediatric Ghost instantly turn into a local punching bag and get publicly mocked, I pulled my eyes away from the void without lingering regrets.

Even if they fought among themselves here right now, it wouldn’t make the patient's fever drop anyway.

I decided to keep looking at the computer chart, treating the gallery members teasing the Pediatric Ghost as background music.

"Hmm, let’s look a bit further then."

As I readjusted my grip on the mouse and spoke, Son Jongun, who was watching anxiously from the side, let out a sigh of relief.

"Yeah. Seeing you know about Kawasaki, I can leave you to it a bit longer."

To be honest, it is a huge discourtesy for a resident from another department to dig through the chart of a critical patient in a different department.

However, Son Jongun seemed to accept me as a perfect discussion partner. Or maybe he was just letting things take their course.

"Solu-Medrol was given at 500, and with no improvement, 625 was given the next day..."

Steroid pulse therapy.

It is an ignorant but most certain method of forcefully shutting down a crazy, rampaging immune system by slamming high-dose steroids into the body over a short period.

Pouring this level of high dose into a six-year-old child and having the fever not budge even an inch meant that the inflammatory storm brewing inside the child's body was so massive that it couldn't be controlled by human-made drugs.

"Driving you crazy, right, Hyunjae?" Son Jongun muttered, washing his face with his dry hands.

His voice was deeply saturated with self-reproach.

The most miserable moment as a doctor isn't when a patient is dying, but when you can't do anything because you don't even know why the patient is sick.

"It’s driving me crazy too," I answered honestly, glancing slightly to the side to peek at the comment section in the corner of my vision.

Among the ghosts fighting like elementary school kids, an informative nickname had finally appeared.

[Comments]

Rheumatology Old Woman: Hoho, if it's not Kawasaki, it's difficult. For now, the differential diagnosis is about systemic juvenile idiopathic arthritis, early-stage malignant tumor, or at worst, Macrophage Activation Syndrome (MAS) or Hemophagocytic Lymphohistiocytosis (HLH).

ㄴ Hippocrates' Descendant: Isn't that too many! How on earth are we to test for all of that!

ㄴ Latte is Mine: The old lady is right. But this information is as small as a rat's dick, so what can we do? We need more lab values and physical findings to get a handle on something.

'Sorry, ghosts.'

I apologized briefly in my mind.

From their perspective, since they could only receive real-world data through my eyes and hands, it was understandable for them to feel frustrated.

'I’ll organize it and give you a fresh update soon.'

I focused back on the chart and scrolled the mouse wheel. Moving past past records to look at the list of lab orders executed today, I spotted a notable item.

"Hmm? Ferritin was included in today's lab?"

"Uh, the professor wanted to check it once. To differentiate something like MAS (*Macrophage Activation Syndrome)..." Son Jongun replied with a exhausted voice.

"That makes sense. If so, you're leaning a bit more toward the possibility of a rheumatological disease right now?"

"Yeah. A consultation was sent to Professor Park Saengju in Pediatric Rheumatology. Anyway, since Pediatric Cardiology is looking at him right now... the professors are putting their heads together too."

A horrible complication where macrophages run wild and devour the body's own cells. If it was that, steroids wouldn't even cut it, and they would have to pour in anticancer drugs or immunosuppressants.

"You're going through a lot, Jongun."

"Don't mention it."

I opened the physical examination printout sheet. Among the physical records, a single phrase caught my eye.

[Skin: Livedo reticularis on both lower extremities]

"There's livedo reticularis too. Can I check this directly myself in a little bit?"

A symptom where the skin develops a bluish, mottled, net-like pattern due to a circulation disorder in the blood vessels. It can appear briefly when it's cold, but if it shows up in a patient with such a high fever, it becomes a very strong clue for systemic vasculitis or an autoimmune disease.

But you can't tell just by looking at the text. I had to see the pattern with my own eyes, press on it, and check the spreading pattern.

At my request, Son Jongun trailed off, looking troubled.

"Ummm..."

It was quite burdensome for a resident from another department, who wasn't even the primary doctor, to go and personally touch a ward patient, especially a critically ill one with an unknown cause. The guardian might be sensitive, and if anything happened, the lines of responsibility would get complicated.

Unable to make a decision, Son Jongun looked back.

Just then, at the end of the station, a resident with the embroidered marking 'Pediatrics Kim Hyoeun' was visible, organizing charts. She stared intently toward us, then promptly raised her hand and threw a thumbs-up with a very determined expression.

"I entirely agree, Teacher! Just having Teacher Han Hyeonjae take a look is something to be grateful for!"

"...What kind of image do you even have among the juniors?"

"I don't think that's a rumor I started."

Son Jongun shook his head as if it was absurd.

