Chapter 230

Episode 230 Invisible Value (2)

"Hyeonjae, for now, call Internal Medicine... Wait. I'll do it myself. It's better if I contact them directly and drag them down here quickly."

Lee Minjae said, picking up the call phone with a grim expression.

In the face of a fatal metabolic acidosis of unknown cause, the backup of an internist—a specialist in the relevant field—was absolutely necessary.

"Yes, Professor."

While Lee Minjae held the handset to his ear and dialed the Internal Medicine on-duty number, I subtly shifted my gaze to stare at the blue window in the void, invisible to others.

Below the post requesting IM help, the comments of the spirits were chaotically written.

Korean Slave 1 (Male): It's normal, you old man. Didn't you see the lab values flashed earlier? L-Lactate is clearly stamped at 0.8.

Nephrology Ghost: Finally, grandpa Hippo has lost his mind. The lactic acid is normal, yet he says it's a lactic acid problem. I guess dementia comes even to spirits.

Hippocrates' Descendant: No, living doctor and ignorant gallery members! Is L-lactic acid the only lactic acid in the human body?! Think back to that forgotten thing crammed in the corner of the textbook!

Nephrology Ghost: Ah.

Going to deliver a baby: What is it? Don't keep it to yourself, tell me too.

'...?'

L-lactic acid isn't the only lactic acid?

'Ah.'

My breath caught for a moment.

'Ah!'

A chemical formula written very small on a dusty page in the corner of a textbook, deep inside my head, popped up like a window.

A patient with a small bowel resection presents with severe high anion gap metabolic acidosis, low ketones, and lab results showing L-lactate is not elevated.

And if typical toxic causes like methanol, ethylene glycol, and salicylate poisoning can all be excluded...

'Did it say we must suspect D-lactic acidosis?'

A crazily rare metabolic disease that one might encounter only once in a lifetime, even after seeing tens of thousands of patients in the emergency room.

I quickly turned my head and called out to Lee Minjae, who had just finished his phone call with the Internal Medicine on-duty doctor.

"Uh, Professor."

"What? The IM resident is coming right down. And this..."

Lee Minjae replied, anxiously looking at the monitor.

After finishing the call with the IM resident, he seemed to be rummaging through the patient's past history on the EMR chart once again.

"I have something to tell you."

"Huh? Yeah. Why? Is there a missing lab result?"

"I think I know what the disease is. It's an acidosis typically accompanied by neurological symptoms or signs, where not only metabolic acidosis but also encephalopathy can occur."

At the topic I threw out, Lee Minjae's brow furrowed slightly.

"Metabolic acidosis and encephalopathy... uh...?"

"Yes. In a patient with short bowel syndrome, if an encephalopathy of unknown cause is accompanied, and there is clear metabolic acidosis while all other causes have been excluded..."

As I pointed out the decisive hints one by one, Lee Minjae's eyes gradually began to widen.

The rare clues he had dismissed, thinking he would never see them in actual clinical practice, were perfectly piecing themselves together in his head.

"D-lactic acidosis comes?"

"Yes, that's right."

At the same time as my answer, all the pathophysiology became clear.

An intestinal volvulus surgery 10 years ago.

Due to that surgery, most of the patient's small intestine was resected, and structurally, it must have led to a short bowel syndrome state where the nutrient absorption area was extremely limited.

'An anatomical environment was created where a large amount of carbohydrates, which should have already been absorbed in the small intestine if it were a normal person, were pushed down to the large intestine completely unabsorbed.'

The fatal trigger that pulled the bowstring here.

The probiotic nutritional supplement that the patient had mindlessly taken in large quantities to cure irritable bowel syndrome must have been crawling with Lactobacillus and Bifidobacterium species that lead anaerobic fermentation in the gut.

Meeting an enormous food source called undigested carbohydrates, these bacteria must have triggered a literally crazy fermentation rampage.

And they would have started to vomit out a large amount of D-lactate as its metabolite.

As that D-lactate poured crazily into the blood through the intestinal mucosa, it turned the blood horribly acidic, and the brain cells pickled in acid lost their minds, causing an encephalopathy where the patient stumbled and slurred their speech.

The body panted with Kussmaul breathing to pump out that toxicity.

However, the blood gas analyzer in the ER is set up to react only to L-lactate, which the human body normally produces.

Since the machine cannot read D-lactate, the isomer spewed out by the bacteria, at all, the lactate appeared perfectly normal at 0.8 on the monitor.

Lee Minjae could not hide his excitement and suddenly grabbed my shoulder.

"Shit, why didn't I think of this?! Hyeonjae, your flow of thought is seriously...! Wow, when those IM jerks come down, I'll completely flatten their noses...!!! Ah, this is no time for this."

Realizing reality in an instant, Lee Minjae quickly hardened his expression.

"Professor, then the treatment is..."

I tried to cheat by glancing out of the corner of my eye at the system window in the void.

'Does such a rare case need bicarbonate right away?'

I turned on the window, repeating the thought internally.

Korean Slave 1 (Male): How should the prescription go? I found the cause, but I haven't seen this case before, so I'm not confident.

Latte is Mine: This is really D-lactate; even after getting the EM board, it's something you might see once in a lifetime, and you see it here, Hell Slave. First, shoot Bivon (sodium bicarbonate).

Korean Slave 1 (Male): Bivon?

At the ghost's immediate prescription instruction, I hesitated for a moment.

A very fundamental dilemma caught my ankle.

'Excessive bicarbonate administration can actually become a poison.'

Pouring Bivon thoughtlessly into a typical lactic acidosis patient is often contraindicated.

