Stubbornness, Part 1

11:00 PM. Phone lines were ringing off the hook, and monitor alarms shrieked from every corner of the room. Nurses scurried about in a blur of motion, while anxious interns hovered restlessly. I, ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠too, was already half out of my mind, wrestling with a mountain of incoming charts. My fingers tapped mechanically against the keyboard, but my brain had slipped into power-saving mode long ago.

Right then, a chime rang out as a triage note popped up on the screen.

"Uh... what kind of patient is this...?"

Before I could even process the information, an EMT wheeled in a stretcher cart. Lying on it was a man who looked to be in his mid-fifties, clutching his stomach. His suit was rumpled but clearly expensive, and a gold watch gleamed from beneath his sleeve.

I stood up from my seat.

"What brings you in today?" I asked, stepping up to the side of the stretcher and keeping my voice as clinical as possible.

"Doctor! My stomach! It feels like it's twisting inside out! I'm dying here!"

The man groaned, pointing to his lower right abdomen. It was hard to tell if he was genuinely in agony or just being dramatic.

"It started last night. I thought it was just indigestion, but then this morning it turned into a sharp, stabbing pain, and now it feels like I'm being gouged with a knife! I've thrown up a few times, too!"

As I listened, my mind quickly ran through a mental checklist of differential diagnoses.

Lower right quadrant pain, tenderness, vomiting, mild fever... This was textbook. A classic case of appendicitis.

I snapped on a pair of latex gloves and began examining his abdomen.

"You said the pain is right here, correct? I'm going to press down."

I gently pressed my fingers onto McBurney's point—the anatomical location of the appendix, situated between the navel and the right hip bone.

"Argh!" the man shrieked.

Tenderness: positive.

"Now, I'm going to let go."

I quickly released my fingers.

"Aaargh! It hurts even more when you let go!"

Rebound tenderness: positive.

I performed a few more diagnostic maneuvers. Rovsing's sign—pressing on the lower left abdomen to see if it triggered pain on the right. Positive. Psoas sign and Obturator sign—pain elicited by lifting or internally rotating the right leg. Both positive.

Everything pointed to appendicitis with textbook precision. The diagnosis was at least ninety percent certain.

All that was left was to run a blood test to check his inflammatory markers and confirm the swollen appendix via CT scan or ultrasound.

I was about to order a routine lab panel and an abdominal CT when the man suddenly slapped my hand away.

"Hey, Doctor! What are you dragging your feet for?"

He pointed at his stomach, his voice dripping with irritation.

"Isn't it obvious just by looking? Hurry up and get me a CT scan!"

I stared at him, dumbfounded.

"Sir, we need to draw blood first—"

"Blood test? What bloody blood test!" the man cut me off.

With a highly sophisticated expression, he began lecturing me on medicine.

"Do you have any idea how much medical research I did last night instead of sleeping? I plugged in all my symptoms, and let me tell you, this might not even be appendicitis!"

He adopted an incredibly solemn face, as if presenting his own groundbreaking research paper.

"According to my findings, this could be diverticulitis. Or, what do you call it... Crohn's disease? The early stages of that thing young people get! Lower right abdominal pain doesn't always mean appendicitis! You doctors really need to hit the books!"

I was utterly speechless.

Diverticulitis typically presents with pain in the lower left abdomen, and Crohn's disease is characterized by chronic diarrhea and weight loss. I couldn't help but marvel at the sheer confidence of his spectacular misdiagnosis.

"So we don't have time to waste drawing blood! Let's just get the CT scan done first, Doctor! That's the only way we'll know the exact cause!"

I pressed a finger to my temple, swallowing a deep sigh.

Ah, here we go.

Step one of the difficult patient manual: validate their knowledge first to open the lines of communication.

"Sir, you've clearly done a lot of research overnight. You're absolutely right that lower right abdominal pain isn't exclusive to appendicitis. Diverticulitis and Crohn's disease are certainly possibilities worth considering. ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠That's a very sharp observation."

At my soulless praise, a smug, self-satisfied smile spread across his face. First step: successful. Now, to the main point.

"However, sir, there are a few things we must verify before we can proceed with a CT scan."

I maintained the friendliest, most logical tone I could muster.

"First of all, drawing blood takes far less time than waiting for a CT scan. We can have the results back in thirty minutes. Right now, we have a backlog of critical emergency patients waiting for the CT scanner, so you'd have to wait a while anyway."

The time-limit attack. One of the most effective strategies in the emergency room.

"Furthermore, a blood test will give us concrete numbers on the severity of the inflammation in your body and how high your white blood cell count is. Having those figures is crucial for us to gauge how critical your condition is and to pinpoint exactly what we need to look for on the CT scan."

I looked at him with wide, earnest eyes.

"Whether it's appendicitis, diverticulitis, or Crohn's disease, any inflammatory condition will show abnormalities in your blood work. Checking that first is the proper medical protocol. Would you please trust me and follow our procedure? I'd really appreciate your cooperation."

