Chapter 206

Episode 206 Thoracic Surgery (3)‌

"In the jugular vein distension..."

Jeong Jae-sang checked the patient's neck and hurriedly placed his stethoscope on the chest. His brow furrowed deeply.

"Decreased breath sounds! Heart sounds are barely audible! Bring the Echo quickly! Quickly!"

At his shout, the silence of the Thoracic Surgery Intensive Care Unit shattered. The nurses moved reflexively. In the midst of the chaos—nurses wheeling in carts, squeezing gel, and turning the defibrillator to standby mode—Jeong Jae-sang grabbed the on-call phone and pressed a speed dial number.

"Yes, Professor. This is Jeong Jae-sang, 2nd Year Thoracic Surgery resident. I'm sorry. I'm calling because the vitals of the patient in Bed 8, Jeong Hae-un, are crashing right now."

He poured out his report in a breathless voice.

"Systolic is 50, and CVP is 22. Auscultation shows signs of decreased heart sounds, and the jugular vein is distended. Delayed massive bleeding seems to have erupted from the pericardium and the area around the lower pulmonary vein, where adhesions were severe during surgery. Yes, yes. Clinically, tamponade is strongly suspected. Yes. Please come quickly. For now, I will perform an emergency pericardiocentesis ahead of time. I will prepare!"

I backed away into a corner where the monitor on the opposite side of the bed was clearly visible, staying out of the way to watch the situation.

Beep—

Beep—

Beep—!

The monitor was still displaying red numbers. If whatever was crushing the heart wasn't removed right this second, the patient would die right here on the ICU bed, not even on the operating table.

'This is bad...'

I immediately called upon the ghosts.

'I've seen plenty of tamponades in the ER, but this is my first time seeing a post-op patient develop tamponade in the ICU, so I don't know much about it.'

Flash.

A blue gallery window materialized in the void.

Dead Medic Gallery

Thoracic Surgery help save me

Author: Korean Slave 1

Patient went into shock on my first day of dispatch. Admitted for hemoptysis. Has a history of an unspecified heart surgery 15 years ago (severe adhesions). Had an RLL lobectomy yesterday. Right now, BP is 50, HR 130, and CVP is rising. The CS teacher suspects tamponade. Help quickly.

As soon as the post went up, the ghosts who had been grilling me all weekend rushed in fiercely.

Comments

Mes of the God: Hey, you brat. Are you whining just because I grilled you a bit last weekend? Of all things, you bring a trivial tamponade case?

↳ Korean Slave 1: No, but it's my first time in a Thoracic Surgery ICU too.

↳ Latte is Mine: Looking at the symptoms, it's definitely tamponade. It's all there. Well... tap it quickly and send him back up to the Operating Room.

↳ Thoracic Surgery Veteran: Tell him to be careful not to scrape the heart when puncturing if the adhesions are severe.

Operating Room Ghost 3: Just stick a needle in and draw the blood, what are you asking for?

The ghosts' reactions were nonchalant. It seemed that while post-operative tamponade due to bleeding in thoracic surgery was an emergency, it was considered a common crisis with a clear cause and solution.

"Gel! Please give me some gel!"

Jeong Jae-sang squirted a generous amount of gel onto the patient's xiphoid process and applied the probe.

"Ugh..."

He stared at the monitor. I also focused all my attention on the screen. Since all the clinical symptoms of cardiac tamponade were present and it was strongly suspected, under normal circumstances, the echocardiogram should show an image black with blood filling the pericardium.

However.

"...Uh?"

Jeong Jae-sang's hand hesitated.

"Uh?"

I also doubted my own eyes. Inside the pericardial sac or around the heart, there was not a single drop of blood or fluid retention that could put pressure on the heart. It was clean. It was incredibly dry.

Blood wasn't pooling and compressing the heart. Instead, a bizarre phenomenon was observed on the ultrasound screen.

