Chapter 231

Episode 231 The Invisible Figure (3)

Kidney Fellow Lee Junseo’s eyes shook at Lee Minjae’s bragging. The fact that an Emergency Medicine resident had correctly diagnosed this ultra-rare disease—which he, an Internal Medicine board-certified doctor, had barely managed to deduce—seemed to have left a pretty heavy scratch on his pride. Probably.

I spoke up calmly. Although we made the diagnosis and initiated the initial treatment, this patient's final destination was ultimately the domain of Internal Medicine.

"Uh, I think the patient needs to go up to the MICU."

At the word "intensive care unit" coming from my mouth, Nephrology Fellow Lee Junseo flinched and replied, "Huh? ICU?"

Lee Junseo frowned slightly, as if he wanted to dispute the ICU admission criteria. Although the acidosis was severe, the vitals themselves hadn't collapsed into a state of shock right away.

"Yes. To prevent hypernatremia and a sudden spike in serum osmolality caused by an excessive sodium load, Nephrology will need to regulate the IV fluid rate closely."

The 8.4% sodium bicarbonate ampules that Lee Minjae had just poured in are excellent for neutralizing D-lactate in the blood. But the cost? If a tremendous amount of sodium is dumped into the patient's body, water will pull out of the cells, causing brain cells to shrink or triggering severe osmotic shock. This wasn't something that could be managed casually in the Emergency Room or a general ward by drawing blood every few hours. Naturally, a real-time tracking of electrolytes and micro-adjustments of IV fluid speed fell under ICU admission criteria.

"If so, then a general hospitalization..."

"Uh, the patient's state is..."

At my words, Lee Junseo followed my gaze and looked toward the Area A bed.

"Ah, encephalopathy."

A sigh escaped Lee Junseo’s mouth as he checked the patient's condition with his own eyes. If a patient whose consciousness fades in and out is left lying in a general ward and stops breathing or has a seizure during the night, the responsibility falls squarely on the on-duty doctor.

"Yes. For now, the encephalopathy issue is severe, and there's also the possibility of other complications due to volume overload. Given their age, we need to monitor heavily to see if fluid builds up in the lungs..."

Lee Junseo nodded at my briefing. "That's true."

"Regarding the SIBO, I think we should request a consultation with Gastroenterology so we can manage it together. Fundamentally, overhauling the intestinal environment is their specialty."

"Yes, um. I get it for now. If so, Professor Lee?" Lee Junseo turned to look at Lee Minjae, who was relaxing nearby, and asked.

At Lee Junseo’s call, Lee Minjae smiled broadly and spoke up. "Ah, yes."

"Then we are transferring the patient to the ICU...?"

"The hospitalization order went out through the system a moment ago."

Lee Minjae’s workflow was quick and precise.

"Then we will transfer them right away."

"Yes, please~ Thank you for your hard work, doctor."

And that way, the suspected stroke patient's case concluded cleanly with a transfer to the MICU, turning into a plot twist involving an ultra-rare metabolic disease. As the sound of the bed's wheels rolling across the Emergency Room hallway faded away completely, "Puhahaha!"

Lee Minjae, who had been standing politely, collapsed onto the station desk and burst into laughter. "Wow~ Han Hyeonjae, you crazy bastard. Wow... this is driving me crazy."

Lee Minjae suddenly snapped his head up and pointed his finger at me. "Do you seriously have something? What exactly is inside your head?! Speak honestly. You actually walk around with Harrison's copied into your brain, right? Don't you? Surely Sabiston is in there too, isn't it?"

Looking at Lee Minjae, I chuckled inwardly. 'I think you're the one walking around with Harrison's in your head.' When I barely reached the destination of the diagnosis using the cheat code of the spirits' advice, hadn't this gentleman immediately calculated the exact number of 8.4% sodium bicarbonate ampules, the mixing ratio, and fired off the metronidazole order without a single second of error?

I put on the exemplary smile of a very pleasant 4th-year resident. "Oh, absolutely not. How could I dare memorize an entire textbook? It's all thanks to you, Teache—no, Professor, guiding me well on a regular basis."

