Chapter 43

Episode 43 Migraine (2)‌

It was not a severe bruise, the kind that looked like a major injury. It was just a faint bruise, commonly found when you bump into the corner of a piece of furniture. It was a minor mark that would usually be overlooked.

However, today of all days, that bruise strangely got on my nerves. Before I knew it, I stopped in my tracks and poked my head inside the curtain.

"Patient."

At my voice, the nurse and the patient looked at me at the same time.

"You have some bruising on your arm. Did you bump it somewhere?"

At my question, the patient looked down at her arm, with a look as if she didn't even know there was a bruise there.

"Oh? You're right. When did that happen...?"

The patient furrowed her brow, searching her memory.

"Did I bump into the desk while closing up yesterday...? I don't remember well..."

The answer was ambiguous. It was unclear whether she truly couldn't remember or if she just considered it no big deal. However, that uncertainty left a very small, uncomfortable ember in my mind.

I couldn't explain the reason. Just... something felt strange.

A young woman exhausted from staying up for several nights. A throbbing migraine. And a bruise she didn't even know about. Taken separately, they were common symptoms and signs that meant nothing.

'...Is it okay to just let it go?'

With a 99% probability, this would be nothing. But the remaining 1%. An Emergency Room doctor is a profession that must always bet everything on that 1% possibility.

I pondered for a moment.

'...Something feels uncomfortable.'

In the end, I decided to follow that unexplainable anxiety within me. I turned to the nurse.

"Teacher, I'm sorry, but let's go ahead with a blood draw first before giving the injection. Please add a CBC (Complete Blood Count). And we'll hold off on the Ketorolac for a moment."

At my sudden order, the nurse's eyes widened slightly, but she soon nodded. The patient had a look that said, 'Even a blood test...?' but she obediently extended her arm.

Leaving that sight behind, I returned to the Station.

Yes. It's probably nothing. I'm just acting too sensitive. Is this the aftereffect of that crazy incident?

Comforting myself that way, I started to focus on the backlog of work again. Time passed, and the memory of that young designer patient faintly faded into the noise of other emergency patients.

About 40 minutes must have passed. An intern approached me holding a bundle of charts.

"Teacher, the lab results for the 28-year-old headache patient in Area B, Bed 9 came out..."

The intern's voice was somewhat strange.

"Everything else is fine, but the platelets are... 38,000."

I stopped my typing fingers. Then, I slowly raised my head.

"What?"

"The platelet count came out to 38,000. The normal level starts from 150,000... Could it be a lab error? Either the sample was drawn incorrectly, or it's a machine error. Should we run a retest?"

The intern's words were rational. A level this absurdly low usually has a high probability of being a lab error.

...Sigh.

I took a short breath. Keeping my calm with an effort, I spoke to the intern.

"Uh, yeah, run a retest. The sample must have been drawn incorrectly. Draw it again with a different tube, and this time, take the sample directly to the lab by hand and check."

My voice was strange to the point of being calm. However, a single line of cold sweat was trickling down my spine.

Please. Please let it be a lab error.

I stared blankly at the spot where the intern had disappeared. 38,000. That number lingered ominously in my head. Going to the corner of the Station, I leaned my head against the wall and began my solitary agony.

For now, let's be calm.

The patient is a 28-year-old female. Chief complaint is a headache. Migraine. She said so with her own mouth. I also thought so.

But the platelet count is 38,000. Does a migraine consume platelets? Fuck, that's nonsense.

If so, my first diagnosis was wrong. This headache is not just a migraine. Then what are the possibilities?

The list of differential diagnoses that I had memorized by heart flashed through my mind like a kaleidoscope. Causes that induce thrombocytopenia.

First, the most terrifying possibility is a hematologic malignancy like leukemia. A case where cancer cells occupy the bone marrow, making it unable to produce normal blood cells. However, the patient's other blood counts were normal. Both white blood cells and red blood cells. If so, can we lower the possibility of cancer for now?

Next? Drugs. Certain medications can destroy platelets. But the patient said she hadn't taken any medication recently. Her medical history was also clean.

Liver cirrhosis or splenomegaly? Platelets can be destroyed if the liver is bad or the spleen is enlarged. But in a young woman? And without any symptoms? The probability is low.

Then what's left is... 'Autoimmune disease.'

A faint possibility arose in my head. A disease where the immune system makes a mistake, regards our own platelets as enemies, and indiscriminately attacks and destroys them. A disease where only the platelet count drops standalone.

