Chapter 213

Episode 213 Crazy Bastard (2)

Hong Seonho, a 4th-year resident and the Chief Resident of Thoracic Surgery, was having an absolute nightmare of a time.

Originally, the life of a thoracic surgery resident was barely human to begin with, but lately, the cause of his intense fatigue was not the pouring surgeries or the overnight duties.

The cause was a single person.

Han Hyeonjae, a 3rd-year Emergency Medicine resident who had been dispatched to their department a week ago.

He was a man whose name was always followed by the modifier "genius," whom professors from other departments praised so highly that their mouths went dry, and who was widely rumored in the ER to be a crazy bastard who didn't care about anything.

At first, Hong Seonho was also genuinely curious about exactly how crazy this person was, and what kind of great skills he was hiding to generate such rumors.

However, it didn't take very long for that curiosity to turn into exhaustion.

It was Friday morning, and the weekly Thoracic Surgery department-wide conference was held as always.

"This is a case of Boerhaave syndrome (*esophageal rupture) that occurred after vomiting, admitted through the ER 45 hours later. In this patient's case, they were admitted in a state where mediastinitis (*inflammation of the mediastinum) had already severely progressed..."

On the stage, 2nd-year resident Jeong Jaesang was pointing at the screen with a laser pointer as he went through his presentation.

"...That is all."

The presentation was good. 2nd-year resident Jeong Jaesang had always been a quite diligent and meticulous resident. He had cleanly organized the case of an esophageal rupture left neglected for 45 hours without any unnecessary fluff.

The problem came after that.

"Good job."

Section Chief Jo Kyeongun, who was sitting in the head seat with his arms crossed, scanned the slides with sharp eyes and opened his mouth.

"So, the dispatched doctor helped you with this presentation?"

Jeong Jaesang flinched and lowered his head.

"Ah, yes. Teacher Han Hyeonjae gave a lot of help during the night regarding organizing data and reviewing literature on surgical approach plans."

As soon as that answer fell, Section Chief Jo Kyeongun's head snapped precisely toward Han Hyeonjae.

"Then let me ask Doctor Han Hyeonjae."

Here we go again.

Hong Seonho swallowed a deep sigh internally.

The biggest problem Hong Seonho felt in Thoracic Surgery these days was that Section Chief Jo Kyeongun kept throwing questions at Han Hyeonjae, the dispatched resident, during every meeting time.

And those weren't questions at a 1st- or 2nd-year resident level, but vicious questions picked specifically to be something you would ask a specialist.

"The esophageal tissue must have already melted into a mushy state from the inflammation. Even if you try to suture it, it will all tear. Primary repair (*initial suturing) is impossible. You know that, right?"

"Yes, I know."

Han Hyeonjae answered calmly.

Watching that, Hong Seonho screamed internally.

Why do you know that, you dispatched resident! You belong to Emergency Medicine! Why are you nodding along about whether the esophagus is mushy or not!

"Right. Then what should we do to prevent this patient from immediately slipping into sepsis? Tell me the repair plan when you open up the esophagus in the operating room."

It was the moment Hong Seonho was fidgeting, shifting his buttocks as he debated whether he should step in to cover for him.

Han Hyeonjae stared into the void for a moment and then opened his mouth.

"Since the inflammation is severe, we abandon primary repair and insert a T-tube into the rupture site to create a path so that pus and leaking saliva can drain directly outside the body instead of into the thoracic cavity. We focus on drainage without forcibly closing the esophagus."

"And?"

"To prevent food and saliva from leaking around the T-tube and causing inflammation again, I would harvest a flap (*tissue flap) from the robust and blood-rich intercostal muscle (*rib muscle) or serratus anterior (*anterior serratus muscle) to encircle and protect the defect site."

"The preservation of blood flow for the flap used in that process is..."

Watching Section Chief Jo Kyeongun follow up with the next question, Hong Seonho felt his head spin.

No, why are you answering that, you crazy bastard!

Hong Seonho simply gave up thinking.

Esophageal reconstruction using a muscle flap. It was a surgical technique that could only be brought up after consulting with Plastic Surgery or by a high-year resident in Thoracic Surgery.

But why on earth does he know that?

The next presentation was by Hong Seonho's junior, 4th-year Cheon Yeongjun.

"Next is an 8-month-old pediatric patient admitted with Tetralogy of Fallot, TOF. This is a case operated on by Professor Seong Hyeonjin of Pediatric Thoracic and Cardiovascular Surgery, where relief of right ventricular outflow tract obstruction and patch closure of the ventricular septal defect were performed."

