Chapter 196

Episode 196 Me? I'm a Detective (4)

"It would be better to take a DWI (diffusion-weighted imaging), right?" Son Jong-woon asked.

"Hmm, I suppose so. A full routine MRI takes too long, and there's no way the kid will cooperate. But with vitals like this, we can't just give him sedatives or sleeping pills either..."

Jung Yoo-jin's judgment was precise.

DWI.

It was the fastest and most accurate technique to catch cerebral infarctions—ischemic lesions. It required no contrast agent, and the scan time was brutally short, lasting only a few minutes.

After all, what we were trying to find were merely the traces of lacunar infarctions caused by vasculitis.

"Yes, we can just do a quick DWI and wait for him to come back up."

"Then who should go... Hm... Kim Hyo-eun?"

"Yes, yes, Professor!"

Kim Hyo-eun, who had just returned to the station after stabilizing the patient's condition in the ward a moment ago, answered in a tense voice.

"Do you want to go down with him? We don't know when the kid's vitals might fluctuate."

"Ah... Yes! I will do that! I'll prepare right away!"

"Yeah. Thanks."

Clack-clack-clack.

The sound of typing, fast enough to break the keyboard, filled the air before Son Jong-woon spun his chair around to report.

"I submitted it as an emergency. They said to send him down right away."

"Alright."

"But Professor, since the kid's condition is what it is, shouldn't I, as the chief resident, go down myself—"

"Go where?" Jung Yoo-jin cut Son Jong-woon off. "You just wait here too, until the PACS images come up."

"...Yep. Understood."

Son Jong-woon turned his gaze back to the monitor.

I very naturally shifted my eyes toward the void, listening to the ghosts' secret tutoring session.

Korean Slave 1 (Male): Then, based on the mechanism, if etoposide had been given earlier, his bone marrow would have melted too?

Pediatric Ghost: He's already immunodeficient from a lack of blood cells, so pouring in etoposide, which stops cell division altogether? Well, yeah. Pretty much.

Rheumatology Old Woman: I gave some help for this diagnosis too. Vasculitis is my specialty, after all. Hoho.

Korean Slave 1 (Male): Then is the treatment a TNF inhibitor?

Pediatric Ghost: Yep, exactly. Because DADA2 stimulates M1 macrophages to spew out an enormous amount of TNF-alpha. So you have to use a targeted therapy that directly inhibits that TNF-alpha.

'I see.'

I subtly pushed the ghosts' explanation window to the far edge of my vision and quietly waited at the real-life station, keeping my hands modestly folded in front of me.

As much as possible.

With the face of an innocent resident who didn't know anything.

It was then.

"By the way, it's quite fascinating," Professor Jung Yoo-jin suddenly spoke up.

"Pardon?" Son Jong-woon asked back, startled.

"No, not you, Jong-woon. Him."

Jung Yoo-jin's fingertips pointed at me.

"Are you classmates?"

"Ah, yes. We were medical school classmates..."

"So that's why you called him. There was a rumor that a genius was among your classmates, so you called him out of sheer desperation. But it turned out he actually is a genius? Is that how it went? It couldn't have been a lucky guess."

Son Jong-woon laughed awkwardly, breaking into a cold sweat.

"Ah... haha. Yes, well, there are some rumors like that, and I'm also close with Hyeonjae..."

"Good grief." Jung Yoo-jin clicked her tongue. "Then why didn't you know it was DADA2?"

"...Pardon? But you didn't know either, Professor..."

Smack!

A crisp, satisfying hitting sound echoed sharply through the station. Jung Yoo-jin's palm had landed perfectly right on Son Jong-woon's back.

"Ah, sharp inhale, ah, seriously, Professor! I'm being serious!" Son Jong-woon twisted his back, tears welling up in his eyes.

"I connected the clues and understood it immediately because this genius friend pointed it out. You didn't get it even after hearing it. There's a clear difference," Jung Yoo-jin shot back confidently.

