Chapter 101
Chapter 101
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Translator: crow
Chapter Title: Assassin (2)
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Fuck. It's over.
I shot out of my chair without even lifting my ass off it.
"Let's go!"
"Yes!"
Baek Eun-seo snatched the chart and followed right on my heels.
We started sprinting like mad toward the triage station.
A few seconds to cross the hallway.
My brain was already spinning at full throttle.
'PE. Pulmonary Embolism.'
'STAT sticker.'
Those two together meant only one thing.
To the triage nurse, this patient was on the verge of dying right now.
'Massive or Submassive. That is the question.'
Massive PE.
Blood pressure under 90, heart on the brink of stopping.
This was pre-cardiac arrest.
You had to pump thrombolytics into the vein immediately or rush them to the OR where thoracic surgery rips open the chest and yanks out the clot.
Mortality rate?
Sky-high.
Submassive PE.
Blood pressure holding above 90 for now, but the right ventricle already strained by the clot, ready to burst.
They're breathing for the moment, but it's a ticking time bomb that could flip to Massive and arrest at any second.
'Looks like PE for sure... and pray it's not the worst kind.'
I panted as I asked Baek Eun-seo, who was running stride for stride beside me.
"Eun-seo, what'd the triage note say again?"
"52-year-old male, has hypertension!"
Unlike a first-year, Baek Eun-seo briefed me perfectly without even glancing at the chart.
"Chief complaint is shortness of breath and heavy chest. Vitals: BP 150/95, HR 110, RR 22, sats 94% on room air!"
"Okay...."
I rolled those numbers around in my head.
BP 150/95.
'...High?'
Blood pressure was normal... no, actually high.
Not Massive, then.
He has hypertension.
That could be his baseline, or maybe the sympathetic surge from the pain and dyspnea right now.
HR 110—tachycardic.
RR 22—tachypneic.
And... 94%.
Low.
Looks normal, but it's low.
A healthy person doesn't drop below 98%.
Clear evidence the lungs were starting to fail.
'Submassive. Ticking bomb. Shit.'
I swallowed a curse under my breath.
Ziiing—
The automatic doors slid open.
The patient was a middle-aged man in his fifties.
His face was deathly pale, tie loosened, shirt's top button ripped open.
His shoulders heaved with every breath.
Baek Eun-seo spotted him and shouted the additional info she'd just checked on the chart.
"He's on Lisinopril 20mg, poor recent med compliance!"
'Got it.'
I nodded.
'Hypertensive not taking his meds properly. So that BP doesn't mean he's stable right now.'
I moved to the bedside and grabbed his sweat-soaked shoulder.
"You okay? Emergency medicine doctor here."
The patient looked up at me with terror-filled eyes.
"Y-yeah, yeah, I'm okay... but my breathing... haa... it's tough right now."
"Pain pattern?"
I pointed to his sternum area.
His chest rose and fell irregularly with each breath.
"Sharp stabbing? Crushing? Tearing?"
The patient wiped cold sweat from his brow, frowning.
"Ah... it's not sharp stabbing... no... just kinda tight and painful, like that."
He struggled to continue, taking a deep breath.
"Worse when I move. Coming off the plane and walking in... breath just caught... ugh... better sitting...."
Pain worsening with inspiration or movement.
Meant a clot snagged on the pleura, irritating it.
Classic PE symptom.
Aortic dissection would rip to the back, MI would crush and radiate to left arm or jaw.
"No pain migrating anywhere?"
I double-checked.
"Not to neck or arms. Not abdomen... back a little maybe, but probably imagination...."
'Back pain.'
Unsettling.
PE can cause back pain, but couldn't rule out dissection entirely.
Pain pattern was pleuritic, though. Betting on PE for now.
"Got it. Any recent events? Leg injury, surgery?"
"Ah..."
The patient caught his ragged breath and thought.
"No... oh, just back from overseas business trip today. Took a plane...."
'...Plane?'
Bingo.
Warning lights and Eureka exploded in my head simultaneously.
Sit cramped for over 10 hours, blood pools in leg veins, clot forms.
That's DVT.
That clot dislodges when you stand and say 'ow, my legs,' pumping straight through right atrium, right ventricle, bam—blocks pulmonary artery.
The hell this guy was in right now.
'DVT risk checked.'
I glanced at the bottom of his suit pants.
Ankles in expensive shoes looked slightly swollen bilaterally.
'Legs mildly swollen, usual constipation or dyspepsia...'
Every piece pointed to PE.
