Chapter 252

Episode 252. Cleanup (2)

‘This is my life….’

What was the point of being called a genius resident? My life wasn’t getting any better right now. I resigned myself to reality, slipped my gown back on, and stepped out of the duty room.

Clatter, clatter!

“Teacher, hurry!”

Inside the Emergency Room, the air was chaotic, bustling with frantically moving nurses and doctors. I quickly headed toward the center of the commotion.

“A seizure?”

“Yes, it looks like a GTCS pattern….”

The patient’s entire body was alternating between stiffening up and shaking, and he was even foaming at the mouth with white froth. I turned my head to check the vital monitor.

[ RR - ]


‘The respiratory rate isn't registering.’

A missing respiratory rate meant the patient was not breathing spontaneously on his own….

For a patient like this who was in a state of generalized seizure, a failure to detect a respiratory rate usually meant that the muscles required for breathing—like the diaphragm—had stiffened up, rendering them unable to breathe.

Tremble, tremble—

The patient continued to seize. I shifted my gaze slightly to check the rest of the vital monitor.

BP and HR were pass. Right now, checking whether breathing was occurring properly was far more critical than checking blood pressure or pulse rate. Besides, their blood pressure and heart rate were bound to be through the roof anyway, so checking it would only confirm the obvious.

[ 85% ]


Oxygen saturation was 85%. It was a natural consequence of not being able to breathe, but it indicated a state of clear hypoxia. The normal range for oxygen saturation is 95 or higher. Furthermore, considering that healthy individuals usually sit around 98 to 99, this was a distinctly abnormal figure.

‘No oxygen is reaching the brain at all….’

Yoon Tae-hyeon hurriedly barked out orders.

“Put, put a 100% oxygen reservoir mask on him and give 15L per minute….”

While Yoon Tae-hyeon was hesitating, I stepped closer to the patient and finished the order.

“BVM bag him instead of just using the reservoir mask. There’s no respiratory rate.”

“Ah, yes sir!”

Yoon Tae-hyeon wore an expression of sheer relief.

“Please also shoot 2mg of Ativan via IV.”

Ativan. Generic name: Lorazepam. It is a benzodiazepine-class anticonvulsant and sedative.

As a drug that enhances the action of inhibitory neurotransmitters in the brain, it is primarily used for acute psychosis patients at risk of self-harm or violent outbursts, or for seizing patients like the one right in front of us. Its onset of action is quite fast, making it useful for acute psychosis patients, and it is also highly effective at snapping a patient out of a non-stop seizure like this.

‘Speaking of Ativan, it reminds me of that one patient….’

An anti-NMDA receptor encephalitis patient. Was that during my 2nd Year?

‘For now, this isn't the time to think about that patient.’

Although we had administered Lorazepam because calming the seizure was the top priority, this drug was a very lethal double-edged sword. This was because it could suppress the brain so powerfully that it might even paralyze the respiratory center that drives spontaneous breathing. That was exactly why oxygen monitoring was absolutely essential.

“Tae-hyeon.”

“Yes, Teacher!” Yoon Tae-hyeon answered with a tense face.

“Keep monitoring the SpO2. Apnea or hypoxia could strike at any moment… so just in case, keep the intubation kit right next to you so we can do it immediately.”

“Ah, yes! Understood.”

It was right when we were keeping our guard up, closely monitoring his breathing.

“The seizure has stopped!”

Only after checking that the oxygen saturation on the monitor was stubbornly climbing back up to 92% could I finally let out a deep sigh.

Having overcome one major crisis, the thought finally struck me that I needed to check the patient's past medical history. I moved toward the station to check the patient's chart.

“Tae-hyeon.”

“Yes, Teacher.”

I brought up a significant fact that had emerged during the acceptance inquiry call with the 119 paramedics.

“Didn't you say the patient was seeing hallucinations and was at risk of self-harm? Did you consult NP after ruling out organic causes?”

