Chapter 158: What is the Cause? (1)

“I’ll call neurosurgery!”

Upon hearing ‘brain hemorrhage,’ An Dae-hoon immediately picked up the phone. At the same time, the surrounding nurses rushed towards him.

A brain hemorrhage - it was crucial to act within the golden hour. If not treated promptly, there was a high risk of crossing a river from which one could never return.

“Uh, yes. Hmm. This requires immediate attention…”

Suhyuk observed as An Dae-hoon made the call and the nurses began administering appropriate care before turning his focus back to the video. The two distinct areas of bleeding on the right side were unmistakably clear.

“[There are already blood clots present. It seems…quite some time has passed.]”

‘Is surgery possible?’

[At this size, surgery is usually recommended, but…] Baruda hesitated to reach a conclusion quickly. Initially, he had been firm with his treatment plans as his knowledge increased moderately. However, now that his expertise was extensive, he sometimes showed hesitation.

‘Why?’

[Please consider the patient’s underlying conditions. This person does not have diabetes or high blood pressure, yet they suffered from cerebral hemorrhage at just 36 years old.]

‘Ah… Indeed, you’re right. Their BMI also seems normal.’

The basis for his hesitation became clearer. It indeed sounded peculiar. Without any apparent trauma, there should be an underlying condition causing the cerebral hemorrhage in this patient.

[However, the patient showed symptoms of infection four days ago. Based on the symptoms alone, it could be mistaken for a simple cold, but considering the fever and uncontrollable headache, there is a possibility that he had some serious infectious disease.]

‘Could this infection have caused the brain hemorrhage?’

[Yes, it’s just a hypothesis, but it is highly probable.]

In that case, controlling the underlying cause might be more effective than surgery. Proceeding with surgery while the root problem remained untreated would be extremely risky. Fortunately, Taehwa Medical Center had specialists beyond internal medicine, so Dr. Hwang didn’t need to make a decision alone.

Soon, neurology and neurosurgery teams arrived after receiving the call.

“Oh… Doctor Lee Suhyuk is here.”

In particular, Professor Choi Junyeong from neurology arrived on the scene. Known for his dedication to patients, he likely came down here while attending to other emergency cases.

“Hello.”

Meanwhile, Kim Hyunchul, a third-year resident in neurosurgery, was dispatched. Unlike internal medicine, neurosurgery did not send a first-year resident due to the severity and urgency of their cases. It made sense for someone with more experience to handle this situation.

“Yes, I’m Lee Suhyuk. The patient is… currently between unconsciousness and coma. He has spinal reflexes but minimal response to pain. Communication is impossible. We don’t know when exactly the symptoms started. He was found alone at home by a colleague and brought directly to the emergency room.”

“Ah.”

“Hmm.”

Both Choi Junyeong and Kim Hyunchul had received a rough overview of the situation from An Dae-hoon earlier. However, Lee Suhyuk’s explanation was much more straightforward than Dahoon’s. Listening to An Dae-hoon felt like hearing secondhand information, while Suhyuk sounded like an expert with firsthand knowledge providing details.

“The images…”

“Here they are, Professor.”

“Hmm.”

Choi Junyeong took the lead first. Typically, patients with brain hemorrhages would immediately be referred to neurosurgery, but surprisingly, many cases did not require surgery. Moreover, without knowing when symptoms initially appeared, surgery might already be futile.

“The bleeding is significant… There’s also a hematoma nearby. The brain tissue seems slightly swollen.”

“Yes, we administered steroids and mannitol.”

For increased intracranial pressure, steroids and mannitol were used. This could be considered quite appropriate internal treatment. Choi Junyeong nodded with the expression of an ace from Internal Medicine as he continued to examine the images. He asked more questions about the patient:

“Ah, yes. Did you perform a spinal tap?”

“No, Professor. Considering the elevated brain pressure, I judged there was a risk of herniation if performed carelessly.”

“Oh.”

As always, Suhyuk’s answer was precise, and it had clear justification. Professor Choi Junyeong lamented why his department didn’t have such talent as he nodded approvingly.

“I agree with your judgment. However… Doesn’t it seem like the brain pressure isn’t high enough to warrant immediate hypotensive therapy?” His gaze shifted towards Kim Hyunchul.

Kim Hyunchul, while observing the images, had similar thoughts at that moment.

“Yes. There doesn’t seem to be any reason for hypotensive therapy yet. However, my opinion is… It would still be better to perform a lumbar puncture.”

“Why do you think so?”

“Looking at the patient’s history, there aren’t any significant underlying diseases apart from infection, right? There is a possibility that bleeding occurred due to meningitis or other severe inflammation. In that case…”

To detect infections within the brain and spinal cord, blood tests were somewhat inconvenient. The blood-brain barrier prevented most substances from passing through easily. To obtain direct information, it was necessary to examine cerebrospinal fluid directly. For this, a lumbar puncture had to be performed.

[Oh, this fellow is quite sharp.] Baruda admired Kim Hyunchul’s rational approach, impressed by his logical reasoning.

It felt like Kim Hyunchul was breaking the stereotype of neurosurgery due to Choi Nokphil’s actions.

“If possible, it would be best to proceed with caution. Preparing for hypotensive therapy and carefully performing the procedure seems advisable.”

Suhyuk agreed with his opinion. It sounded quite plausible, and there were no other means to determine the cause. Therefore, Suhyuk nodded and opened his mouth:

“Professor, I also think…it would be better to proceed cautiously. Since the neurosurgeon is available, shall we prepare the surgery room for hypotensive therapy?”

“Hmm… Indeed. Yes, let’s do this cautiously. Should we call the resident?”

