2
# Chapter 2. Code Black (2)
---
That same night, inside a car speeding down the road toward Korea University Hospital.
The woman I'd met for the first time today, Kim Ha-yeon, was driving.
I'd considered taking a taxi, but as luck would have it, the hotel was packed with guests attending wedding ceremonies and other banquets, and the taxi line was ridiculously long, so I gave up.
Then I tried calling one through a taxi app, but when it showed a seventeen-minute wait before the taxi would arrive, I gratefully accepted Kim Ha-yeon's offer.
I couldn't just sit there doing nothing on the way to the hospital, so I called the ER again.
I expected Dr. Lee Hyung-seop to answer, but an ER nurse picked up.
"This is Han Joo-won from Anesthesiology. Is Dr. Lee Hyung-seop in surgery right now?"
"Yes, Doctor."
"How are things in the ER operating rooms right now?"
"We're short on anesthesiologists, so some patients haven't been able to go into surgery. But, Doctor, I just came back from vacation and returned to my shift today. Did something happen in Anesthesiology? There wouldn't normally be this many anesthesiologists away at the same time."
Something had happened.
The Korean Society of Anesthesiologists and Pain Medicine workshop.
Unfortunately, it was today.
If circumstances had allowed, I would have wanted to attend it myself. There was a new nerve block technique and ultrasound-guided procedure training program that I'd really wanted to learn...
"They're attending a society conference and workshop."
"Ah~! Of all days, it had to be today..."
Exactly.
Through the nurse's receiver, I could clearly hear the alarms coming from various medical devices mixed with the shouting and screams of doctors, patients, and their families.
It was enough to tell me that the place was complete chaos.
I wasn't physically in the ER yet, but with the urgent situation being that emergency surgeries couldn't be performed because there weren't enough anesthesiologists, what could I possibly do to help?
"Did all the anesthesiology doctors on duty go into the operating rooms?"
"Yes."
"Then find out how many anesthesiology residents who couldn't get into the operating rooms are there."
"Understood."
I glanced at Kim Ha-yeon while talking on the phone.
She was driving someone else's car for the first time today, yet she was surprisingly steady and fast.
She moved smoothly with the flow of traffic, and somehow managed to get through intersections just before the yellow light turned red.
"We have about twenty minutes until we reach the hospital."
She informed me while driving.
"Yes. Ms. Kim Ha-yeon, thank you so much. I'll transfer the cost of the meal to you right away. Please give me your bank account information."
"No, it's okay."
"No. I'm grateful enough that you came out to meet me today. So let me pay for the meal."
"I said it's okay."
"No... I..."
While we were arguing over who should pay for dinner, the ER nurse's voice came through the phone again.
"Doctor!"
"Yes?"
"Three anesthesiology residents are out here helping us right now. I'll put one of them on the phone."
"Yes, yes."
"I'm handing the phone over now. I'm Sim Jin-woo, a second-year resident, Doctor."
"Oh, Jin-woo. Who's down there with you right now?"
"Dr. Lee Jin-a and Dr. Park Seong-ho."
"Really? Hmm. It looks like I'll arrive at the hospital in about nineteen minutes. We need to do something in the meantime. First, have three operating rooms opened. You three will each go into one of them. Then, under my instructions, you'll administer anesthesia and take care of the patients. You can do that, right?"
I was planning to place the three residents in separate operating rooms and control the situation remotely.
I'd already done the same thing several times, so there was nothing particularly unusual about it.
There was just one problem.
I'd already received a stern warning from Korea University Hospital's Medical Ethics Committee over it.
The basis of the warning had been simple:
"If a patient were to die and a lawsuit followed, could a single anesthesiologist bear the responsibility, not to mention the damage to the hospital's reputation and credibility? Therefore, do not participate in surgery remotely ever again!"
Fortunately, the head of our department had stepped in and protected me the last time.
But in a situation like this, I was about to repeat the exact same thing today.
And this time, our department chief might not be able to cover for me.
At worst, I might get fired.
I didn't want to leave this good job, a place where I could experience so many surgeries.
But what else could I do?
Even if I got fired, shouldn't I do everything I could to save patients who could still be saved?
I felt that otherwise, I'd regret it for the rest of my life.
"Doctor? How are we supposed to do that?"
"Last time, even a first-year resident managed it alone. Don't think you can't do it. And I'll take full responsibility for everything, so don't worry about what happens afterward. Just do as I say. First, tell the ER doctor to prepare three operating rooms right now. Then get yourselves ready for surgery and each take charge of one room. We'll keep this line open as a group call the entire time. Do you understand what I'm saying?"
