Chapter 44

Episode 44 Migraine (3)

I returned to the station with a heavy heart after finishing the explanation of hospitalization to the patient.

‘ITP. Idiopathic Thrombocytopenic Purpura.’

A disease where the immune system temporarily loses its mind and destroys its own platelets. Of course, it is a serious illness, but among hematological diseases, it is relatively common, and treatment starts with steroids, making it one of the nicer ones, so to speak.

Yes, that must be it. Unless it's a lab error, ITP is the most likely possibility. Especially since it frequently occurs in young women. All the circumstances are pointing to that. I struggled to reassure myself that way.

However, an unknown, lingering uneasiness settled in a corner of my mind and would not disappear. In the end, unable to overcome that anxiety, I summoned the all-powerful tutors inside my head. Let's just do a double-check to be absolutely sure. If those crazy ghosts also agree it's ITP, then I can hand the patient over to the Hemato-Oncology department with a truly peaceful mind.

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Title: 28/F, headache, bruising, platelets 38k. Is it ITP?

Author: Korean Slave 1 (Male)

Even the retest came out like this. At this point, it's safe to view it as ITP and use steroids, right? Is there anything else to consider?

It was an extremely ordinary question. However, the moment that question was posted, the Gallery turned into a chaotic hell.

Hematoma is Hell: Is this crazy bastard really looking to die!!!!!!!!!!!!

…Excuse me?

For a moment, I doubted my own eyes. Did I ask something wrong?

Hematoma is Hell: ITP? Cut the ITP crap, you quack! Why did the patient come in complaining of pain right now? Huh? A headache! She came in because her head hurts! But her platelets are smashed to pieces! Can't your brain interpret what this means?!

That was the start. All sorts of department ghosts jumped in and started biting my head off.

Latte is Mine: Tsk tsk. Kids these days lack the basics. Headache, thrombocytopenia, bruising. Just looking at these three, a siren should normally be ringing in your head! And you're spouting nonsense about ITP looking at this!

Cardiology Ghost: Hey, when the patient's lab was drawn, did you check the LDH and bilirubin levels? No signs of hemolytic anemia? What about kidney function? Are the kidney numbers intact?!

Hematoma is Hell: Aren't you ordering a peripheral blood smear? Are you not ruling out TTP?? While you prescribe steroids and casually stand by with your hands behind your back, the patient's blood clots will worsen to the point where it's practically a party, and they'll just head straight to the afterlife! You crazy bastard, do you want to die!!

TTP. Thrombotic Thrombocytopenic Purpura.

Ah. Ah, right. How could I have forgotten this? How could I have not even thought of this?

TTP. A disease where blood clots are insanely generated for no reason in all the microvessels throughout the entire body. As the clots are made, they consume every last platelet, causing the platelet count to hit rock bottom. Red blood cells forced to pass through those narrowed blood vessels are torn to shreds, resulting in hemolytic anemia. And those clots block the blood vessels leading to the most important organs in our body—like the brain, heart, and kidneys—causing the organs to slowly rot away. If the diagnosis is even slightly delayed, it is the worst emergency disease in the field of hematology, with a mortality rate approaching 90%.

The symptoms of that disease: thrombocytopenia, microangiopathic hemolytic anemia, neurological symptoms, renal failure, and fever.

My patient… …headache. …thrombocytopenia. …bruising.

I slumped onto the chair at the station, feeling the blood in my entire body run cold. While I was reassuring myself that it was a nice disease, blood clots might have been forming inside the patient's cerebral blood vessels.

Hematoma is Hell: Make a PBS slide right now and check for Schistocytes first, you idiot! If it's TTP, you're fucked, you brat!!!!!! Run!!!!!

I snapped out of it at that last comment. This is no time to be sitting here blaming myself. I bolted up from my seat and grabbed the intercom as if letting out a scream.

Extension number 7111.

Press. Press. Press. Press.

"Yes, hello, this is the central lab—"

"This is the lab, right? The retest that just went out for the 28-year-old female patient in ER Area B, Bed 9! Patient ID 1397131, please make a peripheral blood smear slide with that sample right now and look under the microscope! Forget everything else, just quickly tell me whether there are schistocytes or not! It's urgent! It's STAT! STAT!"

"What?"

"Run a peripheral blood smear for patient ID 1397131! It's urgent!"

"Ye… yes."

My voice was trembling with fear. Lowering the handset, I covered my face with trembling hands.

Please. Please let it not be. Please don't let broken red blood cells be visible.

Crouched in a corner of the station, I was aimlessly refreshing only the EMR window. I saw other patients, did my charting, and even nodded off, but all my nerves were focused solely on the single phone call that would come from the lab.