An incredibly complex congenital heart defect surgery. Cheon Yeongjun continued the presentation while breaking out in a cold sweat.

"...After weaning from the cardiopulmonary bypass machine, the patient is currently under observation in the ICU. That is all for the presentation."

As Cheon Yeongjun was about to bow and step down, Jo Kyeongun opened his mouth.

"Dispatched doctor?"

Section Chief Jo Kyeongun never failed to look for the dispatched resident whenever a conference was held. Throwing pediatric heart surgery questions at a resident from another department was nonsense in itself, but there was no one in this meeting room who could tackle him on it.

"Yes, Section Chief."

Han Hyeonjae stood straight up.

"Let's simulate the operating room situation."

Section Chief Jo Kyeongun's eyes flashed sharply.

"You've completely blocked the VSD (*ventricular septal defect) and widened the narrowed pulmonary artery side, and you just weaned them off the CPB (*cardiopulmonary bypass). But the infant's RV (*right ventricle) pressure suddenly jumped and rose higher than the systemic blood pressure."

Jo Kyeongun assumed the worst-case scenario.

"Point out what was missed in the operating room, and name two physiological variables that must be immediately adjusted before turning the ECMO or pump back on right away."

An insane level of difficulty. It was a question that would make even pediatric heart fellows break a sweat.

"Regarding the physiological variables, are you referring to adjustments through medication or vent settings?"

"That's right."

Jo Kyeongun gave a short affirmation to Han Hyeonjae's counter-question.

What do you mean, 'that's right'?

Hong Seonho's insides were burning up. The esophageal rupture earlier could arguably be seen in trauma or the ER, but physiological management after weaning from a heart-lung machine in a congenital pediatric heart surgery?

Even if an Emergency Medicine professor came, no, even if it were a general adult cardiac surgery specialist, this was an area they wouldn't know.

"Haha, well, Professor. For the dispatched teacher to answer, the difficulty is too specialized and peripheral..."

In the end, unable to take it anymore, Hong Seonho stepped forward to act as a shield in his capacity as the Chief Resident.

However.

"Seonho. Just a moment. I am not asking you right now, Seonho, I am asking the dispatched doctor."

"Yes."

At Section Chief Jo Kyeongun's chilling one word, Hong Seonho shut his mouth immediately. He couldn't step on the tiger's tail.

Hong Seonho was driven to near-madness. Looking at the dispatched teacher, Han Hyeonjae, who kept zoning out into the void as if he had lost his mind or hit a panic wall from reaching the limits of his knowledge, even he felt frustrated and sorry for him.

He should have just said he didn't know when I was covering for him.

Yet at that moment, focus returned to Han Hyeonjae's eyes as he stared into empty space.

"The cause is that residual stenosis (*remaining narrowing) was left at the distal part of the pulmonary artery in the operating room, and the pulmonary annulus (*pulmonary valve ring) still remains narrow, so blood from the right ventricle cannot escape, causing pressure to build up."

A precise diagnosis of the pathophysiology.

"The solution is to immediately change the vent settings through consultation with Anesthesiology to induce hyperventilation (*hyperventilation), thereby lowering the partial pressure of CO2 in the blood and inducing alkalosis. At the same time, nitric oxide gas must be injected to drop the PVR (*pulmonary vascular resistance) to the extreme."

His voice was incredibly calm, and the answer was so perfect that it was a textbook itself.

The dozens of thoracic surgeons filling the meeting room stared at the dispatched resident, completely losing their minds.

The one who broke the long silence was Jo Kyeongun. He slowly uncrossed his arms and straightened his torso, which had been leaning against the backrest.

"...That is correct."

Hong Seonho doubted his own ears. That fastidious and dogmatic Section Chief Jo Kyeongun accepted the perfect answer from a resident of another department without changing a single syllable.

And that wasn't all. Was it just his imagination that Jo Kyeongun's tone, which had been sharply edged toward Han Hyeonjae day by day, was growing softer?

...

* * *

...

On that day too, as always after lunch, I was buried deep within the sofa of the Thoracic Surgery doctor's office.

After making rounds all morning, this was a brief moment of peace before the afternoon surgeries began. I was indifferently looking through charts, unable to suppress a wry chuckle at myself for finding the Thoracic Surgery doctor's office oddly more comfortable than the Emergency Medicine duty room.

Thump.

Jeong Jaesang, a 2nd-year Thoracic Surgery resident, opened the doctor's office door and walked in, gasping for breath. Fine beads of sweat were formed on his forehead, and in his hands were his personal loupes and cap used in the operating room.

