Chapter 208

Episode 208 Thoracic Surgery (5)

That way, we safely finished the morning rounds and gathered in the doctor's office meeting room at ten minutes before 7 o'clock. As if they had made a promise, residents with zombie-like appearances started coming out one by one from the corners of the wards, the ICU, and the duty room. A sitting man saw me and stood up.

“I’m Hong Seonho, a 4th-year resident, and I'm serving as the Head of Doctor's Office for Thoracic Surgery.” He rubbed his hollow eyes and extended his hand to me.

Honorifics? What a respectful gentleman with excellent character.

His face coexisted with the enlightenment and fatigue that a gentleman who had survived for four years in Thoracic Surgery would naturally have. I quickly bowed at my waist.

“Ah, yes. Hello. I am Han Hyeonjae (Male), a 3rd-year resident in Emergency Medicine. I’m dispatched here for two weeks. I look forward to working with you.”

“Ah, I heard about you. I heard you wrapped up a situation in the ICU earlier where an accident almost happened...” He shook my hand and stared intently at my face. “...But your face looks like someone I’ve seen somewhere before.” He tilted his head.

I felt the same way. He was probably one of the numerous residents from other departments I had frequently encountered in the Emergency Room. Or perhaps he was a person who was watching from the side when I was throwing a fit in the Emergency Room.

Don't know.

It felt like the memory was just on the tip of my tongue. Hong Seonho was staring at me with a similar look in his eyes, but perhaps his brain cells went on strike because of his fatigue, as he seemed to give up on trying to remember any more than that. Since it seemed like we both didn't notice, let's just move past it for now.

At that moment, a woman with a rather small build popped out from behind Hong Seonho.

“Hello! I am Ju Minyeong, a 1st-year resident in Thoracic Surgery!” Despite her booming voice, the dark circles under her eyes had dropped all the way down to her jaw, creating a bizarre disharmony.

“Uh... Ah, nice to meet you. But...” Without realizing it, I looked her up and down. “A 1st-year resident in Thoracic Surgery...” My words trailed off.

Thoracic Surgery resident applications were known to be dried up nationwide. But to think that there is a 1st-year resident? Still, that was too much of a slip of the tongue.

“It sounds like you're asking why there's a 1st-year resident here,” Hong Seonho chuckled, reading my inner thoughts.

I hurriedly waved my hands in denial.

“Oh, no. Not at all. I just thought an excellent talent had joined... And, well, I figured your motivation for applying must be incredible.”

At my excuse, Ju Minyeong smiled brightly and replied, “I just failed to run away! I was packing my bags to escape, but while packing in the duty room, I decided to close my eyes for just a moment... and I ended up sleeping until morning, missing the timing to leave!”

“...”

“When I opened my eyes, Teacher Hong was standing there holding a gown! Hahaha!” She suddenly barged into the conversation and blurted out a deeply sorrowful story as if it were some heroic tale. To think she got kidnapped because she fell asleep while trying to run away. I didn't know whether to laugh or cry.

“...”

A brief silence flowed through the meeting room. Hong Seonho cleared his throat to control the situation.

“It’s a joke. It's a joke she makes often. She applied because she genuinely wanted to do it herself. Though, of course, she probably regrets it now.”

“No! I sincerely love Thoracic Surgery...!” Ju Minyeong shouted with lifeless eyes.

I nodded with a bitter smile.

“But Chief,” I looked around at the people gathered in the meeting room and asked cautiously, “Can this hospital really run with this many people? Can you cover everything?” No matter how I looked at it, there were far too few people. I couldn't even see a 3rd-year resident.

Hong Seonho shrugged his shoulders. “Ah, there's one 4th-year guy who is off today. If you include him, there are four residents, so...”

“So since there are four...?” I waited for the rest of his words. Since there are four, you are working yourselves to death?

However, Hong Seonho continued with a very proud expression on his face. “With this number, wouldn't we be in the top tier nationwide for the number of Thoracic Surgery residents? Excluding the Big 5, having four residents at a regional private university hospital makes us practically the Avengers.”

“...”

I lost my words. Four residents are blocking all the heart surgeries, lung surgeries, ECMO, ICU care, Emergency Room calls, and ward care that run 24 hours a day, 365 days a year? And that’s considered top tier? This place is crazy. Absolutely crazy.