This is because the administered bicarbonate converts into carbon dioxide in the body, and when this gas passes through the cell membrane, it actually worsens intracellular acidosis.

Moreover, it inhibits lactate metabolism in the liver, increasing the risk of paradoxically accelerating lactate production in the blood, so for acidosis...

Ah.

In an instant, a clear answer brushed past my mind as if a tangled skein of thread was being unraveled.

'D-lactate is far beyond the human liver's metabolic capacity.'

The human liver is overflowing with enzymes that break down L-lactate, but enzymes to effectively break down D-lactate barely exist.

In other words, it is a completely different disease from typical L-lactic acidosis, which naturally metabolizes and disappears in the liver once IV fluids are given, oxygen is supplied, and tissue perfusion is revived.

Expecting it to naturally metabolize and recover upon the resumption of oxygen supply, like L-lactate, is close to impossible.

If we wait for the liver to resolve this massive, hydrochloric acid-like D-lactate piled up in the blood, the patient's heart will stop first.

If so, there is no choice but to physically neutralize it by pouring in a powerful alkali from the outside.

'We have to give it.'

The moment I gained enlightenment and hurriedly turned my head.

Click.

Click, click.

Clack-!

The cheerful sound of keyboard typing echoed at the station.

Lee Minjae had the EMR screen pulled up and was crazily inputting prescriptions with a hand movement that lacked even a single gram of hesitation.

'8.4% Sodium Bicarbonate 5 ampules. Total 100 mEq mixed into 1L of D5W fluid for IV infusion...'

On the monitor screen I stole a glance at, the very answer I had barely reached after agonizing bloodily upon hearing the ghost's advice a moment ago was being set and passed through in a perfect dosage and mix ratio.

As I showed signs of freezing in surprise, Lee Minjae, who was clicking the mouse, turned his head and asked.

"Why, Hyeonjae? Do you see something? Is there something even stranger with the lab values?"

"Ah, no, it's nothing."

I hurriedly managed my expression and brought out the additional measures I had thought of while tracing the pathophysiology just a moment ago.

"I think we should also order an NPO right away."

If intestinal bacteria are eating carbohydrates and spewing out D-lactate, it is common sense to block the food supply chain of those bacteria at the source.

The gastrointestinal tract must be completely emptied and rested.

At my suggestion, Lee Minjae nodded his head very willingly.

"Right. Order NPO. And of course, we have to catch the bacteria too."

Click, clack-!

"Metronidazole 500 mg TID. There's no antibiotic like this for catching anaerobic bacteria. For now, this should be enough."

'...Wow.'

No, what at all is this person's identity?

D-lactic acidosis is a unicorn-like disease that an emergency medicine doctor might see once in a lifetime.

But how could the treatment protocol and prescriptions pop out right away like this, tick-tick, as soon as the diagnosis dropped?

Did he not just write papers during his two years as a fellow, but chew and swallow the entire Internal Medicine textbook whole?

I captured those prescription details in my eyes and floated them up to the window in the void.

Korean Slave 1 (Male): (Picture) Is this right?

Latte is Mine: Surprisingly, it's right. Correcting the acidosis with Bivon, catching the causative bacteria with metronidazole, and blocking the food with NPO.

Mes of the God (Male): What is this. Clear away the squiggly words.

Let's spin the dialyzer: If EM hits that directly, it's convenient for IM.

While the compliments of the ghosts poured out, the nurses checked Lee Minjae's orders, hurriedly mixed the medications, and ran to the patient in Area A.

Just as the prescription went in and I was about to take a breath while monitoring the patient's breathing.

Thump-thump-thump-thump-!

The sound of someone sprinting crazily from the end of the emergency room hallway was heard.

A man coming with the hem of his white gown fluttering and even sweat dripping from his forehead.

A man who stopped in front of the station as if slamming on the brakes, panting for breath.

It was the Nephrology on-duty doctor.

"Huff... huff... Are you the teacher... who gave the consult? Professor Lee Minjae?"

The Nephrology fellow, Lee Junseo, could not even catch the breath that rose to the tip of his jaw, and spitting words out urgently and quickly while holding his knees with both hands.

"Our resident friend called for help, so I opened the EMR and saw the lab results... I did see them. But this. The lactate, yes. It's a disease that doesn't get screened by the emergency room machine, but this is D-lactate a... I mean, D-lactic acidosis! Because that disease is suspected!"

The excitement that he had caught a rare disease that couldn't be caught by the emergency room machine.

Lee Minjae sipped the paper cup containing coffee leisurely and replied very indifferently.

"We diagnosed it."

"Pardon?"

Lee Junseo's eyes blinked like an idiot.

As the name of the rare disease he had ambitiously thrown out bounced off without any sense of impact, he had a look of brain freeze.

"We diagnosed it in the emergency room. D-lactic acidosis."

"That... on the lab values, the lactate would have appeared normal..."

Without a word, Lee Minjae turned the monitor screen toward him.

On the screen, the prescription lists already entered in the emergency room long before the Nephrology fellow ran down were vividly displayed.

"Bivon, Metro... NPO... Huh? Uh?"

Lee Junseo's jaw dropped as he verified with his own two eyes that the D-lactic acidosis treatment protocol stuck in textbooks, which he had intended to come down and order, was uploaded as an order under the name of Emergency Medicine.

Toward the Nephrology fellow trapped in shock, Lee Minjae pointed at me, standing beside him, with the most proud expression in the world.

"Our department's 4th year diagnosed it. The prescription goes out just like this?"