‘What else would it be but a crazy bastard who cuts open bellies in the ER.’

"That's not what's important right now."

"Right. I'll explain it well to the guardian, so..."

It was right at that moment.

"Uh... Uh, Teacher! Labs are up...!"

Teacher Kim Hyoeun, who had been giving the thumbs-up, shouted urgently while looking at her monitor.

Son Jongun sat up straight and said, "What is it, what's the problem now?"

He grabbed the mouse and pressed refresh.

Click.

On the screen, the results for the immune tests and inflammatory markers sent out this evening uploaded in a row. The first thing that caught my eye was the immunoglobulin level.

[IgG: 450 mg/dL (Low)]

[IgM: 30 mg/dL (Low)]

"Hmm? Immune deficiency? Or consumption?" I muttered while looking at the screen.

IgG and IgM, the proteins responsible for immunity, were falling far below the normal range. This meant it was either a congenital immunodeficiency where the immune system couldn't function at all, or an insane inflammatory reaction was occurring somewhere in the body, completely consuming the immunoglobulins.

But that wasn't the real problem.

The moment my gaze landed on the item below that, I couldn't even breathe.

"Jongun. Look down there..."

At my trembling voice, Son Jongun's gaze also shifted downward.

[Ferritin: 1,250 ng/mL (▲▲)]

"..."

"..."

The ferritin level of a normal child is at most dozens, or a hundred units at best.

"Oh, shit."

It meant a catastrophic state where the macrophages, which were supposed to protect the child's body, had completely lost their minds and were devouring normal cells and organs indiscriminately.

Macrophage Activation Syndrome, or Hemophagocytic Lymphohistiocytosis.

Whichever it was, if they didn't put out the fire right now, the pediatric patient would die of multiple organ failure.

I quickly snapped my fingers to summon the interface into the void.

[Camera Mode]

Click. Click. Click.

I quickly took pictures of the entire lab result window and the latest progress note into the system, leaving them in the gallery.

Korean Slave 1 (Male): (Picture) (Picture) (Picture)

Setting the screen aside for now, I looked next to me to find Son Jongun already running around the station, shouting orders.

"Hyoeun, go look at Doyun's condition! Quickly! Go check if his vitals are shaking!"

At that sound, Pediatric Resident Kim Hyoeun jumped up from her seat.

"Uh, Teacher Park Hyeonjin, please look for a PICU bed right this second! If there's no vacancy, let's move Seonwoo in general ward 17 a day early! And we'll stop Solu-Medrol right now and switch to Dexamethasone! Check it since the order went through EMR!"

Son Jongun shouted various orders to the nurses.

Switching the type of steroid. It meant he was placing his bets on Dexamethasone, which crosses the blood-brain barrier better and has a more powerful anti-inflammatory effect in line with the protocol.

Turning pale, Son Jongun panted and turned back to me.

"Hyeonjae, thanks for coming! I... I have to report to the professor right now..."

In this crazy situation, how could he have the leeway to look after a junior colleague from another department?

"Hey, hey, I’m not leaving! I told you I’d help!"

"What can you even..." Son Jongun tried to blurt out in a surge of emotion but caught himself.

He seemed to hold back from asking how someone from Emergency Medicine would know about a pediatric ICU patient.

"Ah. No. Forget it. Yeah. If you help, I'd be grateful. Keep watching the labs here and wait, or follow Hyoeun and double-check the kid's status."

"Okay."

Hardly had my answer dropped before Son Jongun pulled his phone out of his gown pocket and busily made a call. His fingertips were trembling minutely.

"Ah, yes, Professor! I'm the 3rd-year pediatrics resident, Son Jongun. Yes, yes. No, the fever isn't dropping. It's not that, it seems MAS has broken out just now. The ferritin level that just came out is..."

Leaving behind Son Jongun, who was making a desperate report over the phone, I followed Kim Hyoeun, who had grabbed a stethoscope and was running toward the patient room.

While striding rapidly across the hallway, I pulled up the gallery screen in the void once more.

[Dead Medic Gallery]

With just a few pictures I had thrown in, the ghosts' discussion was already ablaze.

ㅇㅇ(121.188): Isn't there a missed abscess tucked away somewhere? A micro-abscess not seen on CT, located in a blind spot like behind the liver or under the diaphragm?

ㄴ Latte is Mine: Hey you guy, aren't you reading the chart? Blood Culture was sent out 3 times and they all came back clean. If an abscess ruptured, bacteria would have grown in the blood. Rejected.

Hematoma is Hell: What about the possibility of leukemia or lymphoma? In pediatrics, there are cases where a malignant tumor is hidden and only drives up inflammatory markers like crazy.

I busily moved my fingers while walking to leave a reply.