A hellish time where one minute felt like an hour. My mind was full of all kinds of worst-case scenarios.

'That bruising and headache are so unsettling. If it really is TTP…'

Just then.

Ringggggggg!

The station's telephone rang sharply. It felt as though all the noise in the Emergency Room was buried by that single ring. I picked up the handset almost reflexively. My heart was pounding like crazy. Please. Please tell me it's not.

"Yes, Emergency Medicine."

My voice was trembling without me realizing it.

"There!! The patient in ER Bed B-9! The peripheral blood smear result for the 28-year-old female patient is out!!!!"

I swallowed hard at that urgent shout.

"Numerous schistocytes are observed on the slide, and it looks like Grade 3 or higher! Furthermore, severe thrombocytopenia accompanied by giant platelets is distinct, and even the findings for Polychromasia are clear! This perfectly fits the findings for thrombotic microangiopathy like TTP or HUS!!!! You need to check this quickly—"

Fuck. My worst expectation—no, the prophecy of the Gallery ghosts—had become reality.

They said numerous broken red blood cells were observed. Grade 3. It's a state where the corpses of red blood cells are roaming around. Because the platelets and red blood cells are all dying off, the bone marrow is sending poorly trained platelets and red blood cells into the battlefield after only a one-week accelerated rookie course.

Distinguishing whether this is TTP or HUS doesn't mean much right now. Either way, they are both part of the same fucking family of thrombotic microangiopathy that will cause the patient to pass away if not treated immediately. Besides, it fits TTP better anyway.

I hung up the handset before the words could even fully finish. There isn't even time to panic. From now on, every single minute and second is directly linked to the patient's life.

"Internal Medicine! Internal Medicine, fuck!"

I sprang up from the chair and ran like mad toward the whiteboard in the center of the station. The surrounding nurses stared at me with startled eyes, but I couldn't see anything. Only the densely written names and contact information entered my vision.

Hemato-Oncology. Hematoma. Who is the hematoma on-call?

I traced down the whiteboard with a trembling finger.

[Internal Medicine (Hemato-Oncology Part) On-Call]

1st Call (Internal Medicine R2 Kim Jieeun)

2nd Call (Hemato-Oncology Fellow Jin Saehee)

Two names were visible. Kim Jieeun. Jin Saehee.

Wait a moment. Do I contact the 1st call, or the 2nd call?

Reason and instinct clashed violently inside my head. According to protocol, I should naturally contact the 1st call, 2nd-year resident Kim Jieeun, first. A low-ranking 1st-year resident passing the 2nd-year to contact the fellow directly is practically a suicidal act that goes against hospital etiquette. Kim Jieeun would be absolutely furious, and the fellow, Jin Saehee, might chew me out, asking, 'Where did this random 1st-year come from calling me directly?'

But… But now is not a situation to argue about hierarchy. How much would a 2nd-year like Kim Jieeun know about TTP? In the end, she would look at the patient, panic, and contact her senior, the fellow, anyway. Of course, this was just my brain's assumption.

At least ten minutes would be wasted in that process. And during those ten minutes, blood clots would be blocking blood vessels and destroying organs in the patient's brain, heart, and kidneys.

"Even so, a hematoma doctor needs to see this."

I made up my mind. Whether my hospital life goes to shit or not, let's save the patient first. My hospital life is already ruined anyway. I'm not even afraid.

"2nd call!"

I pulled out my cellphone and frantically pressed the number for the hematoma fellow, Jin Saehee, written on the on-call schedule. Just before pressing the call button, I paused to catch my breath.

Phew… Haa… Shit… Shit…

The tips of my fingers had turned cold. From now on, every single word I utter will decide a person's life.

Ring… Ring…

The ringback tone sounded twice, and the call connected. From across the handset, a woman's voice carrying a hint of fatigue was heard.

[Yes, this is Jin Saehee from Hemato-Oncology.]

"Hello, Dr. Jin Saehee. This is Han Hyeonjae, a 1st-year resident in Emergency Medicine. I am calling urgently regarding a patient admitted to the Emergency Room."

I caught my breath as much as possible to keep my voice from shaking and continued speaking.

"It is a 28-year-old female patient. The chief complaint was a headache, but the blood test confirmed platelets at 35,000. And on the peripheral blood smear performed just now… numerous schistocytes were observed at Grade 3. Since TTP is strongly suspected, I passed the 2nd-year doctor and contacted you directly. Sorry."

When my report finished, a second of silence flowed from the other end of the handset.

[…Wait a minute. What? Schistocytes Grade 3 and platelets at 30,000? TTP?]

Her voice instantly transformed into a state of sharp alertness.