In fact, she wasn't wrong.

The difference between a fellow and a resident lay in the volume of knowledge, but also in the ability to judge whether a new hypothesis fit the patient's clinical presentation when it was thrown at them.

"Ah... sharp inhale... Yes, Professor..." Son Jong-woon spoke up, sounding wronged. "But it feels like Hyeonjae's title suddenly changed from 'the Emergency Medicine guy who just throws out a rough diagnosis and sends the patient up' to 'a genius' just a moment ago..."

Jung Yoo-jin raised her hand high.

"Want another one?"

"No, ma'am." Son Jong-woon bowed his head at the speed of light.

"Hurry up and study. He's your patient. What DADA2 is, what the mechanism is, why we shouldn't use etoposide, and what the treatment is."

"Yep!"

From a corner of the station, I quietly watched the scenery of the Pediatrics chief—who had been clinging to me and pleading just a while ago—now tearing his hair out while frantically digging through Up-to-date and PubMed.

Son Jong-woon's eyes grew wider and wider as he clicked the mouse.

"Professor."

"What."

"There are only about 600 reported patients? Not just domestically, but worldwide." Son Jong-woon pointed at the review paper on the monitor, speaking as if it were absurd.

A disease first discovered in 2014. An ultra-rare genetic disease with only hundreds of cases diagnosed across the entire world.

"That's right," Jung Yoo-jin answered casually.

"Then I'd like to carefully offer the opinion that perhaps it's normal not to be able to answer right away..."

"Are you going to stay ignorant your whole life just because it's a rare disease?"

"No, ma'am. Using today as a turning point, I'll dig deeper into the differential diagnosis of rare diseases."

Only then did Jung Yoo-jin nod, looking satisfied. "Good."

"Then, so that I can diagnose any patient at once in the future, I'll read every single case report for all rare diseases...!"

For some reason, Son Jong-woon was suddenly burning with an overwhelming passion. However, Professor Jung Yoo-jin cut down that burdensome enthusiasm in a single stroke.

"Forget it. No need to go that far. How are you going to cram tens of thousands of rare diseases into your head? When I say study rare diseases, I just mean that at the level of a pediatrics resident, you should know how to properly suspect them when a patient doesn't respond to routine treatment."

"Oh, wait, really?"

"It's obviously good for a resident to study rare diseases. But this kind of thing is the job of a specialist with accumulated clinical experience. That's why we exist, and that's why subspecialties are divided. Residents should just build a solid foundation."

Jung Yoo-jin placed a hand on her forehead as if she suddenly remembered something.

"Ah, right. I need to contact Professor Park Saeng-joo too. The patient is currently admitted under Professor Park, right?"

Professor Park Saeng-joo of the Pediatric Rheumatology division. He was currently Heo Do-yoon's official attending physician. He was also the person who needed to know first that this entire board had been flipped upside down.

While the two were busy discussing the attending physician, I had already finished cheating perfectly by looking at the gallery in the void.

'Etanercept and Adalimumab... Bone marrow transplant...'

A treatment guideline for DADA2 fed to me in real-time by the ghosts. How nice.

Son Jong-woon was busy answering Jung Yoo-jin's questions.

"Ah, yes, yes. He was initially seen by Cardiology, but after being judged refractory to Kawasaki disease, he was admitted under Professor Park Saeng-joo today. I did report to him earlier when the ferritin levels rose... Should I call him on the phone again?"

"No, forget it. What are you going to explain? Are you going to tell him an Emergency Medicine resident suspected DADA2 so you took an MRI? The professor will grab the back of his neck. I'll just leave a text message."

"Yep, Professor."

Jung Yoo-jin pulled her smartphone out of her gown pocket and started typing rapidly. Watching that scene blankly, her gaze suddenly shifted toward me.

"Hey, genius friend."

"...Ah, yes, Professor!" I answered hurriedly at the sudden call, straightening my posture.