Rumble—

When the ventricles were in diastole, filling with blood, the structure of the heart looked somewhat normal. However, the moment the heart entered systole, squeezing and decreasing in volume.

Bzzt—!

The entire image of the heart on the ultrasound screen was engulfed in white noise and went black. It was a phenomenon where nothing could be seen, just like a TV screen that had lost its broadcast signal. Then, when the heart relaxed and expanded again during diastole, the image of the heart reappeared like magic, as if it had never gone dark.

Disappearing when contracting.

Appearing when relaxing.

"What is this?"

Jeong Jae-sang's pupils shook.

"Is it a coronary artery air embolism? Or... is the bleeding pooling in the back and not visible? Why is the Echo breaking up like this? Is this air...?"

Flustered, he tilted the probe this way and that, but the phenomenon remained the same. There was no blood, and the heart kept disappearing. He couldn't be absolutely certain it was tamponade.

If it wasn't tamponade, he couldn't perform a puncture. Because there was nowhere to poke. Poking a perfectly fine heart would be murder.

"Sigh... The Echo is..."

While Jeong Jae-sang's mental state was collapsing, I felt a chill run down my spine. Anyone could see this was not a normal ultrasound pattern. I typed like crazy.

↳ Korean Slave 1: What is this?? There's no blood at all, but the ultrasound keeps shutting off during systole. It turns white like there's noise.

↳ Thoracic Surgery Veteran: ? What kind of bullshit is that. Did you miss the bleeding because you caught the wrong Echo view? It could be pooling in the back due to adhesions.

↳ Korean Slave 1: No, no, no, no, no, the view is fine. The subxiphoid view is accurate, but there's no blood and the image keeps flying away.

↳ Mes of the God: Hold on, hold on. This isn't cardiac herniation, wait, wait.

↳ Mes of the God: Can you bring the vent settings right now??? Quick.

I hurriedly turned my head toward the ventilator monitor at the head of the bed. Scanning the complex graphs and numbers... I typed them in.

↳ Korean Slave 1: FiO2 0.6, PEEP 8, Pressure Control Mode.

The moment I finished typing and pressed enter, comments from Mes of the God instantly began to flood the screen.

↳ Mes of the God: Hey, you fuck, AIR!!!!!!!! IT'S AIR!!!!!!!!!

↳ Mes of the God: Fuck, puncture it!!!!!!!! You're screwed!!!!!!!!!!

↳ Mes of the God: Hey, you crazy bastard!!! Stick it right now!!! Otherwise, the heart will burst!!!!

↳ Mes of the God: Even if there's no blood, you have to puncture!!! Puncture no matter what!!!!

↳ Mes of the God: Don't ask questions for now, just perform the puncture!!!!!! I'll write down the explanation later, so tell him to stick the needle in right now!!!!!!

There was no explanation. However, that overwhelming dread and urgency pierced through the text. Panic from Mes of the God.

There was no more time to think. The ghost's judgment, at least until now, had never been wrong. If we didn't puncture right now, this patient would die within a minute.

Jeong Jae-sang was still breaking out in a cold sweat, hesitating with the needle held mid-air.

"The blood... the blood..."

I had to shatter his hesitation. I snapped my head up and shouted so loudly that the Thoracic Surgery ICU echoed.

"Teacher!! You have to puncture!!!"

However, Jeong Jae-sang merely looked back and forth between the monitor in front of him and my face, his hand holding the needle trembling violently.

"Teacher, no fluid is being caught on the Echo... If so, the pericardium... If I attempt a puncture like this and stab the heart, it becomes murder..."

"Move!"

The countdown had already started.

'There is absolutely no time to convince him step by step.'

With every passing second, the patient's brain cells were suffocating and turning white. I roughly shoved Jeong Jae-sang's shoulder aside.

"Uh, ugh?"

While he stumbled back from the push, I snatched the brown povidone bottle sitting on the tray.

