Is It Not the Heart? (1)
The emergency room was in utter chaos, with only a couple of hours left before shift change. It was littered with the remnants of all the accidents and emergencies that had erupted throughout the night. My eyes were completely hollowed out, and the charts waiting to be processed at the station were piled high like Mount Everest. I tapped away at the keyboard with soulless eyes. My fingers moved mechanically, but my brain had ceased functioning long ago. If anyone saw me right now, they would probably mistake me for a robot. Beep. This is Hyeon-jae-bot.
Right then. "Doctor! We have a chest pain patient! You need to see him right away!" The nurse at the triage desk called out to me, her voice unusually sharp. Beep. My stalled brain was forced to reboot. I sprang from my chair and headed in the direction she was pointing.
A man was sitting in a wheelchair right in front of the triage desk. Normally, they'd only come in after being triaged. Is it that urgent? The man, who looked to be in his mid-fifties, had a face that was past pale—it was practically gray. Cold sweat glistened across his forehead and the bridge of his nose. Looking at his posture, he was clutching the center of his chest with his left hand, gasping for breath. His expression was incredibly grim. Oh, shit. This is real. I approached him, keeping my voice as calm as possible.
"Sir, can you hear me? When did the pain start, and where exactly does it hurt?"
"About... about an hour ago..." he managed to squeeze out. "Suddenly... the middle of my chest... feels like someone is squeezing it... like a heavy boulder... is crushing it..."
It was a textbook presentation of myocardial infarction. "Does the pain radiate anywhere else?"
"Yes... to my left shoulder... and down my arm... it's tingling..."
Radiating pain. That sealed it. I quickly pulled up his chart to check his history. Hypertension, diabetes, and a fifteen-year history of smoking a pack a day. He possessed every single risk factor for a ruined heart. The most lethal differential diagnoses flashed through my mind: acute coronary syndrome (ACS), aortic dissection, and pulmonary embolism. The moment I missed one of these three, this man would become a cold corpse before my eyes within hours. The only saving grace was that all circumstantial evidence pointed to a single culprit. If I miss this, someone dies. Not me, but the patient. A cold sweat trickled down my spine. It took less than a minute to form a working diagnosis. But from this moment on, every single second would dictate the rest of this man's life.
"Nurse! Move this patient to Zone A immediately! Hook him up to the monitor and secure IV access! Let's get two 18-gauge lines in both arms! And bring the EKG machine over right now! We need an electrocardiogram immediately! Have him chew 300 milligrams of aspirin!"
At this very moment, the EKG was the absolute priority. I grabbed the shoulder of the nearest intern. "Find any senior resident right now! Find out where they are and call them over! Tell them we have a highly suspected case of ACS! They need to get down here immediately! Hurry!"
During the last myocardial infarction case, I had been so frantic that I ended up running a one-man show. But in a situation like this, having a senior resident by my side was much more reassuring. Of course, the thought of logging into the gallery crossed my mind, but is it really necessary? I dismissed the idea. The symptoms were as textbook as they could get, and the diagnostic tests would follow standard protocols anyway. Besides, I didn't want the patient to think of me as some weirdo staring blankly into thin air.
The nurses sprang into action. The intern sprinted down the hallway, phone in hand, searching for the senior residents. Someone else was rushing over, wheeling the EKG machine. I stayed glued to the patient's side, monitoring his vital signs. Blood pressure 145/90, heart rate 95 beats per minute. He was holding on for now. But it wouldn't be surprising if he crashed at any second. I took his hand. It was clammy and cold with sweat. "You're going to be okay, sir. We're going to do everything we can. Just hang in there a little longer." My own voice was trembling.
At that moment, the EKG machine ground to a halt beside the bed. "EKG is here!" Along with the nurse's shout, the rolling sound of wheels behind my back stopped. The nurse pulled up the patient's shirt and began attaching the electrodes to his chest. The brief moment waiting for the strip to print felt like an eternity. My mind was filled with the terrifying electrical waveforms that would indicate a myocardial infarction. Whirrrr—shhh—bzzzzzt— The machine finally spat out the long strip of paper inscribed with the language of the heart. Before it could even finish printing, I snatched the paper, tearing it away. And then...
"..." What? I stared at the strip again, this time much more slowly and meticulously. Normal sinus rhythm. 95 beats per minute. The intervals between all the waveforms were perfectly regular, and the shapes of the P, QRS, and T waves were completely normal. The ST-segment elevation or depression that I had been frantically searching for was nowhere to be found. It was just... a perfectly normal EKG. An EKG so clean it could be featured in a textbook.
