Chapter 258

Episode 258: Anatomical Variation (1)

The inside of the conference room fell silent at my shocking remark.

‘…Hmm, was that too harsh?’

Then again.

Blatantly pulling a "You guys don't know because you’re amateurs, but I know lol" stunt in front of brain experts—could the reaction have been any different?

Several professors began turning on their laptops or looking for data, and Oh Man-seok blankly stared at me in a complete state of daze. Looking at him watching me with a gaze that seemed to say, 'What at all did I just hear?' it might have even looked funny to an outsider.

“The test last year wasn't just luck.”

I came to a conclusion.

“I think that way you can take it.”

I respond to a sniper attack with a sniper attack.

Of least, even so, using polite words and keeping a smile was essential in the midst of it. Because my position, after all, was a 2nd Year Resident sent on dispatch.

Right then, Professor Park Seung-woo, who was organizing something in front, approached me and started a conversation.

“Hey, dispatch? Teacher Han?”

From his voice, expression, and the attitude he treated me with, he seemed to have an immense number of questions, but he seemed to have decided to suppress them for a moment.

“We are going into an Emergency Surgery right now. I was wondering if you’d like to observe.”

“An observation?”

I was a bit flustered by the radical suggestion to abruptly enter and observe an emergency surgery from the morning of my first day of dispatch. Because even so, I thought I would normally follow the ward rounds on the first day, and keep listening to the conference from the back to grasp the atmosphere.

‘Then again….’

Because of my remark, it was a super-crisis situation where the entire surgery plan had to be completely changed. They had just now realized the fact about a fatal and important anatomical variation. From the operator's perspective, it would also be right to want to take this resident who had uncovered such an extremely rare anatomical variation in one go.

“Ah, yes. If so, there won’t be much I can help with, but…”

As I tried to continue the conversation using standard rhetoric, Park Seung-woo stopped me.

“Oh, no, no. We’re satisfied just by knowing this. Seong-hun!”

At that call, Hwang Seong-hun urgently responded.

“Yes, yes, Professor!”

“Follow me!”

At those words, Hwang Seong-hun even left behind the laptop he was using for the presentation and started heading toward the entrance.

“Let’s go. Teacher Han Hyeonjae.”

That way, the strange accompaniment started.

“Then, since we are an emergency, we will leave first.”

Park Seung-woo said that and closed the door.

Thump—

Step—

Step—

Catching the elevator, Park Seung-woo seemed dissatisfied with the attitude that a few professors had taken toward me in the conference room earlier.

“Anyway… they are wicked people, those guys. If there is a genius, they should know how to accept it, but they are just full of arrogance, unable to trust anything but their own experience…”

And then he looked at me and let out a hollow laugh.

“Ha, but Teacher Han?”

This person, at least, is friendly to me right now.

“Yes, Professor.”

At my answer, Park Seung-woo entered the newly arrived elevator and continued his words.

“Even so, you shouldn't be arrogant. Like Professor Oh Man-seok. Haha. Was that a little funny?”

“….”

“….”

At the silence between the two of us, Professor Park finally had to surrender.

“I tried to ease the tension with a joke. You don't laugh at all.”

The elevator started to move.

Whir—

“But what I said just a moment ago is sincere.”

“What words do you mean?”

At my answer, Park Seung-woo pointed at me and asked.

“What is your status.”

“I am a 4th year resident of Emergency Medicine.”

Park Seung-woo nodded.

“Yes, 4th year. No matter how much of a genius you are, it's still an unstable period. Your backing is also…”

Park Seung-woo stopped talking for a moment as if he realized something.

“Well, it is sufficient. Even so, always be humble.”

‘Yes.’

I am trying to be as humble as possible. Unless a first strike comes flying at me first.

“I will keep that in mind. Sorry for disturbing the atmosphere earlier.”

“No, what is there for you to be sorry about? It’s the fault of our department faculty who were just unnecessarily hazing you.”

