Chapter 215
Episode 215 Crazy Guy (4)
“…What did you say?”
Professor Joo Kwang-ho’s voice was low and chilly. It was a calm and spine-chilling voice, the exact opposite of the thunderous shouting from just a moment ago.
However, I had already crossed the line. Backing down here wouldn't just mean my neck getting cut; the patient's neck on the table would be cut.
“It is an acute inflammatory state caused by GCA, giant cell arteritis. If we operate using the existing method under these conditions…”
I swallowed hard.
Gulp.
“The blood vessel will completely burst.”
The moment they tried to cut it open with a scalpel and sew it with a needle, the aortic tissue, which had become flimsy due to the inflammation, would not be able to withstand it and would completely tear apart. Every single time they pulled the thread to anastomose the artificial blood vessel, the needle holes would tear out, causing an uncontrollable massive hemorrhage.
“…”
“…”
Everyone in the operating room, including Jung Jae-sang, the doctors, and the nurses, stared at me with a dazed look.
'That crazy human is finally causing trouble.'
They were probably thinking that way in their minds.
Joo Kwang-ho slowly opened his mouth.
“Can you be certain?”
“I can stake my doctor's license. I am certain.”
This was the conclusion deduced by the ghosts. It was not my meager knowledge, but the diagnosis delivered by the crystal of medicine that had witnessed countless deaths and lives for hundreds of years. There was no way it was wrong.
Facing my unwavering eyes, Professor Joo Kwang-ho’s face twitched.
“The basis. Tell me the basis.”
The meaning carried in those short words was clear. Convince me. If you can't convince me, you die by my hands in this operating room today.
“I will tell you quickly.”
There was no time.
“First, in the history, there was jaw claudication and a nocturnal fever. These are very typical and specific symptoms of temporal arteritis or giant cell arteritis that do not appear in aortic diseases.”
“That's just a simple…”
Professor Joo Kwang-ho frowned and tried to counter. Because it was a symptom that could be dismissed as a temporomandibular joint problem in an elderly patient or a temporary body cold.
However, I cut his words off ruthlessly and pressed on.
“Moreover, if you look closely at the CT image, it is not a crescent sign, but it strangely shows a round shape that is thickened on the opposite side as well.”
It was not the crescent-shaped blood pooling that is the biggest characteristic of an IMH. It was an appearance where the entire blood vessel was swollen thick.
“The inner wall of the blood vessel did not burst due to blood pressure. In addition, fat stranding along the aortic arch was also clearly visible on the CT. It is evidence that the inflammation has spread to the tissues around the aorta and clumped together.”
When even the radiological evidence was pushed forward, Professor Joo Kwang-ho’s pupils shook minutely. He snapped his head around.
“Jae-sang.”
“Yes, Professor!”
The frozen Jung Jae-sang answered with a start.
“What were the CRP and ESR?”
“Uh… that…”
Jung Jae-sang flustered and hurried to check the chart. Because he had only been paying attention to cardiac enzymes levels and blood pressure, he did not accurately memorize the inflammation levels, which were pushed down the priority list in aortic diseases.
“They are 18.5 and 85.”
I answered.
Professor Joo Kwang-ho’s breathing hitched.
“WBC?”
“It's 14,000.”
“…”
Clinical symptoms. Radiological findings. And even the blood test lab values. These three achieved a perfect trinity, pointing to one disease.
Giant cell arteritis.
Professor Joo Kwang-ho slowly withdrew the scalpel he was holding from above the patient's chest. I could see his gaze wandering into the void, frantically running a simulation in his mind.
What if this crazy intrusion by the dispatched resident hadn't happened? What if he had opened the chest thinking it was a general aortic emergency, started the pump, put a scalpel to that inflamed mass of an aorta, and passed a thread through it?
The needle would have failed to catch the tissue and burst through. The patient would have met a table death right on the spot, and he would have been left as an incompetent surgeon who failed to stop a massive hemorrhage.
In that moment, where a few seconds felt as long as a few hours, Joo Kwang-ho opened his mouth.
“We will change the surgery plan.”
…!
Just one second before putting down the scalpel, he fully accepted the diagnosis of the dispatched resident and completely overturned the stage of the emergency aortic surgery.
“Instead of the distal ascending aorta approach, we will go with a right axillary artery side graft cannulation.”
Normally, they would have inserted a tube directly into the rotting ascending aorta to run the heart-lung machine, but if they inserted a tube into that place where the tissue had all melted down, the blood vessel would tear. So, it meant he would bypass the chest, use a different blood vessel, and safely run the pump.