"What is this?" The cry slipped out of my mouth before I could stop it. "Are you sure you placed the leads correctly, nurse?" A somewhat irritable tone escaped my lips. Ah, my bad. Sorry.
"Excuse me? Of course I did. I checked them multiple times." The nurse's voice was laced with bewilderment. Just then, Yoo Sung-hoon, a fourth-year resident, strode into Zone A. "I heard a commotion. Is it this patient?"
Without a word, I handed the EKG strip to Yoo Sung-hoon. He took it and looked back and forth between the sweating, groaning patient and the pristine EKG. He looked at the patient. Then at the EKG. Back to the patient. Back to the EKG. Then up at the ceiling. And finally, at my eyes. What? Why are you looking at my eyes? His brow furrowed slightly.
"The EKG is clean... but the patient's presentation is textbook." His murmur actually brought me a faint sense of relief. Yes, I wasn't the only one who thought this was bizarre. "For now, Hyeon-jae, let's get a portable X-ray and repeat the EKG every twenty minutes."
Ten minutes later. The portable X-ray was complete. The images were immediately transmitted to the PACS. Yoo Sung-hoon and I stood in front of the station monitor to review the patient's chest X-ray. What we were looking for was clear: fluid in the lungs, air in the pleural space, an abnormally enlarged heart, or, in the worst-case scenario, a widened mediastinum indicating an aortic dissection. However, the patient's chest on the monitor looked incredibly peaceful. Both lungs were clear and fully expanded, and the size and shape of the heart were perfectly normal. The contour of the aorta was also smooth. There wasn't a single clue anywhere to explain why this patient was in agonizing pain.
Yoo Sung-hoon's expression gradually hardened. "Could this just be musculoskeletal pain? Maybe a cracked rib. Or maybe he's faking it."
"But the nature of the pain he's describing is too classic. The crushing pressure, the radiating pain..."
"I know. I know, but the test results say otherwise." Skepticism crept into Sung-hoon's voice. My mind grew cluttered. Did I jump the gun? Did I make a fuss over nothing? Was my textbook knowledge completely fooled by a patient's acting?
Forty minutes later. The patient was still crying out in pain, and we were stuck in a seemingly endless wait. The EKGs taken at twenty-minute intervals remained normal. The emergency room began to bustle with activity again. While Yoo Sung-hoon and I attended to other patients, our attention remained entirely fixed on the blood test results. Finally, a notification popped up on the EMR screen.
[EMR Notification: Lab Results Arrived]
I felt sweat pooling in my palm as I gripped the mouse and clicked on the results. Yoo Sung-hoon stepped up behind me, peering over my shoulder at the monitor.
Everything, every single number, was frustratingly normal. No inflammation, no electrolyte imbalance, and no trace of blood clots that would suggest a pulmonary embolism. Yoo Sung-hoon let out a deep sigh.
"See? I told you, he probably just pulled a muscle. Give him an ibuprofen tablet, and if he still complains of pain, tell him to follow up with neurology or orthopedics as an outpatient, and discharge him."
No. It wasn't over yet. "Senior, wait a moment. There's still... one last thing left. Can we at least wait for that before discharging him?"
"...Ah, right. We should review all the lab results before discharging him." And so, we decided to wait a little longer.
One hour and twenty-five minutes after admission. The last line of defense. The final verdict that determines the presence of a cardiac issue when everything else is normal: cardiac enzymes. Among them, troponin is the most sensitive and specific marker. If there is even the slightest damage to the heart muscle, it must rise. The phone rang from the emergency lab. With trembling hands, I picked up the receiver.
"Yes, this is Han Hyeon-jae from Emergency Medicine."
"The troponin result for the patient in Zone A, Bed 2 is out." My heart sank.
"What... what is the result?" The lab technician on the other end of the line recited the number in a completely flat voice.
"Troponin I is less than 0.04. Normal." Click. I hung up the phone.
EKG normal, X-ray normal, blood tests normal, and even the cardiac enzyme levels—our last line of defense—were perfectly normal. Every piece of evidence was telling me that my diagnosis was wrong. Yoo Sung-hoon patted my shoulder, his expression saying, See? I told you so, before walking off to see another patient. I was left alone. Fuck. What on earth is going on? Was all the commotion I caused over the past hour just my own delusion? What the hell is this? Am I going crazy? What is it?! Let's think of the only option left. ...The gallery.