Idiopathic Thrombocytopenic Purpura. ITP.

It felt like all the pieces were fitting together. Yes, as of now, this is the most rational suspicion.

I could no longer keep agonizing alone. I looked around. Fortuitously, 2nd Year Choi Sumin (Female) was just finishing charting another patient.

Approaching Choi Sumin, I reported with a voice as calm as possible.

"Teacher Choi Sumin. I am reporting regarding the 28-year-old female headache patient in Area B, Bed 9."

"Oh, that migraine patient? Does she say it still hurts even after giving the medication?"

"No, it's not that... I saw some bruising on the patient's arm, so just in case, I ordered a CBC, and the platelet count came out to 38,000. A retest has been sent out for now."

At my words, Choi Sumin's expression stiffened in an instant. Choi Sumin immediately grabbed the mouse and opened the patient's chart.

"38,000? What about the other levels?"

"White blood cells and hemoglobin are all normal."

"Hm..."

Choi Sumin stared at the monitor with her chin propped on her hand. The same list of differential diagnoses as mine must be unfolding in Choi Sumin's head as well.

"Teacher. In my opinion, since there are no other findings at all for now, wouldn't the possibility of ITP be the highest?"

At my cautious opinion, Choi Sumin nodded.

"I think so too. To think of other possibilities, it's just too typical. Let's see the retest results first. If it comes out the same in the retest..."

Not long after, the intern ran back to me with a face that was almost on the verge of crying. In his hand, he held a warm, freshly printed result sheet.

"Teacher, it's the retest result... it's 35,000."

What was bound to come had come. It was not a lab error.

Choi Sumin took the result sheet and let out a deep sigh.

"Ha... Hyunjae. You go yourself and explain to the patient. Tell her she needs to be hospitalized."

"Pardon? Me?"

"Yes. It's a case you discovered. Go and explain it well, calmly and in an easy-to-understand way."

I swallowed dry saliva. I have to tell a patient, who said she wanted to leave after getting a shot of painkiller, that we suspect a serious autoimmune disease for which she must be hospitalized right now to undergo detailed testing.

Moving with heavy steps, I headed toward the patient's bed again.

When I pulled back the curtain, the patient was looking at her smartphone while receiving the IV fluid. I pulled up a chair next to the bed and sat down.

"Patient. I have something to tell you for a moment. You might be very surprised, but please listen calmly. It seems your headache is not the simple migraine we initially thought."

I began to explain slowly, choosing words that were as easy as possible.

"Have you perhaps heard of platelets?"

"Platelets?"

"They are very important cells that rush first to block a wound and stop the bleeding when our body gets hurt and bleeds. You can think of them as a sort of repair construction team for our body."

I took a moment to catch my breath.

"A normal person has about 150,000 to 400,000 of these platelets in their blood. However, we just did your blood test, and your platelet count came out to 38,000."

The patient's eyes went round.

"What? Is that very low?"

"Yes. It is a very, very low level. Because of the lack of platelets to block it, blood vessels burst easily even at a very small impact, which is why bruises form easily."

"Why am I..."

"The disease we are currently most strongly suspecting is Idiopathic Thrombocytopenic Purpura, or ITP for short."

I used an analogy so the patient could understand.

"It's a difficult name, but I'll explain it simply. Originally, our body's immune system should only attack bad bacteria or viruses that come from the outside. However, sometimes this immune system makes a mistake and mistakes our body's normal cells for enemies, attacking and destroying them. That is called an autoimmune disease. In your case, it appears that the immune system is mistaking our own platelets for enemies and continuously destroying them."

As my explanation grew longer, the patient's face turned increasingly pale.

"Your life is not in immediate danger right now. Don't worry too much. However, if the platelet count is this low, a very dangerous situation can occur. For example, if even a small blood vessel in the head bursts, it could lead to a brain hemorrhage. Perhaps we cannot completely rule out the possibility that the headache you are experiencing is also such a warning sign."

The patient's pupils shook with fear.

"Therefore, you cannot go home today."

I spoke firmly.

"You must be hospitalized right away. You need to be admitted to our hospital to undergo additional detailed tests to confirm if this is truly ITP or if there is another cause. And at the same time, we must start treatment to calm the immune system down a bit so that it no longer destroys the platelets."

All explanations were finished. The patient stared blankly into the void without a word.