Chapter 23
Episode 23 Is It Not Heart Disease? (1)
The Emergency Room was chaotic with a couple of hours left ahead of the shift change. Traces left behind by all sorts of accidents and incidents that had burst out throughout the dawn. My eyes were completely hollowed out, and at the station, charts to be processed were piled up like Mount Everest. I was tapping away on the keyboard with that way of expressionless, soulless eyes. My fingers moved mechanically, but my brain had already stopped working a long time ago. If anyone saw me now, they would probably think I was a robot.
Beep. This is Hyeonjae-bot.
Just then, it happened.
“Teacher! A chest pain patient just came in! I think you need to see him right now!”
The nurse at the triage desk called me with a sharp voice, unlike her usual self.
Beep.
My frozen brain was forced to reboot. I sprang up from the chair and headed in the direction the nurse was pointing.
A man was sitting in a wheelchair right in front of the triage desk. Usually, patients are seen after being classified; is it to the point of being that urgent? The face of the man, who looked to be around his mid-50s, was pale beyond gray, and cold sweat glistened on his forehead and the bridge of his nose. Looking at his upper body, he was clutching the center of his chest with his left hand while panting heavily. His expression also looked incredibly serious.
Fuck. This is the real deal.
I approached in front of the man and asked with a voice as calm as possible.
“Patient, can you understand me? When did the pain start, and where and how does it hurt?”
“About… about an hour ago…” he barely managed to continue his words. “Suddenly… it feels like someone is squeezing the center of my chest… like something heavy, like a rock… pressing down on it…”
It was similar to the typical pain pattern of a Myocardial Infarction.
“Does the pain radiate anywhere else?”
“Yes… to my left shoulder… and even down my arm… a tingling sensation…”
Radiating pain. Confirmed match.
I opened the chart and quickly checked his history: Hypertension, diabetes, and a smoking history of more than a pack a day for over 15 years. He had all the worst conditions that would inevitably damage the heart.
The most lethal differential diagnosis list popped into my head: Acute coronary syndrome, aortic dissection, pulmonary embolism. The moment I miss one of these three, this man will become a chilling corpse before my eyes within a few hours. The only saving grace was that all circumstantial evidence pointed to a single disease as the culprit.
‘If I miss it, he dies. Not me, but this patient.’
Cold sweat flowed down my spine. It took less than a minute to make the diagnosis. However, every minute and second from now on would determine the rest of this patient's life.
“Nurse! Please move this patient to Area A right away! Connect the monitor immediately and secure an IV line first! Let’s get two 18-gauge lines in both arms! And bring the EKG over here right now! We are going to run it immediately! Have him chew and swallow 300mg of aspirin!”
The most important thing at this moment was the EKG. I grabbed the shoulder of the intern who was closest to me.
“Go find any senior resident right now! Check where they are right now and call them over! Tell them ACS is strongly suspected! Tell them they need to get here immediately! Quickly!”
During the last myocardial infarction incident, it was so chaotic that I had to put on a one-man show alone, but in a situation like this, having a senior resident around brings peace of mind. Of course, I thought about accessing the Gallery, but I stopped myself, thinking, Why bother? These symptoms were textbook of textbooks, and the tests to be ordered would follow the standard protocol anyway. Besides, I didn’t want to be treated by the patient as a 'strange guy who suddenly stares into the void.'
The nurses started moving busily. The intern ran down the hallway holding a cellphone to find the location of the seniors. Someone was running over, dragging the EKG machine. I stuck close to the side of the patient and checked his vital signs.
Blood pressure 145/90, pulse 95 beats per minute. He was holding on for now. But it wouldn't be strange if he collapsed at any moment. I grabbed the patient's hand. It was damp and cold with cold sweat.
“Patient, it’s alright. We are going to do everything we can from now on. Please hold on just a little longer.”
My voice was trembling. At that moment, the EKG machine stopped by the bed with a loud noise.
“EKG is here!”
Along with the nurse's shout, the sound of rolling wheels stopped behind my back. The nurse rolled up the patient's shirt and started attaching electrodes to his chest. That short moment waiting for the printout sheet felt like eternity. My mind was full of horrible electrical signal waveforms suggesting a myocardial infarction.
Whirrrr— crackle zap zap—
The machine finally spit out the long paper with the language of the heart written on it. I snatched and tore the paper away even before the printout was completely out.
And then.
“……”
What is this?
I looked at the printout sheet once more, this time much slower and more meticulously.
Sinus rhythm. 95 beats per minute. The intervals of all waveforms were regular, and the shapes of the P wave, QRS, and T wave were perfectly normal. The elevation or depression of the ST segment that I had been frantically searching for was nowhere to be seen. It was just… a completely normal EKG. It was an EKG so clean it could be featured in a textbook.
