Chapter 229

Episode 229 Unseen Figures (1)

“What has been ordered from the ER right now?” Yoo Jungmin, a 3rd Year neurology resident, asked while looking at one side of the monitor screen.

I recited the list of prescriptions I had entered. “Routine lab, and since the patient is showing abnormal tachypnea and fluctuating consciousness, we ordered an acetaminophen and salicylate screening, serum ketone, and serum osmolality to differentiate toxic or metabolic causes. And the ABGA went out as well.”

It was quite a broad and unique order lineup to give a patient suspected of a stroke. Even if it looked like a brain problem on the surface, I couldn’t afford to miss systemic symptoms that appear when the metabolic system inside the body is completely shattered.

‘Seeing Kussmaul breathing, it’s a natural measure.’

“Haa… this is.” Yoo Jungmin let out a sigh.

Lee Minjae, I, and Yoo Jungmin put our heads together and looked at the station monitor side by side. The puzzle pieces of the diagnosis did not fall neatly.

“There’s no history other than a laparotomy for volvulus 10 years ago, you know? The guardian said she doesn’t take diabetes or high blood pressure medication, and there’s no recent head trauma either.”

“Right, right. For now, I checked it too, but…” At my supplementary explanation, Yoo Jungmin gripped the mouse with a furrowed brow.

Keeping the non-contrast brain CT open on the window, Yoo Jungmin clicked the mouse wheel and scanned up and down the cross-sectional images of the brain dozens of times. The structures of the brain were made of black and white contrast.

The result was all too clean. No white high-attenuation bloodstain indicating acute cerebral hemorrhage, nor any swollen low-attenuation anatomical lesions suggesting cerebellar infarction were found at all. Structurally, it meant that no traces of a ruptured or blocked cerebral blood vessel were visible radiologically.

Of course, early-stage cerebral infarction might not be caught on a CT, but with the patient’s symptoms being this extreme, the fact that the image was this clean created a massive sense of incompatibility.

“For now, I’ll go and perform a proper neurological examination. The images alone won’t cut it.” Yoo Jungmin stood up from his seat, picking up a penlight and a hammer.

“Ah, the neurology doctor?”

“Yes, I’ll go check personally. Because there might be a subtle difference between what the emergency room teachers saw and what we see from a neurology base.”

I nodded my head and made way.

Neurology’s Yoo Jungmin returned with a stiff expression, wiping away sweat.

“I did the exam. Nystagmus and dysarthria are severely present, but they aren’t focal findings. The pattern of the symptoms doesn’t match a typical cerebral vascular infarction…” Yoo Jungmin shook his head in amazement.

If a cerebral blood vessel is blocked, only the specific area supplied by that vessel should break down, but this patient’s entire brain was malfunctioning as if it were pickled in poison. Rather, a systemic ataxia pattern was distinct, and it was also confirmed that the patient’s state of consciousness showed some fluctuation depending on stimulation.

The conclusion was converging into one. It wasn't a structural problem of the brain itself, but something riding the blood and circulating that was driving the brain crazy. Toxic or metabolic encephalopathy.

At that moment, along with an alert sound, the result of the blood test that went out first updated on the monitor screen in red text. I immediately looked at the ABGA numbers that popped up on the screen.

[pH 7.15]

[pCO₂ 20 mmHg]

[HCO₃⁻ 6 mmol/L]

“Gasp.” Sounds came out of Lee Minjae and Yoo Jungmin’s mouths at the same time upon seeing the screen.

The patient’s blood was hitting a horrible figure of 7.15. An extreme acidic state where it wouldn't be strange if the heart stopped right now.

“Primary metabolic acidosis with respiratory compensation…” I muttered, staring intently at the monitor.

The bicarbonate level had plummeted through the floor to 6, which is a quarter of the normal range. As the blood turned acidic, the patient’s body was desperately squeezing the lungs to survive, blowing off carbon dioxide—an acidic substance—through hyperventilation. It was the moment the cause of Kussmaul breathing was clearly revealed.

“Why, is there something that comes to mind?” Having heard my murmuring, Lee Minjae asked while looking at me with a serious expression.