ㄴ Korean Slave 1 (Male): When I looked earlier, Blast was 0% on PBS (*Peripheral Blood Smear). No tumor cells seen.

ㄴ Hematoma is Hell: Even if PBS is clean, it can be lodged inside the bone marrow. Still, at this point, it feels worth trying a bone marrow biopsy.

Korean Slave 1 (Male): Correct. For reference, ferritin just hit 1300, so he's being transferred to the ICU urgently.

Instantly, new comments in the gallery came to a dead halt.

Leaving a bombshell behind, I ruthlessly turned off the gallery window.

Drrrrrt—

The door to room 612 opened, and I headed toward the window-side bed inside along with Kim Hyoeun.

The child's mother, who had been sitting by the bed with a haggard face, hurriedly stood up as the doctors rushed in.

"Te... Teacher?"

"Mother, we’re just going to take Doyun’s temperature one more time."

Kim Hyoeun pulled out a thermometer and carefully began explaining to the guardian. Meanwhile, I circled to the opposite side of the bed and approached the child.

"Hello? I'm a doctor, can I take a quick look at your legs?"

The limp child merely stared at me, lacking even the strength to resist. I carefully rolled up the child's patient pants above the knees.

The record I saw in the chart earlier. Livedo reticularis.

'This is it.'

Over the small, white skin of the legs, mottled subcutaneous hemorrhage and vascular congestion marks were clearly visible, looking as if a purple spiderweb had been spun over them.

'Capture.'

After turning the child's legs this way and that to check the pattern of the lesion, I accessed the gallery again and threw the pictures in.

Korean Slave 1 (Male): (Picture) (Picture) The livedo reticularis pattern looks like this.

And then I brushed the window away. Rather than waiting for the ghosts' analysis, focusing on the patient in front of my eyes came first.

Beep.

"The fever is... 39 degrees Celsius," Kim Hyoeun said in a dark voice, checking the thermometer.

'It's still severe.'

Despite an enormous amount of antipyretics, antibiotics, and steroids being poured in, dropping a mere 1 degree from 40 degrees was everything. The flames were not being caught at all.

"Mother." Kim Hyoeun opened her mouth toward the guardian as if she had made up her mind. "Doyun's condition has worsened significantly. We need to move him to the intensive care unit."

"What? No, you said the fever would drop if he got this injection, this steroid thing or whatever! You clearly said he would get better if we used the medicine! But suddenly the intensive care unit?!"

Kim Hyoeun couldn't bring herself to meet the child's mother's eyes properly and lowered her head.

"I'm sorry. It's because there's a value in the blood test items that just came out that is very bad. The inflammation has become too severe, so it's too dangerous to handle Doyun's condition in a general ward..."

A mother bursting into tears and a 2nd-year resident handing over a consent form with a trembling voice. It was a scene I had witnessed countless times, but my chest felt heavy every time I saw it.

I silently pulled the blanket over the child, left the patient room, and headed back to the station.

"Yes, Professor Jeong Yujin."

Even though we arrived at the station after seeing the patient, Son Jongun was still holding onto the phone, in the middle of a call.

Professor Jeong Yujin? Pediatric Hematology-Oncology?

Calling a hematology professor instead of infectious disease or cardiology meant they had ultimately judged it as MAS and decided to run the treatment protocol accordingly.

"Yes, yes. It seems we need to dispense Etoposide. Yes, that is correct. I will prepare the HLH-2004 protocol. Yes, yes, CT and bone marrow should go out too. Yesss... Yes. You're coming directly? Understood."

Etoposide. It is a cytotoxic anticancer drug. It meant they were backed into such a dead end that they had to administer anticancer drugs to literally kill off all the immune cells of a six-year-old child.

Click.

Hanging up the phone, Son Jongun collapsed into his chair and looked up at me.

"Oh, Hyeonjae. Did you see the kid? Did you find anything new?"

"It seems more like a typical vasculitis finding rather than a simple skin rash."

I casually turned my gaze to the gallery window floating in the right field of my vision.

Pediatric Ghost77, who had been squished into a corner earlier after being publicly mocked for only practicing neonatology, was posting comments like crazy after seeing my pictures.

[Comments]

Pediatric Ghost77: Found it.

ㄴ Pediatric Ghost77: Did you think I wouldn't know this just because I only see neonates! This is neither Kawasaki nor PAN!

ㄴ Pediatric Ghost77: Once the patient stabilizes—no, stabilize him and shove him into an emergency brain MRI right away!!

I blinked my eyes.

"...Huh?"

He has a fever, cholecystitis broke out, ferritin is skyrocketing, and a net-like vasculitis appeared on his legs.

But suddenly the head? Shove him into a brain MRI?