“The suturing is going to be done with double felt, so please prepare it. We will disperse the pressure by padding it with felt.”
“Yes!”
The scrub nurse began to prepare the Teflon felt and a new cannula line.
“Yes!”
The fellow and the anesthesia department also began to adjust the targets and settings in accordance with the new surgery plan.
A color returned to my eyes.
“Dispatched.”
“Yes, Professor!”
I answered hastily. Changing the surgery plan meant he was staking everything on my diagnosis. What if, upon actually opening the chest, it wasn't inflammation but a simple hematoma? It would mean he had only delayed the surgery time and put the patient in danger by overusing unnecessary techniques.
Professor Joo Kwang-ho warned, “If it's not, you die.”
At that brutal one word, I put strength into both eyes and answered resolutely, “I will make sure that doesn't happen.”
“Give Solu-Medrol 500.”
As soon as the surgery plan turned 180 degrees, the anesthesia department started internal medicine treatment. If it was an acute attack of giant cell arteritis and not a hematoma, they had to cool down that inflammatory response right away. Because if they ran the heart-lung machine, the systemic inflammatory response would explode even more.
“Here is Solu-Medrol 500.”
That way, the anesthesia department finished organizing roughly while administering the high-dose steroid intravenous injection. Following the esmolol that had been dropping the blood pressure to the floor, the steroid entered, and the patient's vitals were maintaining a balance.
I quietly stood up on the footstep behind the operating table and looked down at the scrub nurse’s stand. The knife list could be seen neatly set up on top.
A large and heavy No. 23 knife for coolly cutting through thick skin and subcutaneous tissue. A sharp No. 11 knife used when keenly piercing and making holes in blood vessels or minute tissues. And No. 15 knives used when precisely dissecting tissue in delicate and deep places.
Professor Joo Kwang-ho looked at the tip of the patient's sternum and reached out his hand.
“Starting surgery. Blade 23.”
Snap.
The nurse fitted the No. 23 blade onto the scalpel handle and slapped it into his palm.
Sliiiit!
As Joo Kwang-ho’s hand moved, a straight red line was drawn from the sternum to below the neck along the patient's chest. He cut through the skin and subcutaneous tissue without hesitation while searing the subcutaneous connective tissue and bleeding blood vessels with a cautery. The yellow subcutaneous fat layer parted to both sides, and the white sternum revealed its posture.
'So this is a median sternotomy…'
I quietly stood without breathing in a spot that wouldn't interfere with the operator’s movement, watching the surgery. It was a realism on a different level from what I had only seen in textbooks or YouTube videos. The smell of burning flesh and the scent of blood breached the mask and wafted in heavily.
“Deflation, please.”
This was a process to temporarily stop the operation of the ventilator and let the air out from the lungs to prevent the inflated lungs from being shredded by the saw blade when the saw cut the sternum in half.
“Deflation commencing.”
Pshuooook…
The sound of air escaping was heard from the anesthesia machine, and the movement of the patient's chest stopped.
Whirrrrrr-!!
Along with a sharp mechanical sound, the saw blade dug into the center of the sternum. Along with the vibration of the bone being ground away, white bone dust scattered into the air.
'It's my first time actually seeing a sternum amputation…'
“Retractor.”
As soon as the bone was split in half, the instruction dropped.
“Yes, retractor.”
Jung Jae-sang inserted a heavy metal retractor between the parted sternum and began to turn the crank.
Click, clack, click.
The patient's chest slowly parted to both sides, and finally, the mediastinum hidden deep inside, the throbbing heart, and the aorta in question completed their preparation to enter the field of vision.
…
“No. 15.”
“Here it is.”
To approach the membrane wrapping the heart, Professor Joo Kwang-ho began to delicately open the tissue with a small and sharp No. 15 scalpel.
“Metzenbaum.”
At the very moment he was peeling back and opening the pericardial tissue carefully with scissors…
!
I discovered something. As soon as the pericardium was opened, the pooled fluid slithered out, but it was not clear body fluid or bright yellow fatty fluid.
'Serosanguineous effusion?'
A murky and red fluid where blood was unpleasantly mixed into clear fluid.
'Is it inflammatory exudate?'
If it were a blood vessel rupture due to high blood pressure, blood would pool inside the blood vessel wall; such blood-colored inflammatory fluid would not pool around the pericardium. A giant inflammatory response covering the entire aorta was making even the surrounding tissues bleed.
With the chest left open, Professor Joo Kwang-ho immediately turned his gaze toward the vicinity of the patient's right shoulder. It was to find the right axillary artery, the bypass route, since he could not directly plug the heart-lung machine tube into the ascending aorta.