Ding—

The4thfloor.

Thedoorsareopening.

Step—

Park Seung-woo, I, and Hwang Seong-hun started walking along the hallway toward the operating room.

“Anyway, Teacher Han played a huge role today. You saved a person.”

“Is that so?”

At my counter-question, Park Seung-woo made an expression as if he found it absurd.

“I saw earlier that you knew it well. Whether or not an anatomical variation is recognized before surgery is directly connected to the patient's life. What if we didn't recognize it and approached it in a conventional way?”

Park Seung-woo frowned. He seemed to have imagined something horrible.

“What if an aneurysm rupture happens while unreasonably attempting dissection to find the invisible A1 segment? If blood gushes in that narrow space, we can't even achieve hemostasis, and it's a patient table death.”

“Even so, that is true.”

Hwang Seong-hun chimed in.

“Like Teacher Han said earlier, trying to retract under the optic nerve could cause permanent blindness.”

At Park Seung-woo's words, I quietly nodded my head. Because I had pointed out that part precisely to prevent it. Honestly, there was an intention to crush Oh Man-seok in my tone and attitude, but it was hard to say that the attack itself was filled with malicious intent. Because it really was a situation directly connected to the patient's life.

“By the way, do you know what needs to be done before surgery?”

“What do you mean?”

“ICP care.”

Park Seung-woo really seemed to be expecting a proper answer from me. Unlike the neurosurgery faculty earlier, his gaze seemed certain that I would answer without trouble.

Step—

I initiated the cheating.

Korean Slave 1 (Male): How do you control pre-op ICP and rebleeding?

Mes of the God (Male): You don't even know this?

Latte is Mine: @Mes of the God (Male) Do you know?

Mes of the God (Male): Don't know well

Putting aside the tiki-taka of the ghosts who weren't even a help.

CrackTheHead: Nicardipine or Labetalol. Keep it under 140. They do it in the emergency room too, so you should know?

I relayed that answer exactly as it was. And added my own knowledge.

“To control the BP, we give Nicardipine or Labetalol to keep the systolic blood pressure under 140.”

“Right. Then again, do they do this much even in the emergency room?”

At Park Seung-woo’s smile, I added one more piece of cheated knowledge.

“I know that 1g of Levetiracetam can be administered intravenously to prevent early seizures.”

At those words, Park Seung-woo nodded.

“Right. Naturally.”

As we exchanged medical questions and answers and walked a bit down the hallway, the operating room began to come into view.

MainSurgicalCenter

“Now, let’s go. Which room did you say it was?”

At Park Seung-woo's question, Hwang Seong-hun immediately answered.

“Room 19. Professor Lee Chan-hyuk of Anesthesiology is inside.”

“Got it.”

In front of the operating room entrance, while doing the surgical hand scrub together, I continued my answers to Park Seung-woo's impromptu Q&A.

“In the case of a patient like this, what is different from a general surgery?”

Hmm. What is different from a general surgery, huh.

Korean Slave 1 (Male): What’s different from general surgery?

CrackTheHead: Fuck, I need to know the type of surgery to tell you, is it a craniotomy and clipping or what, tell me something, fuck

‘Aha.’

I left out the most important thing.

“Professor, what skills should the surgery I am observing today be based on? I mean, the specific bone approach site…”

At my words, Park Seung-woo answered as if he just realized.

“Ah, I didn't tell you the surgery name. Just like Teacher Hwang presented in the conference earlier, performing a Right Pterional Craniotomy is the same. Doing a Microsurgical Aneurysm Neck Clipping on top of that is also the same. However, the detailed process changes a bit, do you know it?”

Hmm. Naturally, as a raw empty can, I don't know. But if I cheat from the gallery, I will know.

Korean Slave 1 (Male): Right pterional craniotomy & microsurgical aneurysm neck clipping

CrackTheHead: ok ok

CrackTheHead: Look at No Name.txt number 2. It’s divided into three cases.

