Could It Not Be a Cold? (2)
The nurse checked the order and rushed off to grab the portable EKG machine. I headed back to the patient's bed. Meanwhile, comments began to pop up on the blue interface.
"Doctor! I brought the EKG!" The nurse began attaching the electrodes with practiced, nimble hands. The patient looked utterly terrified by the sudden commotion.
"Doctor... am I going to die? My neck just hurts, why is everyone acting like..."
"You're going to be fine, sir. This is just a routine check, so don't worry too much. Just relax and stay still for a moment." I then turned to the nurse. "Just in case, please bring the crash cart over here. Just to have it ready."
Whirrrrr— The EKG machine began spitting out a long strip of paper. Please, please let it be nothing. Let me just be an idiot who overreacted. But God did not answer my prayers.
The moment I took the EKG strip, my hands trembled slightly. "Fuck..." The curse slipped out of my mouth. Leads II, III, and aVF. In the leads showing the inferior wall of the heart, the ST segments were elevated like mountain peaks. A textbook presentation of an inferior wall myocardial infarction.
I shouted in a flurry, "Let's run one more lead, V4R!"
V4R. A lead that checks the status of the right ventricle by placing electrodes on the right side of the chest. It was an absolute must-check in cases of inferior wall infarction.
A moment later, the additional EKG confirmed my worst fears. Even on the V4R lead, there was a clear ST-segment elevation. An inferior wall myocardial infarction accompanied by a right ventricular infarction. This wasn't just a regular heart attack. It meant the right ventricle, which acts as the heart's auxiliary pump, was failing as well. If you carelessly administered vasodilators to a patient like this, their blood pressure would plummet into the abyss, and they could die of shock.
"Have the patient chew and swallow aspirin 300 mg and Plavix 600 mg right now."
"Yes, doctor!"
"Give him two liters of oxygen via nasal cannula! And absolutely do not give him nitroglycerin! His blood pressure will tank instantly! Instead, start another IV line and run 500 cc of normal saline on a full drop!"
Only after issuing the initial orders did I manage to catch my breath. But anxiety immediately rushed back in. Did I miss anything? What else should I do in this situation? I accessed the gallery once again. I needed confirmation.
I hit submit. Then, I immediately pulled out my phone and opened the hospital directory. Cardiology on-call. Cardiology, Cardiology... As I scrolled down looking for the contact info, new comments began appearing in real-time on the gallery screen.
Heart. Complete AV block. ECMO. I hadn't resolved anything yet. Get a grip, Han Hyeon-jae, you bastard. I cursed at myself inwardly. This was no time to panic. I had to contact the person who would take this patient right now. Cardiology.
[Cardiology - Park Wooyoung] I swallowed hard and pressed the call button. Before the second ring could even finish, the call connected with a click. Over the receiver, amidst a noisy clamor, a somewhat irritable voice flew at me.
"Yeah, what is it?" Behind the voice, I could hear the clattering of metal trays. The staff cafeteria. ...Ah, he's eating. I felt a brief second of guilt, but another thought immediately crossed my mind. If he's in the cafeteria, it's a three-minute sprint to the ER. Maybe this is actually a good thing? Pushing aside the selfish thought, I stated my identity and business as quickly and accurately as possible.
"Hello, senior! This is Han Hyeon-jae, a first-year resident in Emergency Medicine. I'm calling to report a fifty-four-year-old male patient who appears to have an inferior wall myocardial infarction accompanied by a right ventricular infarction—" Before I could even finish my sentence, a loud screech of a chair being dragged echoed through the receiver, followed by a shout.
"What?! An infarction?! Got it!!!" Click. The line went dead.
"?" I stood there dazed for a moment, staring at my phone's call-ended screen. What is wrong with this crazy guy? What does he mean, "got it"? Is he coming or not? What kind of doctor hangs up without even asking about the patient's condition?
Two seconds later, my phone began to ring like crazy. The caller ID showed the same number—Park Wooyoung from Cardiology. I instinctively pressed the answer button.
"Hello?"