“I saw a salicylate poisoning case the year before last. I thought it might be similar.”

Memories from two years ago flashed through my mind. Back then, Baek Eunseo (Female), who was a 1st year resident, suspected encephalitis upon seeing the fever and decreased consciousness. I suspected poisoning, and with the decisive advice of a gallery ghost, diagnosed salicylate poisoning.

“The panting patient back then showed exactly this kind of acidosis. This case looks similar too.”

At my confident words, Lee Minjae nodded his head and quickly scanned other lab values.

“True. Looking at the BUN and creatinine levels, kidney function is normal, so it’s not uremic acidosis. Since the ketone level is also normal, we can rule out DKA as well.”

“Yes.”

I scrolled down the monitor to look at the core electrolyte values.

Na / K / Cl

140 / 4.0 / 102

The levels of sodium, potassium, and chloride floating around in the blood. It was the final key to differentiating the cause of acidosis.

“Calculate the Anion Gap for this.” Lee Minjae asked me.

Reflexively snapping my fingers in the void, I started mental arithmetic in my head. The formula subtracting the sum of chloride and bicarbonate levels from the sodium level: 140−(102+6).

“Since it’s 140 minus 108, it’s 32. The gap difference here is too severe.”

The normal value is between 8 and 12. Right now, it was a glaringly abnormal state. Lee Minjae’s eyes grew wide.

“Hmm… HAGMA?”

Clear evidence that a mysterious acidic substance was accumulating in the body in an enormous amount. It was a typical figure that appears during salicylate poisoning, lactic acidosis, or poisoning from toxic substances like methanol.

As soon as the word HAGMA came out, a strange look of relief spread across the face of Yoo Jungmin, the neurology resident. It was because he was convinced that it wasn't a super-emergency disease in the neurology realm where a cerebral blood vessel ruptures or blocks.

“Ah, if so, from neurology…” Putting down the chart slily, Yoo Jungmin took a step backward.

“Yes, since this requires metabolic correction, it seems like internal medicine clearly needs to see it… We need to see the toxicology results come out to run dialysis or something.” Lee Minjae agreed.

A very fast and clean exit by neurology upon confirming it wasn’t their domain. I stared blankly at Lee Minjae in front of the monitor.

“Shall I call Internal Medicine?”

It was time to summon Internal Medicine, which covers systemic diseases by being divided into numerous subspecialties. Internal Medicine, come forth.

Lee Minjae washed his face with dry hands and nodded. “Uh, yeah. For now, let’s do that. Shove the ABGA values and the HAGMA calculation right in front of them, tell them toxicity is suspected, and ask them to come down straight away to see the patient.”

We stuck close in front of the station monitor, holding our breath as we checked the test results popping up one after another in the EMR window.

‘I should thank that ghost bastard later.’

We almost barked up the wrong tree thinking it was a stroke, but thanks to the knowledge picked up from the gallery in the past, we could turn the rudder toward metabolic acidosis. Whether that was the Cardiology Ghost or the Latte old man during the salicylate incident back then, I couldn’t remember exactly, but anyway, those naggings became flesh and bone at this moment.

Lee Minjae, who was scanning down the numerous figures appearing on the screen, asked me with a heavily furrowed brow.

“Hyeonjae, can you calculate the Osmolar gap for this?”

To strike down the fatal causes provoking high anion gap metabolic acidosis one by one, each element had to be looked at. The reason to calculate the osmolar gap in the first place is that if an unknown alcohol component or a toxic substance like antifreeze is floating around in the body, the blood’s osmolality figure jumps abnormally.

“There’s no difference between the measured and calculated values. It’s less than 10. Ingestion of toxic alcohols like ethylene glycol or methanol is definitely a no.”

“Hmm… then what about oxoproline? It could be a problem caused by long-term intake of something like Tylenol.”

“There is none. Acetaminophen screening came back negative.”

Lee Minjae pointed out the next possibility. “Then what about blood rotting away due to sepsis or ischemia?”

I replied, tapping the lactate level on the monitor. “Lactate is 0.8. It’s within the normal range. It wouldn’t be acidosis induced by tissue necrosis like septic shock or mesenteric ischemia either.”