"Jaesang, you're here? Did you eat?"

When I greeted him naturally like the master of the house, Jeong Jaesang caught his breath and looked at me as if it were absurd.

"...Now you completely look like a Thoracic Surgery resident. There's no need for someone on dispatch to leave their own department's office behind and just settle down here entirely, is there?"

"Hey, it happens. The AC is blasting and the sofa is fluffy. The ER duty room must be a chaotic market right now, so why would I go there willingly?"

I replied brazenly and lifted my body.

"But where are you going? What are you packing in such a hurry? Weren't regular afternoon surgeries scheduled from 3 o'clock?"

"Ah, an aortic emergency just popped up."

Jeong Jaesang answered quickly as he opened a locker to take out and put on his surgical Crocs.

"He's a male patient in his 20s who came to the ER complaining of severe chest pain (*extreme chest pain). On the EKG and marker tests, ACS (*acute coronary syndrome) was ruled out, and when we took a CT, the ascending aorta (*ascending aorta) was dilated to 5.2 cm, so we are going straight into emergency surgery."

"Emergency surgery?"

Ascending aorta 5.2 cm. Considering that a normal aortic diameter is around 3 cm, it was serious. Since it was the part that directly received the pressure of the blood pumped out from the heart, if it ruptured, it meant instant death.

"Yes. Professor Ju Gwangho from the aortic section is operating, and I will probably go in as the second assist."

"Who's the first?"

"A fellow teacher will come in. I just contacted them, so they'll be here soon."

Jeong Jaesang straightened his clothes and shoved the duty phone into his pocket.

"You're working hard. Should I tag along too?"

Jeong Jaesang turned around right as he grabbed the doorknob.

"Eh? Is it okay if you come? For your dispatch schedule, this afternoon was designated as autonomous..."

"Let's just say I'm a member of the Thoracic Surgery doctor's office for the remaining few days. Is it common to get a chance to see an aortic emergency surgery right before your eyes? Let's go."

"Oh, come if you're coming. Don't blame me if you get chewed out."

We slipped out of the Thoracic Surgery ward and pressed the elevator button to head toward the Emergency Medical building where the emergency operating room was located.

'Get off at the 4th floor, cross the overpass, and that should be it.'

While waiting for the elevator, Jeong Jaesang slid the tablet PC he was holding toward me.

"Here is... the chart. Take a look if you want to reference it."

"Hm, okay."

I took the tablet and scrolled down. The ER nursing printout sheet, blood lab results, and the contrast-enhanced chest CT image.

'But even if I look at the aorta, I don't know the details well.'

From an Emergency Medicine perspective, it was a disease where you lower the blood pressure and call Thoracic Surgery, and that's the end of it. What kind of technique would be used inside the operating room and what hidden meaning should be found in those test results was outside my domain.

'I should screenshot this and post it to the ghosts.'

As I stepped onto the elevator, I naturally summoned a blue window in the empty space to my right.

[Dead Medic Gallery]

Reporting today's Thoracic Surgery dispatch log

Author: Korean Slave 1 (Male)

This is an IMH (*aortic intramural hematoma) case.

An emergency surgery for a 5.2 cm ascending aorta that just came up through the ER is starting soon, and below are the screenshots of the lab data, CT findings, etc.

What can I learn from this case before entering the operating room?

[Comments]

ThoracicSurgeryOldbie: Nothing much to know about IMH... Just manage them well with meds before sending them up to the OR.

Mes of the God (Male): ? Hold on

Latte is Mine: But do labs normally spike like that?

Mes of the God (Male): Shouldn't it be otherwise? A simple IMH is just blood pooling from microvessels bursting inside, so why are the numbers soaring like that? Is it an infection or something else?

Hippocrates' Descendant: Tissue necrosis and secondary inflammatory responses can cause CRP and white blood cells to rise, but the numbers do seem excessive.

Korean Slave 1 (Male): ?? What is it. Why is everyone getting serious?

I slowed my pace right in the middle of the overpass. The reaction of the ghosts was different from usual.

Mes of the God (Male): Hell Slave. Look closely at the lab values and the CT cuts. I don't think it's an IMH.

...Uh?

My footsteps came to a dead halt right in the middle of the overpass.

"What is the matter, Teacher?"

Seeing me standing frozen with my eyes fixed on the tablet, Jeong Jaesang, who had been walking ahead, turned around with a look of confusion.

"Jaesang."

"Yes."

I raised my head and looked at Jeong Jaesang with a rigid expression.

"I don't think it's an IMH."