"Yes... yes."
"Don't be scared. Just follow my instructions exactly. Jin-woo, got it?"
"Yes, Doctor."
"Good. I'll take responsibility. Let's save the patients first."
---
"I'm Sim Jin-woo in Operating Room 8."
"I'm Lee Jin-a in Operating Room 11."
"I'm Park Seong-ho in Operating Room 16."
I kept a group call open with the three residents, intending to control the anesthesia and patient vitals for three surgeries simultaneously.
First, I needed to understand the patients' conditions, so I remotely accessed the hospital's EMR through the hospital security app on my phone.
Then I quickly scanned the records.
First, the patient in Operating Room 8, where Sim Jin-woo had gone, was a forty-five-year-old man. He had already been confirmed to have a gastrointestinal perforation and intra-abdominal bleeding from the traffic accident.
"Dr. Sim, what's the patient's blood pressure and heart rate right now?"
"The EMR was just updated. Blood pressure is 80 over 50, and heart rate is 120."
"He has a history of hypertension?"
"Yes, Doctor. There's a three-year medication history, but we haven't been able to confirm whether he took his blood pressure medication today before the accident."
Of course not.
We would need the patient to be conscious, or at least have a family member present, to ask something like that.
"Okay. His blood pressure is unstable, so there's a high chance it'll drop sharply during induction. Have you checked the blood test results?"
"They haven't been updated in the EMR yet, apparently. They came in right before we entered the operating room, right after the CT. His hemoglobin is low at 8.5, and his platelet count is also below 100,000."
"Hmm~ There's a high risk of bleeding during surgery. Have them prepare the massive transfusion protocol, and if his blood pressure drops below 80, start norepinephrine immediately. Induce anesthesia with etomidate, and use rocuronium as well."
"Yes, Doctor."
"As soon as everything is ready, tell the attending surgeon to start the operation immediately. If anything goes wrong during surgery, let me know right away."
"Yes, Doctor."
Operating Room 8 was dealt with for the moment and prepared for surgery.
Next was Operating Room 11.
"Operating Room 11."
"Yes, this is Lee Jin-a."
I examined the medical records of the patient in Operating Room 11 through the EMR and began speaking with resident Lee Jin-a.
"She's a twenty-seven-year-old woman. There's severe intra-abdominal bleeding from a stab wound to the abdomen."
"Yes, Doctor."
"What caused the abdominal wound?"
"We haven't been able to confirm yet. There are pieces of glass around the wound, so we suspect she may have been stabbed or cut by glass during the collision."
"Okay. Huh? This patient has a record of surgery for uterine fibroids a year ago?"
"Yes, Doctor. She had significant blood loss at the time, and there were signs of a coagulation disorder."
"Then the risk of additional bleeding is high. Have you checked the blood test results?"
"Yes, Doctor. Her PT/INR is elevated at 1.6. Should we administer additional plasma?"
"Yes, do that. If the bleeding increases during surgery, administer fresh frozen plasma first, and prepare tranexamic acid as a coagulation agent. Adjust the transfusion rate immediately according to the bleeding, and just do what you've been taught."
"Yes, Doctor."
"Induce anesthesia with ketamine. You know using a high dose of propofol is dangerous, right?"
"Yes, I know, Doctor."
"Good, Dr. Lee Jin-a. I'm here, so don't be too nervous. Monitor her carefully so the surgery can proceed smoothly. Don't lose your focus."
"Yes, Doctor."
"If a problem occurs during surgery, don't panic. Tell me immediately, understood?"
"Yes, I will."
"Good. Don't hang up. Keep this line open until the surgery is over or until I arrive."
"Yes, Doctor."
I then quickly went through the medical records of the patient in Operating Room 16.
"Operating Room 16."
"Yes, Doctor. This is Park Seong-ho."
"Right, Dr. Park. The patient in Operating Room 16 is a sixty-two-year-old man with multiple fractures and internal organ injuries. Good grief~ He also has a history of heart disease? Damn. I guess I'll have to keep a close eye on this patient."
---
The patients in Operating Rooms 8 and 11 seemed manageable enough that I could intervene through Sim Jin-woo and Lee Jin-a only when problems arose.
The problem was the patient in Operating Room 16.
Honestly, this patient's condition was so bad that I wasn't even sure whether I could properly manage the anesthesia and the situation if I were physically present in the operating room myself.
There were still more than thirteen minutes until I reached the hospital, so there was nothing else I could do.