The one hour I had spent sleeping should have been more than enough time to rule out organic causes, have the psychiatry resident on duty come down to finish the evaluation, and transfer the patient up to the psychiatric ward. The fact that he still hadn't properly gone up to the ward meant they were waiting for a psychiatry consultation after ruling out organic causes, didn't it?

Of course, since the patient had just suffered a generalized tonic-clonic seizure, the likelihood of it being a purely psychiatric cause had plummeted. Even so, since a consult had been sent out, shouldn't psychiatry at least explicitly cut him loose from their department by confirming it wasn't their disease?

‘Don’t tell me the psychiatry resident on duty hasn't even come down yet?’

I could understand it. The ward work could be busy. However, this was an urgent ER patient who had even seized; would it kill them to take a look within an hour?

At that, Yoon Tae-hyeon hurriedly waved his hands.

“No, no! It's nothing like that. Psychiatry already saw the consultation earlier.”

“Ah, they saw it earlier?”

He should have told me sooner. I had jumped to conclusions for nothing.

“If so, let’s see where the psychiatry consultation is….”

I moved the mouse to open the consultation tab tucked away in the corner of the EMR window.

To: EM

From: NP

This was it. To Emergency Medicine, from Neuropsychiatry.

‘Using "From" and "To" makes it feel kind of like a romantic letter.’

Indulging in that silly thought, I opened the window. The consultation result sheet from the psychiatry department was written in a typical SOAP note style. If that was the case, I only needed to look at the main highlights: the A and the P.

Assessment:

Substance-induced delirium (r/o Anticholinergic toxicity d/t cold medicine)

r/o Substance-induced psychotic disorder

Psychiatry suspected that some foreign substance acting on the brain had caused acute delirium as the primary cause. In particular, they seemed to suspect toxicity from anticholinergic drugs contained in the cold medicine that the patient had previously overdosed on. The second differential diagnosis was, naturally, substance-induced psychotic disorder.

I scrolled straight down to examine the section where psychiatry had laid out their judgment regarding the future treatment and diagnostic plan.

Plan: Anticholinergic delirium is strongly suspected as the potent cause of the patient's current psychosis. Since organic causes such as V/S instability (tachycardia, hyperventilation, high fever) are distinct, V/S monitoring and hydration under the lead of EM/IM prior to psychiatric intervention…

Hmm. To put it simply:

‘This isn't our psychiatric disease! It's an organic cause, so team up with Internal Medicine and resolve it together!’

That was the gist of it.

“Psychiatry rejected it, saying it seems like an organic cause?”

“Yes, Teacher.”

“What about the lab?”

“You can check it right now.”

I clicked the computer mouse to open the patient's lab results.

“What exactly was sent out?”

At my question, Yoon Tae-hyeon rolled his eyes upward, pondering for a moment, before rattling off the test list.

“A routine lab including a CBC and electrolytes was sent. A toxicology screening, ABGA, and acetaminophen screening were also ordered.”

“An acetaminophen screening?”

Did he order an acetaminophen screening because of the history of taking cold medicine?

“Yes sir.”

“What about the history?”

At my words, Yoon Tae-hyeon pondered again before rattling off the answers as they came back to him.

“He had upper respiratory infection symptoms starting 3 days ago, so he was taking cold medicine from a local clinic. He had anorexia starting 2 days ago and vomiting yesterday. It seems he also had abdomen pain. And he is said to have shown psychosis starting 6 hours prior to admission.”

“Then piece the entire history together. What do you think it is?” I asked.

As a 2nd Year, he should be capable of offering at least one opinion for a patient like this.

“Hmm, I can't help but think it might be a combination of hepatotoxicity from an acetaminophen overdose and dehydration issues caused by acute gastroenteritis.”

“Your reasoning?”

Yoon Tae-hyeon clicked on the triage sheet that described the patient's condition immediately upon arrival and spoke.