Lee Minjae shrugged his shoulders, seemingly pleased by my soulless flattery. "It's so reassuring to have a genius around, just so reassuring. Eh? Anyway, those Internal Medicine folks must never steal him away..." He muttered, tapping my shoulder with satisfaction.

'The genius is you, this person.'

The day of 2nd-year Nephrology Fellow Lee Junseo had been peaceful. Morning rounds were completed safely. Orders for the afternoon dialysis unit patients were also finished. It was peaceful. At least, it was until the moment he sat on the doctor's office sofa, sipping an energy drink. The potassium levels of a chronic renal failure patient who had been causing headaches for days had finally stabilized, and the quiet afternoon was free from any emergency dialysis calls. It was peaceful.

That is, until a 2nd-year Internal Medicine resident called for help.

Bzzzz—

Bzzzz—

Breaking the silence, the on-duty phone vibrated. Checking the caller ID, Lee Junseo let out a soft sigh and pressed the call button. It was a call from Seong Eunyu, a 2nd-year Internal Medicine resident who was in charge of ER consultations. Normally, Lee Junseo would have been annoyed first, wondering what kind of useless patient the Emergency Room folks were trying to push into Internal Medicine again, but now he was a bit flustered. The voice of Seong Eunyu coming through the handset had lost its usual calmness and was trembling slightly.

The Doctor Seong that Lee Junseo remembered was an ace resident junior among the 2nd-year Internal Medicine pool, quite smart and quick in judgment. She wasn't someone who would call a fellow directly with a panicked tone over a typical abnormal lab value or common sepsis.

— Teacher, this is Seong Eunyu, 2nd-year Internal Medicine. Sorry. There's a consultation that came into our side from the ED right now, but I can't seem to get a handle on it.

"Uh, yeah, yeah. What's wrong? Are they trying to admit another strange patient without even running a screening?"

— It's not that, but the patient's lab values are truly bizarre. It feels toxic, but then it doesn't. The acidosis is so severe, but I don't know the cause. Can you check via EMR right now?

"EMR?"

Frowning, Lee Junseo set his drink down on the desk and grabbed the mouse. If Seong Eunyu was calling for help with this much uncertainty, it meant the case deviated significantly from the textbook.

"Give me the patient's registration number."

Clack-clack-clack—

Click.

As Lee Junseo entered the number into the system window and brought up the screen, the patient's state looked quite bad. In particular, the tachypnea rate well over 30 breaths per minute and the bright red results of the arterial blood gas analysis were indicators where a sudden cardiac arrest wouldn't be surprising at any moment. And scrolling down, he found the consultation reply comment just left by Neurology.

▶ Reason for Referral: Altered mental status & Ataxia

▶ Impression: Secondary metabolic encephalopathy d/t severe metabolic acidosis. (R/O Structural brain lesion)

▶ Findings are consistent with secondary metabolic encephalopathy due to severe metabolic acidosis rather than a structural brain lesion; not an indication for acute neurologic intervention.

▶ Recommend conservative care led by IM & EM for correction of Unknown origin HAGMA & metabolic disease w/u.

To put it in one word: 'It's not a broken brain vessel, so we in Neurology are bowing out. Since the blood is rotting from an unknown acidosis, you guys in Internal Medicine figure it out, whether you run dialysis or whatever.' That was it.

"Ha, seeing acidosis and immediately throwing a bomb to Internal Medicine. Even so, the screening..." Lee Junseo let out a hollow laugh and brought his face closer to the monitor. He could see why Seong Eunyu was flustered.

High anion gap metabolic acidosis. If this anion gap had widened all the way to 32, the causes should narrow down very clearly. Lee Junseo began looking through the ER lab results on the screen one by one, crossing off the possibilities in his mind.

'Not methanol. Ketone levels normal. Paraldehyde or isoniazid makes no sense given the history. Lactate level normal. Osmolar gap normal. Salicylate level is merely 25.'

Ruled out, ruled out, ruled out, ruled... out?

Lee Junseo’s finger stopped dead over a specific figure. The cogs in his brain ground to a halt as they caught on a discrepancy.