"Doctor! EKG!"
Far off, Baek Eun-seo was urging an intern, pushing the EKG machine.
"Y-yeah... hurry up."
I gestured to move the patient to the nearest bed in A zone.
That level of dyspnea and hypoxia wasn't for B zone.
Ask some questions while they brought it over.
Had to extract info even in the short gap before electrodes.
I eyed the patient's legs as he perched on the bed.
"Patient, when did your legs start swelling? After the flight?"
Sudden swelling yesterday or today would scream acute DVT.
"Uh..."
The patient groaned in response.
"No... maybe two, three months ago...?"
'...Two-three months?'
I froze.
DVT is usually acute.
Days, max 1-2 weeks.
Chronic edema?
Sure, chronic edema patients can get DVT.
But...
"Ah... I see."
I kept calm and tossed the next question.
"Any family history of heart or lung disease? Parents, siblings?"
"Uh..."
The patient rummaged through memories again.
"Dad's healthy, but Mom... heart disease in her 60s...."
'Heart disease.'
Ominous.
Not PE, not MI, not Dissection.
Flew on a plane.
DVT risk.
PE likely.
But chronic leg swelling, family heart history.
...This dissonance starting to creep in was just my imagination, right?
Not PE?
Or PE but clot from heart or somewhere else?
Or root cause of all this something else?
I shook my complicated head and snatched the EKG strip Baek Eun-seo just brought.
'Focus on the worm in front of me first.'
"Doctor! I'll order heparin..."
As Baek Eun-seo went for the textbook next step, I stopped her without looking up from the strip, hand raised.
"Eun-seo, hold up. Heparin on standby."
"Yes? But why..."
Baek Eun-seo's voice held confusion.
Dyspneic, tachycardic, desatting, plane ride.
Everything screamed PE—why hold anticoagulation?
...
I didn't answer.
All my focus was on the worms printed on the paper.
Baek Eun-seo peered over my shoulder at the strip.
"S1Q3T3, right? S in Lead I, Q in Lead III, T inversion too...."
...
"This has to be PE..."
Baek Eun-seo's voice grew certain.
"No, wait."
I looked at the strip again.
"T-wave inversion to V1, V2, V3... too broad?"
PE T inversions are usually shallow and peaked.
This was wide and deep.
Unsettling.
Chronic edema from before, family heart history.
This EKG now.
Puzzle pieces weren't fitting, grinding.
I recalled the cardiology ghost's old lecture.
'Hel slave! EKG isn't formulaic! It's picture matching! If patient history doesn't match EKG picture, ditch your formulas! Fitting patient to formula makes you a quack, not a doctor!'
...Yeah, ask.
Pretending to glance at the bed, I summoned the blue interface in my pupil.
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[Depressed Doctors Gallery]
[EMERGENCY] Heart question URGENT AS FUCK!!!!
Posted by: HelJoseonSlave1
(EKG image)
52/M. Plane ride, chest pain/dyspnea. O2 sat 94%. S1Q3T3. But T-inversion super wide/deep to V1-V4. Chronic leg swelling 2-3mo, mom died of heart disease. PE feels off. Thoughts?
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[Comments]
Anon (118.235): O2 sat 94% on RA + RR 22? Dyspneic but 94%? Massive PE drops below 90... Not classic PE vibe.
Cardiology Ghost: Hey. What does the patient look like. Tall and skinny?
ㄴ HelJoseonSlave1: Why that suddenly?
ㄴ Cardiology Ghost: Just say. Fingers/toes long and slender?
The patient was still clutching his chest, taking shallow breaths.
Pretending to check his pulse, I examined his hand closely.
Long.
ㄴ HelJoseonSlave1: Just checked. Over 180cm, skinny. Fingers hella long.
ㄴ Cardiology Ghost: Marfan sign. Know it?
The instant I saw that comment, my blood ran cold.
Marfan syndrome.
Ultra-high risk for aortic dissection.
S1Q3T3?
EKG finding?
Blood backing up to heart or dissection blocking coronary ostia can cause T inversion like that.
Not PE.
...Ah.
Fuck.
I bolted back to the station.
Baek Eun-seo looked at me in confusion.
"Eun-seo."
"Yes, Doctor!"
"CTA, stat."
"Yes? Not CTPA?"
Baek Eun-seo was shocked.
Suspected PE but scanning aorta instead of pulmonary arteries?
"Yeah. CTA. Aorta. Chest to abdomen. Contrast. Right now. Hurry."
I grabbed the intercom to radiology.