Joo Kwang-ho carefully cut into the pectoral axillary fascia with a Metzenbaum and a Bovie. As he pulled the muscle bundle with a retractor, the thick right axillary artery running alongside a dense nerve bundle revealed its posture.
'…Crazy.'
I swallowed an exclamation. The touch of finding and isolating only the artery like a ghost without touching a single one of the numerous nerve bundles inside that narrow and complex anatomical structure under the shoulder. Was this the class of a full-time professor in the aorta section of a university hospital?
“Forceps.”
“Forceps.”
Handed tweezers with a very sharp and delicate tip, Joo Kwang-ho carefully peeled off the tissue wrapping the outside of the blood vessel. As the blood vessel was perfectly exposed, the essential process for running the heart-lung machine followed.
“Heparin, please.”
“Ah, yes. Understood.”
To prevent the blood flowing through the blood vessels of the entire body from clotting when passing through the machine, an ultra-high dose of heparin, an anticoagulant, poured in through the patient's vein.
…
3 minutes later.
“Check the ACT.”
The anesthesia department put the blood sample into the machine and checked how much the blood didn't clot. To run the cardiopulmonary bypass, a time of at least 480 seconds had to be secured.
“…It's 502 seconds.”
As soon as Joo Kwang-ho heard that sound, he raised his head.
“Give me No. 11.”
“No. 11.”
The sharp No. 11 scalpel held in Joo Kwang-ho’s hand pricked the surface of the axillary artery where blood was flowing, making an incision. The moment blood was about to gush out, the pre-prepared artificial blood vessel cannula was sucked into the incision.
That way, Professor Joo Kwang-ho wrestled with the blood vessel and thick thread, and only after perfectly fixing the cannula did he raise his bent head.
“Fortunately, it looks like the inflammatory thickening hasn't reached here yet?”
Joo Kwang-ho said as he completed the incision and anastomosis of the axillary artery. If giant cell arteritis had invaded up to this blood vessel and clumped it with inflammation, the artery would have torn as soon as the tube was plugged, and the blood flow going to the arm would have been cut off. It was a moment when pivoting to Plan B hit the mark perfectly.
…
With the tube to draw blood plugged into the right atrium, all preparations finished.
“Commencing bypass!”
“Yes!”
The perfusionist handling the heart-lung machine flipped the switch.
“Target temperature is 25 degrees!”
“Yes!”
To slice away the aorta, they had to drain all the blood from head to toe and stop. To do that, the process of dropping the patient's body temperature to an extreme hypothermia of 25 degrees and freezing it tight so that brain cells and organs could endure even without oxygen began.
Hummmmmmm-
The motor of the heart-lung machine turned vigorously, sucking in the patient's dark blood and starting to spout red blood mixed with oxygen through the axillary artery.
As the body temperature dropped sharply to 30 degrees, 28 degrees, and 26 degrees, the heart reacted to the cold temperature and began to fibrillate like crazy.
“V-fib (* ventricular fibrillation).”
The anesthesia department shouted while looking at the vitals monitor.
“Yes, V-fib.”
Jung Jae-sang answered. It meant the heart was trembling and losing its normal pump function, preparing to stop.
“Circulatory arrest achieved.”
As the heart stopped completely and the blood obscuring the view drained into the heart-lung machine, the raw face of the hugely swollen ascending aorta was finally revealed intact.
“Uh?”
Joo Kwang-ho, who was approaching with a scalpel, examined the surgery site closely. In the case of a general aortic intramural hematoma, the ascending aorta takes on a dark bluish discoloration due to the hematoma pooled thinly inside, and it is supposed to maintain the characteristic elasticity of a blood vessel to some extent when touched.
However.
The patient's ascending aorta that entered the field of vision did not take on a blue color anywhere. The aorta had become red.
Joo Kwang-ho tapped the swollen surface of the aorta with tweezers and muttered.
“It's like wood.”
It meant that a stiff, hard, and fibrosed transformation, like thick rubber or very old and dried tree bark, was felt upon palpation. It was a typical terminal stage symptom of giant cell arteritis, where extreme inflammation had entirely destroyed the elastic fibers of the blood vessel wall.
What if he hadn't bypassed to the axillary artery earlier and had directly plugged a tube or passed a thread here? The moment the needle entered, the aorta would have ruptured like wood splitting.
Professor Joo Kwang-ho’s hand stopped in the void for a moment. He turned his head and stared at me standing on the footstep behind the operating table.
“Dispatched teacher.”
“Yes, Professor.”
“You were right?”