"Ah, sorry! Sorry! Hey, I forgot to ask the most important thing!" Along with his urgent voice, I could hear heavy, ragged breathing, as if he was sprinting down the hallway at full speed. "What's the patient's status? Give me the basics! I'm running over right now, so tell me on the way!"
Well, if it's an infarction, it's only natural to drop your spoon and run. Swallowing a dry laugh, I mobilized all the knowledge the ghosts had drilled into me yesterday, along with every clinical judgment I had just made, and began my report.
"Yes, senior. Here is the report. A fifty-four-year-old male patient presented today around noon with a chief complaint of severe sore throat. He was initially triaged as KTAS Level 5 under suspicion of a common cold, but due to the severe discrepancy between his reported pain intensity and the physical examination findings, we proceeded with cardiac evaluations, keeping a potential heart issue in mind."
"A sore throat? Not chest pain?"
"Yes, that's correct. He is primarily complaining of a burning pain radiating to his jaw and neck."
"Got it, keep going. Vitals?"
"Current vitals are blood pressure 90 over 60, heart rate 55, respiratory rate 22, and oxygen saturation 98 percent. His blood pressure and heart rate have been on a downward trend since admission."
"And the EKG?" The breathing on the other end of the line grew even heavier.
"On the 12-lead EKG we just performed, there is a distinct ST-segment elevation of about 3 millimeters in Leads II, III, and aVF, with reciprocal changes showing ST-segment depression in Leads I and aVL. To rule out right ventricular involvement, we ran a right-sided EKG, which confirmed a 2-millimeter elevation in the V4R lead. As of now, we have diagnosed it as an inferior wall myocardial infarction with right ventricular involvement."
"So, what was your initial management?"
"Immediately after confirming the EKG, since the patient was alert, we had him chew and swallow aspirin 300 mg and Plavix 600 mg. He is currently receiving two liters of oxygen via nasal cannula. Because of the accompanying RV infarction, we withheld nitroglycerin and are currently loading 500 cc of normal saline to maintain his blood pressure. We are still waiting on the cardiac biomarkers."
Finally, I added the advice the gallery ghosts had given me, making it sound entirely like my own clinical judgment. "Also, senior, keeping in mind the risk of bradycardia and AV block that can accompany an inferior wall infarction, we have already attached the defibrillator pads to the patient to prepare for any potential emergencies."
My report was complete. Nothing but heavy panting came through the receiver. Did I overstep? Did I sound too arrogant for a first-year resident? Finally, Park Wooyoung from Cardiology caught his breath and spoke.
"...Hey."
"Yes, senior."
"For an EM R1, that was a remarkably clean call. I'm almost there. Just hang tight."
...Holy shit. I just said all of that without stuttering once. Just as a wave of self-pride was about to wash over me, another comment flashed through my mind, sending a chill down my spine.
'Is the playhouse session over for you medicine guys? With that level of damage, cardiogenic shock is bound to hit. Are they preparing to run ECMO before sending him up to the lab? What are they going to do if he dies on the table?'
Right. With a patient whose right ventricle was failing and whose blood pressure was barely hanging on, no one could predict what might happen during the procedure. His heart could stop completely, or he could fall into irreversible shock. In such a moment, the ultimate last line of defense was a machine that could take over the functions of the heart and lungs. ECMO. And that was the domain of Thoracic Surgery.
Without realizing it, I urgently cut in. "Uh, Cardiology senior!"
"Yeah, what?" The heavy panting still echoed over the line.
"I'm sorry, but I think we need to prepare for both cardiogenic shock and cardiac arrest. Would it be alright if I contact Thoracic Surgery right now to request a backup for a potential VA-ECMO?"
A brief silence fell over the phone. A mere first-year Emergency Medicine resident had just declared to a Cardiology fellow that he was going to hang up to contact Thoracic Surgery. A bottom-of-the-barrel R1. Normally in this situation, the cardiologist—who would take final responsibility for the patient and perform the procedure—should be the one to make that call and request backup. But you never knew. From what I could tell, this guy wasn't exactly in his right mind either.
"Uh... yeah, absolutely! If they question why a first-year is calling, just use my name!"
Okay. Success.