“What is this?”
The shout inside my heart burst out without me realizing it.
“Did you attach the leads properly, nurse?”
A somewhat edgy voice slipped out. Ah, sorry.
“Pardon? Of course. I checked it several times,” the nurse's voice was filled with absurdity.
Just then, 4th-year resident Sung-hoon Yoo walked with strides into Area A.
“It sounds loud here, is it this patient?”
Without a word, I handed the EKG printout sheet to Sung-hoon Yoo. Sung-hoon Yoo took the printout sheet and looked alternately at the sweating, groaning patient and the perfectly clean EKG.
Looked at the patient once.
Looked at the EKG once.
Looked at the patient again.
Looked at the EKG once more.
Looked at the ceiling once.
And looked into my eyes once.
What the, why are you looking into my eyes?
The space between his eyebrows narrowed subtly.
“The EKG is clean… but the patient's condition is a textbook case.”
Hearing that mutter, I actually felt a faint sense of relief. Yes, I wasn't the only one who thought it was strange.
“For now, Hyunjae. Let's take a portable X-ray and run an EKG every 20 minutes.”
10 minutes later.
The portable X-ray shooting finished. The picture was immediately transmitted to PACS, and Sung-hoon Yoo and I stood in front of the station monitor to check the patient's chest X-ray.
What we were looking for was clear: findings like fluid in the lungs, air trapped inside, an abnormally enlarged heart, or in the worst-case scenario, a widened mediastinum due to a torn aorta. However, the patient's chest on the monitor was completely peaceful. Both lungs were cleanly expanded, and the size and shape of the heart were normal. The contour line of the aorta was also smooth. Nowhere could we find a clue as to why this patient had to be in such deathly pain.
Sung-hoon Yoo's expression hardened more and more chillingly.
“Isn't this just musculoskeletal pain? Maybe a cracked rib. Or malingering.”
“But the pain pattern the patient is complaining of is too typical. From the pressure to the radiating pain…”
“I know. I know, but the test results say no.”
A sense of skepticism was harbored in Sung-hoon Yoo's voice. My mind also became complicated. Did I get ahead of myself? Did I make too much of a fuss? Was my textbook knowledge completely fooled by the patient's acting?
40 minutes later.
The patient was still shouting that it hurt, and we were continuing an indefinite wait. The EKGs taken every 20 minutes were likewise normal. The emergency room began to turn busily again, and while Sung-hoon Yoo and I were seeing other patients, all our attention was focused on the blood test results.
Finally, a notification popped up on the EMR screen.
[Blood Test Results Arrived]
I clicked the results, feeling sweat building up in my hand holding the mouse. Sung-hoon Yoo also came up behind my back and peered into the monitor together.
CBC: Normal.
Chemistry: Normal.
CRP: Normal.
D-dimer: Normal.
Everything, every single number was terribly normal. There was no sign of inflammation, no electrolyte imbalance, and no trace of a blood clot indicating a pulmonary embolism.
Sung-hoon Yoo let out a deep sigh.
“See. I told you he just sprained something. Just give him an ibuprofen tablet, and if he keeps saying it hurts, tell him to see neurology or orthopedic clinic outpatients and discharge him.”
No. It wasn't over yet.
“Teacher, wait a moment. There is still… one last thing left, can we see that before discharging him?”
“…Ah, right. We should see all the test results before discharging.”
So we decided to wait a little longer.
1 hour and 25 minutes after admission.
The final stronghold. The ultimate judgment that separates the presence or absence of a heart problem when everything else is normal: cardiac enzyme levels. Among them, the most sensitive and specific troponin level must rise if the heart muscle is damaged even minutely.
A call came from the emergency lab. I picked up the handset with a trembling hand.
“Yes, this is Han Hyeonjae from Emergency Medicine.”
“The troponin result for the patient in A-2 is out.”
My heart dropped with a thump.
“How… how did the result come out?”
The lab employee on the other end of the handset recited the numbers with a completely emotionless voice.
“Troponin I, less than 0.04. Normal.”
Click.
I put down the handset.
EKG normal, X-ray normal, blood test normal, and even the cardiac enzyme level, which was the final stronghold, was completely normal. All evidence was saying that my diagnosis was wrong.
Sung-hoon Yoo gave my shoulder a tap and went off to see other patients with a look that said, "See, I told you I was right."
I was left alone.
Fuck. What at all is this? Then why is this patient in pain? Was all this commotion I caused for the past hour entirely my mistake? What at all is this. Am I crazy? No, what is this!!
Now, let's think about the remaining method.
…The Gallery.