“It was mentioned that the cold medicine packets were empty. And since he had vomiting and abdominal pain, there was one thing I suspected.”

“You're suspecting fulminant hepatic failure, right?”

An overdose of acetaminophen leads to acute liver failure. When the liver loses its detoxification function like that, ammonia travels up to the brain, causing hepatic encephalopathy. The symptoms of hepatic encephalopathy include hallucinations and gibberish, which aligned well with this patient.

“But… the lab is a bit strange.”

The blood test? Ah, right. Since I had gone in to sleep an hour ago, it was about time for the results of most tests, including the labs, to have already come out. I moved the mouse to pull up the test result sheet.

“…Uh?”

[ AST 25 U/L ]

[ ALT 30 U/L ]


AST and ALT, the values indicating liver function. The liver levels were sitting well within the normal range.

‘If so, that means there was absolutely no destruction of liver parenchyma cells or inflammation….’

Although the acetaminophen screening results weren't out yet, this meant the hypothesis that acetaminophen poisoning had caused this patient's state was rejected. The hypothesis assumed that an acetaminophen overdose had led to liver failure, and substances like ammonia that failed to be detoxified traveled to the brain to cause hepatic encephalopathy.

Since liver failure—one of the intermediate steps—was completely absent to begin with, this was rejected without even needing to look at the acetaminophen screening. The bilirubin level, a jaundice marker that indicates biliary abnormalities in the liver, was also normal.

However, the problem wasn't the liver. The moment I scrolled down to look at the arterial blood gas analysis and the chemistry lab, my head began to spin a little.

[ pH 7.58 ]

[ pCO2 18 mmHg ]

[ BUN 2 mg/dL ]


The pH and pCO2 were indicating respiratory alkalosis, and despite being in a state of dehydration from vomiting, BUN—the symbolic marker of dehydration—had not risen at all.

This…. The pieces of these values didn't fit together at all.

“Tae-hyeon.”

“Yes, Teacher.”

“You think that respiratory compensation occurred due to dehydration, right?”

“Yes, Teacher.”

However, there was one massive, medically inexplicable flaw in Yoon Tae-hyeon's plausible claim.

‘Then why did alkalosis occur right now?’

The patient's current pH was 7.58. It was a blatant alkaline state. In the case of respiratory compensation for metabolic acidosis, no matter how much a patient hyperventilated by breathing heavily, the pH might hover in the alkaline range briefly during the very initial stage, but it would almost always remain in an acidic state.

‘In other words, we have to view this as primary respiratory alkalosis from the start.’

“There’s an increase in WBC, so I wonder if it might be an infection….”

“Even if it rose, it's only eleven thousand.”

The WBC count was currently 11,500. It was a bit of a stretch to suspect encephalopathy caused by an infection with a level like this.

So for now…. Let's hand it over to the experts.

“Let’s send consultations to Neurology and Infectious Diseases. Ask them to rule out encephalitis or meningitis.”

“Yes, yes. Then I will send consultations to Neurology and Internal Medicine like that.”

Ultimately, I decided to hand the patient over to the departments that specialized in the brain and infections. From a mild fever, headache, and hallucinations to generalized seizures and a coma. Given the symptoms, there seemed to be a fairly high possibility of HSV encephalitis due to a central nervous system infection or some other autoimmune encephalitis.

“Just call them on the phone for that.”

“Is it okay to do that?”

“It's urgent, so we have to resort to that at least.”

“Then we will take a look for a bit,” said Choi Hyun-jin, a 3rd Year from Neurology.

“Yes, yes. Please take good care of him.”

However, despite Neurology having arrived, I couldn't shake off this lingering discomfort.

‘If it really is encephalitis, why was the BUN level low, and why did alkalosis occur?’

It was officially time to use the Gallery of the Dead Medics. Setting the Neurology consultation aside, I needed to hear their opinions too.

