A Fatal Misdiagnosis
I returned to the station with a heavy heart after explaining the admission process 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 was a serious condition, but among hematological diseases, it was relatively common and considered one of the "milder" ones, with treatment starting simply with steroids.
Yes, that had to be it. Unless there was a lab error, ITP was the most likely diagnosis. It was especially common in young women. Every piece of evidence pointed toward it. I tried to reassure myself. Yet, an inexplicable, lingering unease remained anchored in a corner of my mind. Ultimately, unable to shake the anxiety, I summoned the all-powerful tutors inside my head.
Let's just double-check to be absolutely sure. If even those crazy ghosts agreed it was ITP, I could hand the patient over to Hematology-Oncology with a truly peaceful mind.
It was an utterly ordinary question. But the moment it was posted, the gallery erupted into a chaotic living hell.
...Excuse me? For a moment, I doubted my own eyes. Did I ask something wrong?
That was only the beginning. Ghosts from every medical specialty imaginable pounced, tearing me to shreds.
TTP. Thrombotic Thrombocytopenic Purpura. Ah. Ah, right. How could I have forgotten this? How did this not even cross my mind?
TTP. A disease where microthrombi—tiny blood clots—form relentlessly throughout every microscopic blood vessel in the body for no apparent reason. As these clots form, they consume platelets at an alarming rate, causing the platelet count to plummet. Meanwhile, red blood cells trying to squeeze through those narrowed vessels are torn to shreds, leading to microangiopathic hemolytic anemia. Those clots then clog the pathways to the brain, heart, kidneys, and other vital organs, slowly causing them to infarct and fail.
If diagnosis is delayed even slightly, the mortality rate approaches a staggering 90%. It is the absolute worst emergency in the field of hematology.
The classic pentad of symptoms: thrombocytopenia, microangiopathic hemolytic anemia, neurological symptoms, renal failure, and fever.
And my patient had...
...A headache.
...Thrombocytopenia.
...Bruising.
I collapsed into my chair at the station, feeling the blood drain from my face. While I was busy reassuring myself that it was a "mild" disease, microclots might have been actively forming inside the blood vessels of her brain.
That last comment snapped me back to reality. This was no time for self-pity. I bolted upright and snatched the intercom, practically screaming into it. Extension 7111. Beep. Beep. Beep. Beep.
"Is this the lab? The retest that just came in for the twenty-eight-year-old female patient in ER Zone B, Bed 9! Patient ID 1397131! Use that sample right now to make a peripheral blood smear slide and look at it under the microscope! Forget everything else, just tell me if there are schistocytes or not! Hurry! It's an emergency! STAT! STAT!"
"Excuse me?"
"Run a peripheral blood smear for Patient ID 1397131! It's urgent!"
"Y-yes, understood."
My voice trembled with sheer terror. Hanging up the receiver, I buried my face in my shaking hands. Please. Please let it not be. Please, don't let there be any fragmented red blood cells.
Huddled in a corner of the station, I mindlessly clicked the refresh button on the EMR screen. I saw other patients, wrote charts, and even nodded off for a second, but my entire consciousness was hyper-focused on waiting for a single phone call from the lab. It was a hellish stretch of time where every minute dragged like an hour. My mind ran wild with the worst-case scenarios. That bruise and headache are too suspicious. If it really is TTP...
Right then—Ring! Ring! The station telephone shrieked. The chaotic din of the emergency room seemed to instantly vanish behind the sharp ring. I snatched the receiver almost reflexively, my heart hammering violently against my ribs. Please. Please tell me it's not.
"Yes, Emergency Medicine." My voice shook despite myself.
"Is this the ER?! The patient in Bed B-9! The twenty-eight-year-old female! The peripheral blood smear results are out!!!!"
I swallowed hard at the technician's frantic tone.
"We're seeing numerous schistocytes on the slide, looks like Grade 3+ or higher! On top of that, there's severe thrombocytopenia with giant platelets, and clear signs of polychromasia! This is a textbook match for a thrombotic microangiopathy like TTP or HUS (Hemolytic Uremic Syndrome)! You need to check this immediately...!"
I was screwed. My worst nightmare—no, the prophecy of the gallery ghosts—had become reality. Numerous fragmented red blood cells had been spotted. Grade 3+. It was a literal graveyard of red blood cell corpses. With platelets and red blood cells dying off rapidly, the bone marrow was desperately churning out untrained, immature cells, sending them straight to the battlefield after a mere one-week boot camp.
Distinguishing between TTP and HUS at this point was practically meaningless. Either way, they were both godawful thrombotic microangiopathies that would kill the patient if not treated immediately. Besides, the presentation aligned far better with TTP anyway.
I slammed the receiver down before the technician could even finish. I didn't even have time to panic. From this moment on, every single second was a direct line to the patient's survival.
"Internal Medicine! Internal Medicine, damn it!"
I bolted from my chair and sprinted toward the whiteboard in the center of the station. The surrounding nurses stared at me in shock, but I was blind to them. My eyes locked onto the dense grid of names and phone numbers. Hematology-Oncology. Hem-Onc. Who is the Hem-Onc on-call? My trembling finger traced down the board.
• 1st Call: Kim Ji-eun (Internal Medicine R2)
• 2nd Call: Jin Se-hee (Hematology-Oncology Fellow)
Two names stared back at me. Kim Ji-eun. Jin Se-hee. Wait. Do I call the first line or the second? Reason and instinct clashed violently in my head. Protocol dictated that I contact the first call, the second-year resident Kim Ji-eun, first. For a lowly first-year resident to bypass a second-year and call a fellow directly was a suicidal breach of hospital etiquette. Kim Ji-eun would be furious, and Jin Se-hee, the fellow, might rip me a new one, demanding to know what kind of insolent first-year dared to call her directly.
But... but this was no time to worry about hierarchy. How much would a second-year like Kim Ji-eun even know about TTP? She would likely panic upon seeing the patient and end up calling her senior fellow anyway. It was just my assumption, but that process would waste at least ten minutes. And during those ten minutes, microclots would be clogging the blood vessels in the patient's brain, heart, and kidneys, destroying her organs.
"A hematologist has to see this immediately." I made up my mind. Whether my residency was ruined or not, I had to save the patient first. My hospital life was already a mess anyway; I had nothing left to fear.
"Second call!" I whipped out my phone and frantically dialed the number for the Hem-Onc fellow, Jin Se-hee. Just before pressing call, I took a ragged breath. Whew... Haa... Fuck... Dammit... My fingertips were ice-cold. Every single word I was about to say would decide a person's fate.
Ring... Ring... After two rings, the call connected. A slightly tired female voice came through the speaker.
"Yes, this is Jin Se-hee, Hematology-Oncology."
"Hello, Dr. Jin. This is Han Hyeon-jae, a first-year Emergency Medicine resident. I'm calling regarding an urgent case currently in the ER." I took a deep breath, trying my best to keep my voice from shaking as I continued.
"She's a twenty-eight-year-old female. Her chief complaint was a migraine, but her blood work showed a platelet count of thirty-five thousand. And on the peripheral blood smear we just ran... we observed numerous schistocytes, Grade 3+ or higher. Because TTP is highly suspected, I bypassed the second-year resident and called you directly. I apologize."
A heavy, one-second silence fell over the line as my report ended.
"...Wait. What? Schistocytes 3+ and platelets at thirty thousand? TTP?"
Her voice instantly snapped into a state of hyper-alertness.