"Why Emergency Medicine?"

"Pardon?"

A foolish sound slipped from my mouth at the incredibly direct and unexpected question. Jung Yoo-jin tilted her head, scanning me from head to toe.

"With that level of knowledge, it's normal to go to a department specialized in diagnostics. There's Internal Medicine, where they rack their brains to find the name of a disease, there's Pediatrics, Laboratory Medicine, and Radiology too."

She was asking why, with a brain that could connect clues so tenaciously and pull out a rare disease nobody knew about in an instant, I chose Emergency Medicine—the very definition of broad but shallow knowledge.

I scratched the back of my head awkwardly.

She probably thought I came here out of a grand sense of duty, or some magnificent ambition to save patients on the front lines of life.

"My grades were mediocre, and I got a B-turn during my internship."

I couldn't get into popular departments. And I hated vital departments where I had to be on-call constantly. So, the department I chose was Emergency Medicine.

"...Tsk. Right. Well, school grades aren't everything when it comes to clinical skills." Jung Yoo-jin nodded without pressing further. "So, what's the treatment?"

Uh. A surprise question attack.

"If it's DADA2, you have to give a TNF-alpha inhibitor. If you're right, what specific drug are you going to use?"

I confidently brought out the model answer the ghosts had drilled into me.

"I'm thinking of Enbrel."

The most representative TNF inhibitor with proven safety.

"Enbrel? That's a subcutaneous injection. The effect will be slow. Don't you have any intention of giving Remicade, which can be injected directly into the vein instead?"

It was a test. A test of whether I properly knew the treatment methods for this disease. But why was she testing me on this?

"I understand that Remicade lacks long-term data regarding DADA2." I slowly poured out the knowledge I had just learned piece by piece. "Even in literature, Enbrel has the most stable and definitive data accumulated for vasculitis symptoms and stroke prevention in DADA2. I believe it's right to hold the immediate fire with the high-dose dexamethasone currently being administered, while bringing in Enbrel as the inhibitor."

"We'll go with that for the medication." She nodded slightly, accepting my opinion. "Then what's the long-term cure plan? It's a genetic defect, so just giving medication won't solve the fundamental cause."

The final question. The answer a Professor of Hemato-Oncology would be most curious about. And the answer she wanted the most.

"I understand there is no definitive cure other than a hematopoietic stem cell transplant. There is no choice but to transplant bone marrow from a healthy donor to plant new immune cells that can produce normal ADA2 enzymes."

"Right. Hematopoietic stem cell..."

It was just when Jung Yoo-jin murmured softly, her expression turning complex.

"Professor. The images are up."

The brain MRI images that had been pushed through as an emergency just a moment ago had been uploaded to the PACS system.

"Ah, shoot, look at the timing."

Jung Yoo-jin hurriedly stepped in front of the monitor and clicked the mouse.

Click.

As the image popped up, a black-and-white cross-section of the brain filled the monitor. Jung Yoo-jin slowly turned the mouse wheel.

Then, small, brightly shining white dots appeared within the black-and-white screen.

Clear ischemic lesions shining in white.

"Ah..." A groan escaped Son Jong-woon's mouth.

Multiple lacunar infarctions that occurred as very small microvessels became blocked.

"It came out," Jung Yoo-jin murmured quietly.

"Even so, it's a relief. It's lacunar, and for now, the number..." Son Jong-woon let out a sigh of relief as he rolled the mouse. "And for the location, at this level... it narrowly avoided the motor nerves or critical areas."

It was a crisis where, if things had gone wrong, the kid might have had to live with hemiplegia or a speech impediment for the rest of his life. But they had caught the cause before it was too late.

Jung Yoo-jin slowly straightened her back. Then she turned her head and spoke toward Son Jong-woon.

"Hey. Jong-woon."

"Yes, Professor?"

"Let's put in the order. Enbrel, 25 milligrams."