A short time passed, and it was exactly 7 o'clock. The sound of shoe heels walking in a group started to be heard from the hallway.

Creak.

The meeting room door opened, and a crowd wearing white gowns flooded in. The first person to walk in was Professor Jo Kyeongun, the Thoracic Surgery Section Chief who had glared at me earlier as if he wanted to kill me. Following behind him was Professor Han Ihyun, who had saved me earlier. And then the Lung Cancer Center Chief, the esophagus specialist professor, the heart specialist professor...

One person. Two people. Three people... They kept coming in without end. They naturally occupied the seats of honor and the center table, while we residents were naturally pushed to the corners.

I blankly counted the number of people. Three residents. One dispatched resident. And nine professors.

...Shit.

There was never an inverted pyramid quite like this. There were four disciples who needed to receive teaching, but nine masters to teach them.

This isn't an educational setting; it's a hearing.

Section Chief Jo Kyeongun adjusted his glasses and shot a fierce look toward our side. “Alright, let’s begin.”

My breath caught in my throat. It was hard to even breathe under the pressure radiating from the nine professors. I cried out in my mind, Please save me, please.

“...As for this week's announcements, they are asking us to pay more attention to sterilization. Since words came down from the Infection Control Room and the QI team as well...” Hong Seonho read down his notebook with a reluctant expression.

At that, Jo Kyeongun raised his head. “Especially,” he crossed his arms, “Sterilization,” he narrowed his eyes, “Please be careful.” Jo Kyeongun's gaze aimed precisely at the space between my eyebrows.

What the.

I feigned ignorance, avoiding his gaze and pretending to scribble with my pen. Why are you staring at me, Section Chief? I told you it was because it was an emergency. If I saved the patient, that's all that matters.

Though I grumbled on the inside, on the outside, I put on the expression of the most apologetic resident in the world and quietly bowed my head. If our eyes met here, it was obvious I would be publicly executed.

“For now, let's push back one regular surgery today and discuss the emergency surgery that needs to go in right away at 8 o'clock. That patient whose chest burst earlier.”

Professor Han Ihyun, who was sitting next to him, connected his laptop as if he had been waiting for this and abruptly pulled up a presentation.

“This is a case operated on yesterday by Professor Yu Jun from the General Thoracic Surgery department. It occurred after an RLL Lobectomy...”

On the screen, the patient's pre-surgery CT picture and the chest X-ray picture taken by Jeong Jaesang this morning appeared side by side.

“...Currently, a pigtail catheter has been used to keep it decompressed. Vitals are stable. However,” Professor Han Ihyun pointed at me with his laser pointer, “Teacher Han currently?”

“Ah, yes? Professor.”

“Earlier in the ICU, you strongly claimed that we needed to perform an extubation, but if we want to do a re-operation right now, we have to maintain anesthesia, so we won't be able to pull out the tube, right?”

“Ah. Yes. That... is correct.”

To perform general anesthesia surgery, a ventilator is essential. However, if a ventilator is connected, the positive pressure will cause air to keep leaking and press on the heart. It was a dilemma.

Professor Han Ihyun rested his chin on his hand as if intrigued and asked, “Then what should we do about this situation where we must perform anesthesia but cannot give positive pressure?”

“Hmm.” I rolled my brain. “Umm.”

The lung cannot do its job. No, we must not give pressure to the lung. Instead of the lung? A ventilator? No, that gives pressure. Breathing... breathing. Instead... of... the lung's role...

Is it ECMO?

An Extracorporeal Membrane Oxygenation machine that replaces the functions of the heart and lungs. If we run this, we can let the lungs rest.

“ECMO...?” As I cautiously uttered the word ECMO, Professor Han Ihyun's eyebrows twitched.

Hmm, looking at his expression, that's not it.

It was an expression that it was too excessive. Using general anesthesia and even attaching an ECMO just because some air is leaking would be like burning down the house to catch a flea.

“Let me think for a moment.” I quickly turned my gaze and opened the void window. To be exact, let me ask.

ᄂ Korean Slave 1 (Male): If we go into re-operation in this case, what should we do with the vent? Do we run ECMO?

ᄂ Mes of the God (Male): You crazy bastard, why would you run ECMO?

ᄂ Thoracic Surgery Veteran: If a lung popped, you just don't use that lung. One-Lung Ventilation, Double-Lumen Tube. Duh.

Ah.