'Wait. Is it right to rule out lactate?'

Surely, the value spat out by the ER equipment was normal. However, the blind spot of the machine hidden behind the numbers flashed through Lee Junseo’s mind.

'The blood gas analyzer cartridge that gives immediate results in our hospital's emergency lab only measures L-lactate, which is metabolized by the human body.'

If so, what if a type of lactate that the machine couldn't read was filling up the patient's blood? Lee Junseo’s pupils began to shake.

'It's extremely rare and uncommon, but what if D-lactic acidosis, which is pumped out by intestinal bacteria, has occurred...?'

His gaze rapidly shifted to the patient's past history column.

[10 years ago, Small bowel resection performed due to Volvulus.]

His heart thumped. The puzzle pieces began to lock together. It fit perfectly with the history of short bowel syndrome from having the small intestine resected. A case he had only read about in text in textbooks, something difficult to encounter even once in a lifetime in clinical practice.

"Eunyu!" Lee Junseo shouted urgently into the handset.

— Yes, yes, Teacher! Did you see something?

"I'm heading down to the ER right now!"

— Uh, what? You're coming down yourself?

"Hang up for now! I'll explain later!"

Lee Junseo slammed the phone down without even waiting for Seong Eunyu’s reply. He needed to deliver this news to the ER quickly, inform the wandering Emergency Medicine doctors of the diagnosis, and immediately prepare for sodium bicarbonate administration and treatment. His mind hurried his footsteps. When the elevator took too long, he kicked open the emergency exit door and dashed down the stairs toward the ER.

Even in the midst of that, Lee Junseo hurriedly pulled out his phone in his pocket to recheck the exact treatment guidelines for D-lactic acidosis for the first time in a long while.

'Cover the acidosis with Bivon, destroy the gut bacteria with metronidazole, and cut off carbohydrates with NPO.'

Panting heavily, Lee Junseo arrived at the ER station at a full sprint and, with a face drenched in sweat, confidently sought out Professor Lee Minjae.

And then. A few minutes later.

"A 4th-year in our department diagnosed it, so the prescription is going out like this?"

"...Huh?"

A single word from Emergency Medicine Clinical Assistant Professor Lee Minjae. And the perfect treatment prescriptions displayed prominently on the monitor as if to show off. Hearing those words, Lee Junseo felt like his soul was being dragged right out of his mouth. The dramatic appearance as a savior that he had imagined while running down the stairs was shattered into pieces.

To make matters worse, the 4th-year Emergency Medicine resident—looking at him while he was worrying over whether to start dialysis—even lectured (?) him with a highly logical and suffocating argument about why the patient needed to be transferred to the MICU for IV fluid rate adjustment and encephalopathy management. After being dragged around in his own specialty by a mere 4th-year resident from another department, right around the time he finally arrived at the Medical Intensive Care Unit.

As he connected the monitoring equipment and wrote out prescriptions, a chilling thought suddenly flashed through Lee Junseo’s mind.

'Wait. That resident...'

4th-year Emergency Medicine resident Han Hyeonjae. The name wasn't unfamiliar. No, it was stranger not to know that name among the residents and fellows rolling around the hospital floor. He was the protagonist of those crazy rumors whispered throughout the hospital.

— That ER resident guy, did you hear he got disciplinary action this time?

— They say there's a crazy bastard in the ER.

— You know, that Doctor Han Hyeonjae in EM. There's a crazy genius.

— Doctor Han? I know him. He's a legend in Pediatrics too. Last time, he placed a UVC in one shot inside the doctor helicopter.

— I heard he even changed the aorta surgery plan during his last dispatch rotation?

Rumors are bound to be exaggerated. Lee Junseo had also thought it was just inflated hot air. But after experiencing it firsthand today, the thought crossed his mind that those rumors might not be mere exaggerations.

"Ha..." Lee Junseo stared blankly at the monitor and let out a long breath. Rather than his pride being hurt, it was just a severe sense of terrible helplessness felt in front of an overwhelming talent.

'There are just too many geniuses in this world.' Lee Junseo thought.