Ding-

Along with a cheerful notification sound, a waiting result window popped up.

“Ah, salicylate screening is up…” The words coming out of my mouth cut off abruptly.

Lee Minjae and I froze simultaneously, looking at the monitor. It was because the number that appeared on the screen was too different from the picture we had expected.

[Salicylate level : 25 mg/dL]

“Huh?” A dumbfounded sound leaked out of my mouth.

“Huh?” Lee Minjae also made a dumbfounded sound.

We were screwed. Literally, truly screwed.

For such extreme acidosis and Kussmaul breathing to come from aspirin poisoning, the blood salicylate concentration must exceed at least 40 to 50, and in severe cases, it’s normal for it to soar close to 100. But 25? It’s 25?

It was nothing more than an utterly ordinary therapeutic concentration. With a measly figure like this, there was no way it could make a patient pant.

“What about other, other causes?” Lee Minjae raised his voice in panic. “It’s not ketones, kidney function is perfectly fine, it’s not methanol… If lactate is normal too, what at all is the cause that made this patient’s blood this acidic?”

A cold sweat flowed down my spine as well. Even when matching all the causes of HAGMA that appear in emergency medicine textbooks, there wasn't a single puzzle piece that fit this patient.

That meant all diseases matching the current symptoms were completely excluded.

Shit. Does this make sense? A fatal metabolic acidosis of unknown cause where textbooks do not apply. Even at this very moment, the patient’s heart muscle was being pickled in acidic blood and slowly stopping.

I hurriedly turned around, casting my gaze toward the void out of Lee Minjae’s sight, and brought up the blue window.

‘Even Lee Minjae, who has a professor title, is in a dizzy state of mind, so of course I have to use a cheat key.’

[Dead Medic Gallery]

Internal Medicine help after a long time

Author: Korean Slave 1 (Male)

(Picture)

Save me, ghosts.

62-year-old female patient panting with consciousness fluctuations + Kussmaul breathing.

HAGMA hit 32, so I thought it was salicylate poisoning, but it’s not.

Ketone, kidney, toxic alcohol, lactate are all normal.

[Comments]

Latte is Mine: ? What's this. HAGMA is as high as 32, but it’s not aspirin?

ㄴ Let’s Run the Dialysis Machine: Isn’t it a lab error? The anion gap widened like that, but it’s neither ketones, lactate, nor uremia.

ㄴ Cardiology Ghost: In my dozens of years on the single path of cardiology, this kind of bizarre lab is a rarity after a long time.

Cardiology Ghost: If it’s not toxicity, could it be a state where blood going to the intestines is insufficient because cardiac output dropped drastically?

ㄴ Latte is Mine: To say that, the lactate level is too normal at 0.8?

A situation where even the ghosts couldn’t catch a clue and were arguing back and forth. Just as it was about to fall into an unsolved case of unknown cause, an old man appeared.

Hippocrates' Descendant: Could you show the patient's past medical history or recent medication history, namely the history, living doctor? When a diagnosis is blocked, one must always return to the patient's life!

I hurriedly pulled up the initial examination printout sheet from the EMR chart, took a picture, and uploaded it.

ㄴ Korean Slave 1 (Male): (Picture)

In fact, it was the history of a common elderly patient with really nothing much to it.

Partial small bowel resection performed for volvulus 10 years ago.

No specific medications ingested recently.

Taking only lactic acid bacteria nutritional supplements as health functional food.

Usually has irritable bowel syndrome as an underlying disease.

Other than this, it was a history without a single piece of bait, so both Lee Minjae and I hadn’t paid much attention to it. If she had swallowed a handful of depression pills or aspirin, or drank heavily instead, the diagnosis would have been much easier. What connection could a bowel surgery done 10 years ago have with the current acute metabolic acidosis?

ㄴ Hippocrates' Descendant: I have understood, living doctor!

ㄴ Hippocrates' Descendant: This is a lactate problem!

‘Lactate?’

Panicking, I stared intently at the lab values on the EMR monitor once again.

L-Lactate : 0.8 mmol/L

The number on the screen was clearly pointing to 0.8.

‘It’s normal, you old man.’