Right. There are two lungs. My mind snapped awake at the scolding of the spirits. If air is leaking from the right lung, we just turn off the right lung and make the patient breathe using only the left lung.

“Uh... by using a DLT and setting it to a one-lung vent...?” I muttered, searching my memory. ...Ah, whatever. The professional details are the anesthesiologist's domain anyway.

I reached a conclusion with a serious expression. “I believe we must consult with the anesthesia department to perform one-lung ventilation. By blocking the ventilation of the damaged right lung and maintaining breathing solely with the left lung, we will be able to proceed with the surgery while preventing air leakage caused by positive pressure.”

At my words, Han Ihyun chuckled. “Well, that's correct. It's also a task that the anesthesia department needs to take the lead on.” He nodded as if satisfied and continued his questions. “Good. Then I'll ask just one more thing. In this patient's case, why on earth did pneumopericardium occur, and do you know why it manifested as a tamponade?”

Nine professors and three residents were staring only at my mouth.

“...Hmm.” I closed my eyes for a moment and ran a simulation in my mind. “Just a moment. Let me organize things for a second.”

Yesterday, the patient received an RLL lobectomy. That meant the right lower lung was cut right off. But why did this phenomenon happen?

“Let's assume that a microscopic air leak occurred because the wound did not heal perfectly at the cross-section where the lung was cut and sutured, meaning the bronchial stump or the lung parenchyma.” This was knowledge gained from being nagged all weekend long by Thoracic Surgery Veteran and Mes of the God (Male). Post-surgery air leaks were common.

“The patient was on a ventilator. The setting was at a PEEP of 8. That's a pretty high pressure.” In this case, the air that should have just leaked out in small wisps gets forcefully blown out into the thoracic cavity because of the high pressure forcibly pumped in by the machine. Up to this point, it was the mechanism of a pneumothorax. But why did it enter the heart? That was the problem.

“I understand that the patient had a history of receiving chest surgery in France 15 years ago.” I combined my knowledge with the patient information I heard from Jeong Jaesang earlier. “And looking at yesterday's surgery record, it says the adhesions were very severe. In the process of forcibly tearing and dissecting those adhesions, a microscopic defect was created in the pericardium.”

And I mixed in the knowledge obtained from being nagged by the spirits.

“Originally, the air leaking from the lung should normally fill the thoracic cavity. A pneumothorax should have occurred.” But by some twist of fate, a very clever hole happened to be punctured in the heart sac? “However, for this patient, the high-pressure air leaking from the lung naturally flowed into a portion of the pericardial tissue that was damaged during the process of dissecting the adhesions.”

Then, let's think about it carefully. Would the heart really be compressed simply because air entered? The air could just move in and out. If a pneumopericardium occurred, what was the reason it led to a fatal, tension cardiac tamponade?

There was only one answer. A structure where it can enter, but it cannot get out.

“It appears that a one-way valve, meaning a check valve mechanism, took effect.” I spoke with a voice filled with certainty. “When the heart enters systole, the volume of the heart decreases, creating a negative pressure inside the pericardium and leaving an empty space. At this time, the air leaking from the lung gets sucked into the hole.” That was the process of drawing it in.

“The problem comes after that. During diastole of the heart, that hole gets covered by the surrounding ragged flesh or adhesion tissue, closing like a valve. The air that entered cannot get out.” You can enter as you please, but you can't leave.

“Therefore, every time the heart beats, air just keeps stacking up step by step inside the pericardium without being able to escape. Just like continuously blowing air into a balloon. Consequently, a tension occurs where the pressure keeps rising.”

Finally, I clenched my fist to demonstrate. “In the end, that enormous air pressure squeezes the heart in the middle from the outside. Because the heart is crushed and cannot expand, it can neither receive blood from the veins nor pump blood into the arteries.” That was the phenomenon where the heart shriveled up and disappeared on the ultrasound.

“Accordingly, a cardiac tamponade occurred where the blood pressure plummeted... This is how I understood it.”

After finishing my explanation, I quietly shut my mouth. Only silence lingered in the meeting room. Nine professors were staring straight through me.

Was I wrong? The spirits were the ones who told me. There's no way it's wrong. Ah, should I have just cheated using the whole thing? Without mixing in my own thoughts.

Just around the time anxiety started creeping in on me, a single voice leaked out from somewhere, breaking the silence.

“Wow... .”