Chapter 228

Episode 228 2nd Year (2)

Creak—

The Emergency Medicine doctor's office.

As I stepped inside, four unfamiliar faces huddled together in a neat row turned toward me at the same time. These were fresh 1st-year residents, barely out of their intern phase.

I scratched the back of my neck and quickly scanned their faces.

'One who looks absolutely, completely clueless; one who just looks plain nervous; plain nervous 2; and finally, one who is entirely petrified.'

Four in total.

They were the precious juniors who would be grinding their blood and sweat into the Emergency Medicine department this year.

"Ah, hello, sunbae!"

"Hell—!"

I casually waved my hand to stop the 1st-years who were scrambling to stand up, bending at a 90-degree angle. When I signaled them to sit back down, they looked at one another awkwardly, caught in limbo.

"It's fine, it's fine. Just sit for now. This isn't the military; no need for all that."

The 3rd-year, Baek Eunseo, who had been standing next to me with her arms crossed, chimed in softly, backing up my gesture.

"Sit. Our department isn't that cold and rigid."

At her words, the 1st-years cautiously perched on the edges of their chairs, lowering their buttocks halfway.

Baek Eunseo turned to me to report the situation.

"First, Kim Jihun, the Head of the Doctor's Office, and I gave the kids a rough overview of how the Emergency Room operates. We wrapped up a quick, makeshift orientation session. We were just waiting here to introduce them to you when you arrived, Teacher."

"Oh, really? Good work. Got it."

I stepped forward and lightly offered a hand. I had absolutely no intention of acting tough or trying to assert dominance from the start.

"Nice to meet you. I'm Han Hyeonjae, a 4th-year in Emergency Medicine. I'm sure you've heard the rumors, so you know ER work is going to be pretty brutal. Even so, let's do our best for the year."

At my simple greeting, the 1st-years began introducing themselves, their faces tightening up again.

"Ah, yes! I am 1st-year Yang Siwoo. I will do my best!"

"I am 1st-year Kim Gaeun. I look forward to working with you!"

"I am Jeong Seungrok! I came here prepared to bury my bones in this place!"

'This one seems quite sharp.'

And finally, the last doctor, the one who had looked completely clueless from earlier, bowed his head.

"I am Jang Jaehee, who just joined this time."

"Right, I know."

Everyone knows you just joined this time, kid.

My gaze drifted to the void for a moment.

Last night, when news broke that the 1st-years were coming in, the ghosts had been in an absolute festival mood.

Latte is Mine: Start by smashing their heads with charts.

Operating Room Ghost 3 (Male): Kick them in the shins! If they wander around dazed in the ER, patients die!

The ghosts had given a grand speech about how a 4th-year needs to kick shins and firmly establish discipline, but I didn't think much of it.

After all, making them function like proper human beings wasn't my responsibility.

Discipline for the 1st-years?

Baek Eunseo standing next to me or the other 3rd-years would handle that on their own.

'Wait, maybe not. She's usually so polite and soft-hearted; what if she gets dragged around by the kids instead of keeping them in line...?'

Feeling inwardly worried, I cast a swwish glance back at Baek Eunseo.

However.

"..."

The gaze in Baek Eunseo's eyes was unusual.

A chilling heat was flashing through them.

'Huh, that passion is blazing hot.'

My worry was a complete and utter waste of time. She was a 3rd-year resident who had rolled through the ER, drenched in blood while hovering between life and death with countless patients. There was absolutely no way she was soft.

'Never mind then. No need for me to step in at all.'

Baek Eunseo looked at me, smiled brightly, and continued.

"For today's duty, I think two of the 1st-years will join us. I will make sure to run them hard."

"What about the other two?"

"They're going home right after orientation. Since they're scheduled for the day shift tomorrow, I'm letting them get a good night's sleep tonight. It's not like they'll get proper sleep starting tomorrow anyway."

"Mm, alright. You guys are going to suffer a bit starting today."

Leaving behind the pale faces of the 1st-years, I finished the brief introductions, opened the office door, and stepped outside.

Cre-e-eak—

Thud.

As soon as the door closed, the peaceful yet familiar white noise of the ER welcomed me, just like any other day.

Right then, a nurse who was running from the triage station with a chart spotted me coming out of the inner ER. She waved her hand urgently to grab my attention.

"Over here, oh! It's Han! Teacher Han!"

"Yes, yes? What is it? Did something happen?"

When I stopped and asked, the nurse poured out her report while catching her breath.

"A, well, a suspected stroke patient just walked in on foot instead of riding a 119 ambulance. They just registered, but the symptoms feel a bit off. For now, I triaged them to Area A to monitor them."

"Ah, right!"

Stroke.

A disease where the golden time is as vital as life itself.

Without a moment's delay, I dashed toward the triage area, suddenly turning to look at Lee Minjae, the brand-new Clinical Assistant Professor who was standing right in front of the station.

"Professor Lee!"

I shouted loudly right in the middle of the ER hallway.

However, on day one of being a professor—no, having held the title for less than a few hours—Lee Minjae just stared blankly at the monitor, completely motionless.

Because he was so used to being called "Teacher Minjae" as usual, his brain failed to recognize that the grand title of "Professor Lee" was actually calling out to him.

"Professor Lee... Ah, seriously."

A short sigh escaped my mouth at the sight of my superior, who was the only one failing to grasp reality when time was ticking away.