Dead Medic Gallery

Case of a 27-year-old male patient

Author: Korean Slave 1 (Male)

(Lab results picture) (Prescription picture)

What do you guys think it is?

Comments

FireUpTheDialysisMachine: There’s a high possibility that severe hyponatremia is the main issue. Where did the electrolyte lab go?

Korean Slave 1 (Male): My bad, my bad.

Korean Slave 1 (Male): (Picture)

FireUpTheDialysisMachine: ??? Why is the sodium normal?

Cardiology Ghost: He vomited that much, so why are his sodium and electrolytes normal?

Exactly. When a patient vomits, a massive amount of electrolytes should be depleted along with gastric juice, but this patient's electrolyte levels were entirely too peaceful.

Latte is Mine: Seeing how his vitals are fluctuating, it looks like sepsis based on qSOFA.

Korean Slave 1 (Male): The lactate is fine though.

Hippocrates' Descendant: O living doctor, could this not be anticholinergic delirium! Given that he took cold medicine, I believe my opinion is justified!

Korean Slave 1 (Male): Rejected.

Hippocrates' Descendant: How harsh, O living doctor!

Even though I watched the debate go back and forth among the ghosts of the gallery like that, no clear solution seemed to be in sight.

Latte is Mine: Hell Slave.

Korean Slave 1 (Male): Yeah?

Latte is Mine: Can you do history taking again? With the guardian?

Korean Slave 1 (Male): Yeah, what should I ask?

Latte is Mine: I’m asking just in case, but go check if the patient avoided protein-heavy foods.

‘Protein?’

Whether a patient could or couldn't eat protein-heavy foods well didn't align with encephalitis, nor did it match other infectious symptoms. Naturally, it didn't seem to have much to do with poisoning either.

But when did I ever have the luxury of choice?

With that, I walked out of the ER doors and found where the guardian was waiting.

“Hello, Mother.”

“Ah, ah… Teacher. Is Ju-ho okay?”

I bit my lower lip hard.

“Currently, a teacher from another department has come down to check on the patient's condition… I came because I have an important matter to ask.”

“Ah, yes, if anything helps, of course I can tell you.”

“By any chance, did the patient have a personality that avoided protein-heavy foods usually?”

At my question, the patient's mother rolled her eyes, appearing flustered.

“Protein? If he ate things like tofu or meat… he did say his head felt like it was splitting open with pain. Recently… so I was worried about it.”

“Ah, yes, thank you for your cooperation, Mother.”

Giving a polite bow to the patient's mother, I walked back into the ER.

O window in the void. Open up.

Pop!

Comments

Korean Slave 1 (Male): Yeah, she said his head ached whenever he consumed protein.

Latte is Mine: Oh. I think I know what it is.

Korean Slave 1 (Male): ?? What is it?

After leaving that comment, I headed toward the station, only to find that the station was chaotic.

“What's going on?” I asked, and Choi Hyun-jin from Neurology answered.

“Ah, there was a focal seizure. We gave 2mg of Lorazepam and put him on Depakine.”

Hearing those words, I quietly nodded my head.

Depakine, generic name: Valproate. As a type of anticonvulsant, it is a drug widely used in clinical practice for everything from generalized tonic-clonic seizures to absence seizures in children.

‘Mixing 1500mg into saline for a 15-minute IV infusion….’

It was a necessary treatment to prevent the seizure from failing to stop and progressing into the worst-case state called status epilepticus. It was a standard, safe, textbook treatment as well.

I left a comment to update the situation.

Korean Slave 1 (Male): Valproate is running.

Then, after a brief moment, a reply was posted.

Latte is Mine: Ffffuuuuck, which quack bastard did that, ffffuuuuck!!!!!!!!!!!!! STOP IT!!!!!!!!!!!!!!!! The patient has UCD (Urea Cycle Disorder)!!!!!!!! OTC deficiency!!!!!