Doing this, at least, increased the chances of saving the patient compared with simply sitting back and doing nothing.
Of course, once the surgeries were successfully completed, there would definitely be hell to pay over the fact that three surgeries had been performed without an anesthesiology specialist physically present in the operating rooms.
And I was afraid of who would bear the responsibility if a medical accident occurred.
Yet I had a strange confidence that nothing like that would happen.
"Dr. Park, this patient had a myocardial infarction three years ago and is currently taking both a beta blocker and an anticoagulant, so his risk of bleeding is extremely high. Prepare to administer an anticoagulant reversal agent."
"Yes, Doctor."
"The beta blocker may blunt his heart-rate response. Keep monitoring his blood pressure and heart rate, and tell me immediately if you see any changes."
"Yes, Doctor. But his blood pressure is already low. What should we use for induction?"
"You're a resident and you're seriously asking because you don't know this? Use etomidate as the primary agent and combine it with a low dose of ketamine to minimize cardiovascular side effects."
"Yes, yes. You're right, Doctor."
"Prepare norepinephrine, and start administering it immediately if his blood pressure drops further."
"Understood."
---
There were about nine minutes left until we reached the hospital.
I hoped nothing would happen before I arrived.
That hope was shattered without mercy.
"Operating Room 8, Doctor."
I had been continuing to look at the EMR for Operating Room 16 while giving instructions to Park Seong-ho when Sim Jin-woo from Operating Room 8 urgently called me.
"Yes, what is it?"
"The blood loss is greater than expected, Doctor. It's making it difficult to locate the source of the intra-abdominal bleeding."
"What's his blood pressure now?"
"It's dropped to 70 over 40."
"Increase the norepinephrine dose to 0.1 mcg/kg/min and prepare an epinephrine ampule as well. Increase the transfusion rate and lower the alveolar pressure. If the signs of shock persist, suggest to the attending surgeon that they reduce the intra-abdominal pressure."
"Yes, Doctor."
While I waited for Sim Jin-woo's report,
his voice soon came through.
"We've located the bleeding site. Blood pressure is stable at 85 over 50."
"Okay. Good job. Don't let your guard down until the very end. Keep watching carefully."
"Yes, Doctor."
Just as I thought one problem had been resolved, Operating Room 11 called me.
"This is Lee Jin-a in Operating Room 11, Doctor."
"Yes."
"Her oxygen saturation has dropped to 85 percent."
"Don't panic. Stay calm! Increase the alveolar pressure and increase oxygen delivery. If the blood loss looks significant, adjust the transfusion rate. Ah! Check her coagulation status again. If necessary, increase the plasma administration."
"Yes, Doctor."
I waited briefly for the next report from Operating Room 11.
Since it was quiet, it seemed there were no further problems in either Operating Room 8 or 11.
I waited for the results of the measures we'd taken.
"The liver repair is almost complete."
"Her oxygen saturation?"
"It's recovered to 95 percent."
"Good. Well done. Don't lose focus and keep monitoring."
"Yes, Doctor."
The small problems that had arisen in the two rooms were resolved, allowing me to focus on Operating Room 16 again.
There were still a little over six minutes until I reached the hospital.
"Dr. Park Seong-ho."
"Yes, Doctor."
"Why is the EMR update so slow? It seems like there's a bit of a time lag compared to what's happening on-site. What's the patient's blood pressure and heart rate right now?"
"Oh! Damn. His blood pressure just dropped to 60 over 30. His heart rate is also fast at 120, but the rhythm is somewhat irregular."
"Hey! Can't you keep your head in the game!!!"
I unconsciously shouted through the phone.
Kim Ha-yeon, who was driving, was startled and glanced at me.
I raised one hand and gestured to her that I was sorry, then continued talking on the phone.
It was understandable that he might be frightened going into an operating room alone as a first-year resident without his supervising professor beside him.
I understood how he felt.
But if he continued being this flustered, he could cause a serious accident in the operating room later.
"I'm sorry, Doctor."
"The irregular heart rate is probably due to the beta blocker. Increase the norepinephrine to 0.2 mcg/kg/min and prepare amiodarone if the irregular rhythm continues. His blood pressure is low, so prepare 1 mg of epinephrine as well. Watch the situation, and if it looks necessary, administer it intravenously immediately."
"Yes, Doctor."
"I'll be there in about three minutes. Let's all stay focused just a little longer."
The residents in Operating Rooms 8, 11, and 16 all answered after hearing my words.
"Yes, Doctor."
---