The man fell silent, seemingly at a loss for words.

He still looked displeased, but faced with the promise of a faster process and the logical medical justification of checking his inflammatory markers, he couldn't find a pretext to keep arguing.

"Ahem...!"

He let out a dry cough ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠and reluctantly extended his arm.

"Fine! But make it quick! Don't dawdle!"

I let out a silent sigh of relief. Phew, at least he's somewhat reasonable.

"Nurse Jung!"

The charge nurse looked up.

"Patient in B-10 needs a routine lab panel and CRP! Please draw his blood!"

"On it," Nurse Jung replied, calmly wheeling the blood draw cart toward the treatment area with her usual practiced efficiency.

I didn't forget to offer a parting service line to soothe the man's lingering anxiety.

"Actually, based on your symptoms, I have a few suspicions of my own, so we'll be getting that abdominal CT scan ready right away. We'll pre-book the CT slot while we wait for your blood results. So please, don't worry too much."

Only then did the man's expression soften slightly. I quietly retreated to the station.

***

It took some time for the internet-expert patient's blood results to process and for him to get his CT scan. In the meantime, the ER doors slid open and closed without a moment's rest.

"Uuugh... blood... so much blood..."

A college student, sporting a ten-centimeter gash on his forehead from a drunken fall—a glorious badge of honor from a late-night bender—was hauled in by his friends. The wound was deep and bleeding heavily.

Using his drunken slurs as background music, I administered local anesthesia with lidocaine, irrigated the dirty wound, and meticulously stitched it up with nylon sutures. The student's slurred, desperate pleas for me to minimize scarring were already dissolving into a haze of anesthesia and alcohol.

Sorry, buddy. This isn't plastic surgery.

"My whole body... it's itching... swelling up... I can't breathe..."

A beekeeper who had been stung by bees rushed in, his entire body covered in hives and on the verge of anaphylactic shock.

I immediately secured his airway, administered an intramuscular injection of epinephrine, and pumped him full of steroids and antihistamines. Only after confirming that his wheezing breath had stabilized did I finally manage to catch my own.

By the time I had frantically treated three or four more patients, dozens of minutes had flown by. The stubborn middle-aged man had slipped entirely from my mind.

Right then, a small notification window popped up in the bottom right corner of the EMR screen. The internet-expert's CT scans and lab results were finally in.

I clicked the mouse to open the images.

Abdominal CT. As expected, it was appendicitis.

But... it was far more severe than I had anticipated.

A normal appendix should be about the width of a pinky finger, but this man's appendix was swollen to over 1.5 centimeters—nearly the thickness of a thumb. The wall was heavily thickened, and the surrounding fat tissue had turned hazy and messy from the inflammation.

Fat stranding... check.

To make matters worse, a small, stone-like appendicolith was wedged at the tip of the appendix.

And most critically: a portion of the appendiceal wall appeared faintly disrupted, with a small pocket of air bubbles and dirty fluid pooling around it.

...Suspected perforation.

I swallowed hard. It was a ticking time bomb.

His inflammatory markers were off the charts. Every piece of evidence pointed to a single, terrifying conclusion: if he didn't get surgery right this second, he was screwed.

I stood up.

Pulling back the curtain, I found the man still lying on the bed, groaning in pain.

"Sir, your results are back."

I wheeled over a mobile monitor and pulled up the CT scan right in front of him.

"This is a cross-sectional CT scan of your abdomen. If you look here at the lower right side, you can see this swollen area. This is your appendix, located at the end of your cecum."

I pointed to the severely inflamed, swollen appendix on the ‍‍‌‌⁠​​⁠‌​​‍​​‍​‌​⁠‍‌‍⁠⁠‌⁠‌‍‌‍‌‌‌‍⁠​‌​‌​‌‍‌‌‌⁠‍​​‌‍⁠‌‌⁠⁠screen.

"It's swollen to more than twice its normal size, and there is severe inflammation surrounding it. Furthermore, if you look closely right here, the tip has actually ruptured, and there are signs of pus and air leaking out."

The man grimaced, looking back and forth between my face and the monitor.

"Your condition is far more serious than we initially thought. If you don't undergo emergency surgery immediately, the infection could spread throughout your entire abdomen, leading to sepsis. This is a highly dangerous situation. We need to get you into the operating room right away."

"Surgery...?" the man stammered, as if unable to believe his ears.

Then, a wave of anger and distrust washed over his face. He bolted upright in bed and yelled:

"Surgery? Here? What are you talking about!"

He glared at me as if I were a con artist trying to swindle him.

"If I need surgery, send me to Seoul! Right now! You know Ohsung Hospital, don't you? I'm a VIP there! I'm going to Ohsung Hospital!"

He pointed aggressively at his stomach and roared:

"I am not getting sliced open in some backwater provincial hospital like this! Call an ambulance this instant! I'm going to Seoul!"