Respiratory Failure
The Double Board delusion Lee Min-jae had unleashed spread like a plague. In less than a day, the rumor had infected the entire Emergency Medicine department.
I woke from a catnap in the on-call room at dawn and was pulling a fresh gown from the supply closet when a voice came from behind me.
"Hyun-jae?"
It was fourth-year Yoo Sung-hoon, wearing the same chronically exhausted face as always.
"You really going to Internal Med?"
"What?"
"Now's about the right time for it. There's always a few guys who make the call around first-year fall and transfer out. So — quitting training? Or is Min-jae actually right about the Double Board?"
I squeezed my eyes shut. The past year flashed through my mind — the days of getting chewed out, of being soaked in other people's blood. I wasn't giving up. I'd have to be out of my mind to put myself through this again. The fact that I still had four years of this hell to survive was already horrifying enough. And they wanted me to go to another department and repeat the whole process for another three or four years? Double Board? That wasn't something a human being should do.
I answered in the firmest voice I could manage.
"No. I'm not transferring. I'm not quitting."
"Then Double Board?"
"No — I'm not doing Double Board either."
"Hmm."
Yoo Sung-hoon studied me for a moment, his expression hovering somewhere between belief and skepticism, then shrugged and went on his way.
But this was only the beginning.
I was putting in orders at the ER station when third-year Choi Soo-min approached with a worried look on her face.
"Hyun-jae."
"Yes?"
"Are you really doing Double Board? That's a brutal path. You'll wreck yourself."
I was almost ready to cry.
"I'm not doing it. Who even started this ridiculous rumor…"
"No? That's a relief, then. Anyway, don't push yourself too hard."
She patted my shoulder and left. It was no comfort at all.
I'm not transferring, you bastards…
And then, finally, the one I'd been dreading arrived.
My classmate. Jo Soo-yeon.
"Hyun-jae!!"
"Huh? What's this about?"
"You traitor bastard! I knew it from the start! How dare you abandon EM?! You were the one who talked me into this and now you're the one bailing?!"
I pressed my fingers into my temple. My head was throbbing.
No. I'm not going. I'm not doing it.
I screamed it dozens of times inside my own skull, but nobody believed a word I said anymore.
I'm not going. I'm not doing it. I can't do it. Just finishing four years here and getting out is my only goal. Please, just believe me, you bastards.
Friday, one in the morning.
Our hospital's Regional Emergency Medical Center — one of the busiest emergency rooms in the country — still hadn't gone to sleep.
"Prep suction! BP keeps dropping! 80 over 50!"
"Heart rate 140! Doctor, we need a C-line in right now!"
In the Resuscitation Room, a war was underway to save a polytrauma patient brought in from a traffic accident. Every senior resident, the attendings, even the professor had piled on, fighting for the patient's life.
I sat at my station, quietly working through charts. That wasn't my fight to join. Not yet. The best I could do was clear the pile of lower-acuity patients accumulating at the station, shaving even a little of the burden off my seniors.
That was when it happened.
Beep — beep — beep — beep —!
An alarm exploded from a completely different direction. Area B. Where the relatively stable patients were kept.
I turned my head. On the station monitor, the oxygen saturation of the patient in B-12 was flashing red.
"Shit."
I was out of the chair and running for the bed. The seniors were all tied up with the trauma.
A woman in her seventies lay on the gurney. She had a history of COPD, and she'd come in yesterday afternoon with worsening shortness of breath. Her sats had been low on arrival, so they'd been giving her oxygen by nasal cannula and watching her course. She'd stabilized enough that they were considering discharge in a little while.
Her condition now was a different animal entirely. Her face was ashen, her lips a dusky blue. Nothing about her looked like she was actually breathing. She was barely conscious.
"Min-joon! You were watching this patient, right? What happened?"
I shouted at first-year Choi Min-joon, who was hovering beside the bed in a helpless fidget.
"Sats dropped out of nowhere so I cranked the oxygen first! She's on a face mask at 10 liters and it keeps falling!"
He wasn't wrong. An oxygen mask sat over the patient's face, and the flowmeter was pegged at 10 liters. But she was getting worse. Her consciousness was slipping further.
Choi Min-joon's face had crumpled into something close to tears.
"What do I do? Should I max it to 15 liters? Or do we need to intubate right now?"
Sats dropping. COPD patient. I'd seen this. I'd definitely learned this — I'd even been tested on it. What was the exact mechanism again?
Wait. How the hell did this guy even pass the licensing exam.
Anyway. Not the point right now.
My mind was going blank. I'd known this. I was sure I'd known this.
The Gallery!
I pressed the stethoscope to the patient's chest, pretending to listen to her breath sounds, and summoned the blue interface across my vision.
The second the post went up, I shouted at Choi Min-joon.
"Get her jaw up — open the airway!"
In the seconds I'd bought, a comment unfurled in the corner of my vision.
Every piece of the puzzle snapped into place.
I hooked the stethoscope around my neck and shouted at Choi Min-joon.
"Choi Min-joon! Drop the oxygen! Right now — down to 2 liters!"
"Drop it? Her sats aren't even hitting 80! She's dying, Hyun-jae!"
"She's a COPD patient! Did you forget the history?! Did you even sit the licensing exam?! You give her any more oxygen here and her heart's just going to stop, you idiot!"
"…Ah!"
I shoved Choi Min-joon aside and wrenched the oxygen dial myself, then shouted at the nearest nurse.
"I need an ABG kit and a heparinized 1-cc syringe, now! I'm going in at the radial!"
"Yes, Doctor!"
"Lee Soo-jin! Portable X-ray and the BiPAP machine, right now!"
The nurses snapped into motion. I delivered a loving smack to the back of a panicking Choi Min-joon and shoved an Ambu bag into his hands.
Moments later I drew the arterial blood with the kit the nurse had brought. Only after I watched the bright arterial red fill the syringe could I let myself breathe for a second.
"This goes to the lab right now! Tell them STAT!"
That was the moment a nurse and a respiratory therapist came running, hauling the heavy BiPAP machine behind them.
"Doctor! We've got the BiPAP!"
The respiratory therapist looked at me.
"Doctor, how do you want the initial settings? Give me an IPAP and EPAP."
…
My mind went blank all over again.
Fuck. Settings? How the hell would I know?
Thanks to the Gallery, I knew she needed BiPAP. What I did not know, not even slightly, was what numbers to put in. Did I just ballpark it at 10 and 5? And if I blew a hole in her lungs?
"Doctor?"
The respiratory therapist pressed me. Choi Min-joon and the nurses were all staring at my mouth. Cold sweat ran down my back as I scrambled for a way to buy time.
"Give me a second. I need to recheck her mental status and chest rise before I decide."
I used the excuse to step in close to the patient, flipped her eyelid as if I were checking a pupillary reflex, and opened the Gallery window again.
The instant I hit submit, the same Pulmonology Ghost came roaring back.
The insult landed, but that wasn't what mattered right now.
"Initial settings: IPAP 12, EPAP 5, respiratory rate 14."
"Got it."
The respiratory therapist worked the machine with practiced hands. A moment later, a nurse called over from across the floor.
"ABG's back on B-12!"
My heart slammed against my ribs.
"Doctor! pH 7.15, pCO2 92, bicarbonate 30!"
"…That's it!"
My fist clenched on its own.
"Okay. Leave the BiPAP where it is. Follow-up ABG in thirty minutes! Neuro checks every ten — tell me the second she starts coming around!"
I'd done it.
Again.
With the help of this insane Gallery, I had saved a patient.