Splash, splash, splash!

I poured the betadine solution over the patient's xiphoid process and the middle of his chest.

"Give me the syringe!"

I snatched the 50cc syringe equipped with a thick and long 18-gauge needle, prepared for the puncture, right out of the nurse's hand.

'I trust you. If you're wrong, I die, the patient dies, and you won't be able to rest in peace either.'

I firmly pressed down on the patient's xiphoid process with my left hand to catch the landmark—the narrow gap where the ribs and sternum meet. Toward that space where the heart was crushed, crying out to be saved as it beat.

"Phew."

A short breath. And an entry without hesitation.

Thunk.

"Gasp..."

Jeong Jae-sang, who was watching from the side, drew in a breath. The heavy resistance of the sharp needle tip piercing the skin, passing through the subcutaneous fat, and penetrating the tough fascia traveled up to my fingertips.

I angled the needle down to 45 degrees. The target was the left shoulder—the safest and most certain route toward the pericardium.

'Please.'

The needle went a bit deeper.

Pop.

A very minute yet thrilling sensation of piercing through some tough membrane traveled up through my fingertips. It was the pericardium.

'This is it.'

I immediately pulled back the piston of the syringe with my right hand. If it were a typical tamponade, dark red blood should come gushing into the syringe here.

However.

Hiss—!

"......!"

It wasn't blood. What was drawn into the syringe was transparent air, devoid of color or form. With a sharp popping sound like air escaping a tire, the syringe piston was pushed up into the void.

The moment the pressurized air escaped, I turned my head.

"Check the vitals!"

Everyone's eyes locked onto the monitor.

Beep— Beep— Beep— Beep—

The arterial blood pressure waveform, which had been crawling along the bottom between 50 and 40, fluctuated as if responding to the sound of escaping air. The height of the graph began to soar like magic.

[ABP : 65/40]

[ABP : 80/55]

[ABP : 92/60]


"Uh... uh...?"

Jeong Jae-sang's mouth fell wide open.

"The vitals... they're coming back! BP 90! It's going up to 100!"

The heart rate, which had been frantic at over 130 beats per minute, dropped sharply into the low 100s, regaining stability. The compressed heart had secured space and began to pump blood powerfully once again.

I glanced over at the gallery window.

↳ Mes of the God: Cardiac tamponade caused by tension pneumopericardium. Extubate.

"Haah..."

To ensure the remaining residual air was completely removed, I emptied the syringe filled with air and pulled the piston once more.

Hiss—

This made it certain. It wasn't blood that had accumulated, but air.

Tension Pneumopericardium.

Air leaking from the lung surgery site had flowed not into the thoracic cavity, but inside the membrane surrounding the heart, tightly constricting the heart like an airbag. It fully explained why the heart couldn't be seen due to the ultrasound waves reflecting off the air.

He was saved. I wiped the cold sweat beaded on my forehead and let out a sigh of relief.

"Teacher. That... what just happened..."

Jeong Jae-sang was still staring at me blankly, seemingly unable to grasp the situation.

"It's tension pneumopericardium. Air filled up, which is why the Echo didn't show anything."

It was just as I calmly explained, removing the needle and about to apply pressure with gauze.

Whir—

The sound of the automatic door at the entrance of the ICU opening. And the air settling down chillingly.

I turned my head reflexively. Standing there with his arms crossed was a large man. A bushy beard. A tiger-like gaze. And that gaze was precisely scanning me, holding a needle to the patient's chest, a dazed Jeong Jae-sang, and the messy cart.

Professor Jo Kyung-woon, Chief of Thoracic Surgery and Director of Education and Training. His eyebrows twitched.

He didn't say a word. But that silence was scarier than any curse.

'First day of dispatch.'

'6:30 AM.'

'Carrying out a procedure without the professor's permission.'

'Even ignoring sterilization.'

Why on earth does this person show up at a timing like this?