And I had to be horrified by that vast amount. Did they seriously write this in advance? And divided into three cases at that?

‘Why is there so much…’

For now, I should answer slowly, starting from what I can see.

“The point and ways in which this patient differs from an ordinary general surgery are clearly revealed at the following point.”

Ah, shit. Because I read the stiff and mechanical sentence exactly as it was, it felt oddly awkward, like a robot.

‘Are you crazy, Han Hyeonjae? Why did you read the sentence exactly 1 to 1? Speak naturally.’

Anyway, I can't keep my mind straight.

“In what point is it different?”

Park Seung-woo finished washing his hands and started moving his steps. I also followed behind him.

“In a general anterior communicating artery aneurysm surgery, after checking the internal carotid artery bifurcation, don't we immediately use a brain retractor to lift the frontal lobe and find the normally running A1 segment through the space above the optic nerve?”

At my answer, Park Seung-woo continued his re-questioning as if satisfied.

“Then do you know the reason why we look for the A1 segment at the beginning of surgery?”

With the knowledge I had learned in advance from the ghosts, I could easily answer that question.

“Isn't it because we have to apply a temporary clip for proximal control against rupture?”

“Correct,” Park Seung-woo answered, and Hwang Seong-hun, who was behind him, quietly nodded his head.

‘I didn't even know he was there.’

Because you have no presence.

“So what is different in this patient? Isn't that the most important thing?”

At Park Seung-woo's question, I diligently rolled my eyes and started to answer.

“In this patient, the A1 segment does not exist in that area at all.”

“Right. Because it runs inferiorly.”

“Instead, it is the worst structure where the anterior cerebral artery is forcibly passing through the narrow bone gap below the optic nerve.”

Park Seung-woo started putting on a gown. Hwang Seong-hun followed suit and started putting on a gown, and I also started wearing a surgical gown. Because even for just watching, sterilization is important.

I continued my answer.

“Therefore, if one attempts to retract the frontal lobe and optic nerve in the conventional way, the optic nerve will be strongly compressed between the bone and the retractor, blowing up ischemic necrosis and permanent blindness. Even if we can save them, it creates a disability.”

At those words, Park Seung-woo made a strange expression.

“Right, but even if it becomes a disability, wouldn't it be better than dying? So, what is the solution you thought of?”

He probably isn't asking because he doesn't know. If it were an extreme situation in the operating room where one had to choose between visual impairment and death, it wouldn't be handled as a topic for a tense quiz show like this. There is definitely a workaround.

“We must completely reverse the flow of ordinary neurosurgery.”

“What do you mean by reverse?”

Park Seung-woo showed a quite interesting expression, as if trying to check if the answer I would give matched the plan in his head.

“We must immediately hold off on the right A1 dissection and first secure the normal left A1 segment across the opposite left optic nerve.”

“What is the reason? To not touch the right side at all at the beginning?”

“Yes. We will absolutely not touch the right side in the beginning.”

At my answer, the corners of Park Seung-woo's mouth drew an arc.

“How do we treat it without touching the right side?”

I rolled my eyes again. Cheating, ON.

“On the right side, we maximize only the drainage of cerebrospinal fluid from the subarachnoid space without touching the optic nerve physically at all. Dissection is not attempted.”

“You will lower the intracranial pressure first?”

“That's right. I think the decisive difference from normal surgery is that we must naturally lower the ICP to induce brain relaxation, and then essentially apply a bypass dissection technique that indirectly secures the visual field in the narrow gap below the optic nerve under a microscope.”

At my words, Park Seung-woo smiled.

“Now, is there anyone who objects? To this plan?”

“….”

Silence ensued.

“It's identical to the plan I thought of. Good.”

That way, the surgical plan was confirmed, and as the anesthesiologist's timeout ended, Park Seung-woo shouted.

“I will start the surgery. Mes.”