Ultimately, falling back on old habits, I yelled out using the most familiar and urgent title.

"Teacher Lee Minjae!!"

"Huh! Oh, what?!"

Only then, reacting reflexively to the familiar name, Lee Minjae whipped his head around and looked at me with wide eyes.

I pointed my finger toward Area A and shouted frantically.

"Stroke! Stroke! A walking stroke patient just popped up in Area A!"

Only then did Lee Minjae grasp the severity of the situation. He dropped the chart he was holding as if throwing it down and began to dash at full speed toward me.

"Uh, okay, I'm coming!"

As we violently yanked back the curtain of the bed in ER Area A, the patient suspected of having a stroke—who had allegedly walked in on her own two feet a moment ago—was revealed.

Lying at an angle on the bed was a 62-year-old female.

At first glance, she was far from the typical presentation of a palsy patient collapsed from paralysis. She wasn't a trauma patient spilling blood, nor was she a Myocardial Infarction patient rolling around clutching their heart.

"BP is 110 over 70, pulse is 105. Saturation is normal, but the respiratory rate is..."

The nurse trailed off while reading down the numbers displayed on the screen.

"Respiratory rate is 30?"

That is not normal.

A normal respiratory rate for an adult is between 12 and 20 breaths per minute. A value of 30 implies that a severe increase in oxygen demand or a metabolic abnormality has occurred inside the body...

Tachypnea.

I placed my stethoscope on the patient's chest and closely observed her breathing pattern.

And then.

'...Kussmaul respiration?'

When the body falls into severe metabolic acidosis, it forcibly squeezes the respiratory muscles to expel carbon dioxide from the blood, desperately trying to lower the acidity by any means. It was that bizarre, deep breathing pattern you would typically see only in patients with diabetic ketoacidosis, severe renal failure, or drug intoxication.

However, there was absolutely no fruity scent or alcohol smell coming from the patient, which are commonly observed in diabetic ketoacidosis or alcohol intoxication.

'A suspected stroke patient exhibiting Kussmaul respiration?'

If it were a cerebral vessel occlusion, the brainstem would be compressed, leading to irregular breathing or, more expectedly, a drop in respiration. A stroke accompanied by such deep and rapid acidotic breathing while the patient remains conscious is highly atypical.

Something wasn't adding up.

Even so, we could never rule out the possibility of a stroke, not even by a mere 1%.

"Let's get a line with an 18-gauge, and mm... we'll send out an ABGA and routine labs. After the line is secured, start 1 liter of normal saline at 200 cc per hour."

I handed down the treatment orders.

Whether we were taking a contrast CT or pushing emergency medications, securing a thick intravenous line was essential. Furthermore, to differentiate whether the cause of that breathing was truly due to acidosis or a lack of oxygen, arterial blood sampling was required.

"Yes, Teacher."

After confirming that the nurse was tying the tourniquet and preparing the thick needle, I quickly moved my feet back out the curtains toward the station.

Tap-tap-tap-tap.

It was right when I sat down in front of the computer, typing the initial orders into the keyboard.

"Hyeonjae."

Lee Minjae, who had returned after finishing the initial evaluation and conducting a neurological exam, approached my seat.

"Yes, Teach... no, Professor."

Lee Minjae tilted his head while scanning through the notes he had scribbled on the chart.

"There's no distinct focal motor paralysis or sensory loss. No hemiplegia, and I don't see any facial palsy either. There's no nystagmus, and when I tested the strength in both upper and lower limbs, they're all a normal Grade 5."

"Really? If so..."

This meant it wasn't an infarction in the cerebral cortex or the area where the thick motor nerve bundles pass through. Her limbs had solid strength and her senses were perfectly intact. It was completely distant from the hemiplegia symptoms caused by a typical middle cerebral artery occlusion.

"But the trunk and limbs have severe ataxia. She's staggering, unable to keep her balance. There was an intention tremor during the exam too. In particular, her dysarthria is quite severe, so her pronunciation is completely slurred."

At Lee Minjae's words, a deep frown formed between my brows.

Ataxia, intention tremor, dysarthria.

The strength in her limbs was normal, but the function to finely tune and coordinate those muscles was entirely broken.

'If that's the case, the cerebellum?'

These are the perfect, classic signs that appear when the cerebellum—located under the back of the skull and responsible for body balance—is damaged.

If that were true, there were things we needed to differentiate quickly. If blood bursts in the cerebellum and the hemorrhage expands, it can press down on the brainstem, causing the patient's breathing to stop abruptly without warning—leading to a horrible sudden death.

"Should I order a non-contrast CT right away?"

Without hesitation, I clicked the mouse and placed the cursor over the brain CT order field.

"Yeah, let's order it. There's no time to waste."

Lee Minjae agreed as well.

"What about Neurology?"

"Mm, call them right now. Whether it's a cerebral hemorrhage or a cerebellar infarction, it's better for Neurology to come down quickly and look at it together."

"Yep~"

I made the call using the on-duty phone.

...

20 minutes later.

Right after the images of the patient returning from the CT scan and the initial blood test results that had just been drawn popped up on the monitor.

"This..."

The Neurology resident on duty, who had rushed down to the ER, shook his head as he spoke to me and Lee Minjae, who were guarding the front of the monitor.

"I think this might not be a stroke."