“No, sir. I will perform the procedure.”

“You, Dr. Lee Suhyuk?”

In hospitals, it was widely known that practice makes perfect. Indeed, there were numerous cases of surgical professors who initially had poor skills but later became masters after several years of experience. It wasn’t surprising for suspicion to creep into Professor Choi Junyeong’s eyes since neurology residents would have more opportunities than Lee Suhyuk to hone their surgical skills.

“Ah…I’ve heard many times about Dr. Lee’s excellent hands.” Unexpectedly, one of the neurosurgery residents supported Soohyuk.

“Huh? Wait a moment.”

Finding this strange, Baruda immediately searched his character relationship database. The data consisted primarily of personal experiences and anecdotes from Shin Hyun-tae and Lee Hyunjong regarding Suhyuk. However, considering Hyun-tae was the director and Hyunjong was the department manager, there was quite a substantial amount of information available.

Thanks to this, Taehwa Medical Center’s neurosurgery department was divided between two factions - ‘Cervical Spine’ and ‘Brain Waves’, who constantly argued with each other. However, Kim Hyunchul had noted that Choi Nokphil belonged to the thin professor’s faction.

‘I see. I guess I am better than Choi Nokfil.’

Moreover, regardless of what happened, Choi Junyeong trusted Lee Suhyuk. This trust stemmed from Suhyuk’s consistent success in treating difficult patients shared between neurology and neurosurgery departments. Additionally, hearing praise for Suhyuk’s surgical skills from the notoriously proud neurosurgeons left little room for doubt.

“Really? Then let’s give it a try.”

“Yes, Professor. Oh, before we start, shouldn’t we intubate him first? Considering his cerebral hemorrhage…”

An unresolved cerebral hemorrhage could potentially worsen, and the associated brain swelling might increase as well. It would be disastrous if the patient suddenly stopped breathing while under observation. His current condition was too unstable to assume everything was fine.

If we waited and the patient suddenly stopped breathing, it would be problematic. The patient’s condition was too unstable to assume everything would be fine.

“Ah, yes. Indeed. Let’s prepare for all possibilities.”

“Yes, Professor.”

Professor Choi Junyeong nodded, wanting to personally observe Suhyuk’s hand movements. Immediately, Suhyuk attempted intubation smoothly with the plastic tube and laryngoscope provided by the nurses earlier.

His excellent anatomical knowledge combined with…

[Correct, not wrong. Just 2mm to the left. Yes. From Suhyuk’s perspective, not the patient’s.]

…the full support of Baruda made this possible.

“Oh.”

“It’s inserted. Can you squeeze the Ambu bag first?”

“Yes, sir.”

As soon as the tube was placed, Suhyuk handed it over to Ha-yoon standing nearby.

Then he slowly moved the patient to their side without disturbing Hayuni’s work on the tube.

[When I think about it, if we had turned the patient without intubation, there could have been a major incident due to airway obstruction.]

‘Ah, that’s true.’

[I will add this to the Database.]

‘Great.’

This might seem like a minor issue, but it was crucial and helpful for both Suhyuk and Hayuni. Such details were not explicitly mentioned in case reports. With Baruda’s assistance, indirect experience could be rapidly acquired; however, these practical insights came only through personal experiences.

“I need to disinfect… Oh, yes. Thank you.”

Regardless, Suhyuk positioned the patient with a curved back resembling a shrimp and then looked at the assigned nurse.

The nurse assigned to this patient had left for another location, so Suhyuk received immediate assistance from another nurse.

Grip.

Before using the Betadine gauze provided by the nurse, Suhyuk marked the spot with his fingernail where he would insert the needle. As it involved puncturing between the vertebrae, the precise location was crucial.

[Good. I will inject now.]

Thanks to Baruda’s guidance, Suhyuk faced no difficulties. He disinfected the area with Betadine and then inserted the long spinal needle. Immediately upon penetration, he felt a pulsating sensation, likely due to increased intracranial pressure.

[I assess that it is not yet at a dangerous level.]

‘With just this… feeling, you can make such a judgment based on data?’

[No, this serves as one reference point.]

‘Why are you so confident?’

[In any case, it is minimal compared to arterial pressure. It seems slightly higher than usual spinal taps?]

‘Hmm.’

The ending sounded unsure, but his claim didn’t seem baseless either. Consequently, Suhyuk slowly and steadily began extracting the cerebrospinal fluid.

“Ah.”

“Ummm.”

Naturally, the rest of the medical team was extremely tense. They focused solely on Suhyuk’s hand, the patient’s back, and the vital signs monitor. This was because a brainstem herniation would be catastrophic, potentially leading to the loss of the patient.

“Sigh.”

Fortunately, while Suhyuk extracted a sufficient amount of cerebrospinal fluid, there were no significant changes in the patient’s vital signs.

“Please send this for testing.”

Suhyuk handed over the slightly cloudy liquid to the nurse. Just by looking at its color, it was clear that something wasn’t right. It appeared there might be an underlying infection.

“Yes…let’s also perform intubation and get an MRI. This looks like inflammation, so we need an MRI as well.” Choi Junyeong reached the same conclusion upon seeing the fluid. Given his extensive experience with infectious diseases such as meningitis, it was an obvious deduction for him.

“Understood. Is the MRI room ready?”

“Yes, sir. I booked it earlier when scheduling the CT scan. They mentioned having about a 15-minute window available, so it should still be free now.”

“Really? Then let’s go immediately.”

“Yes.”

Following Professor Choi Junyeong and Suhyuk’s instructions, Dahoon pulled the bed towards the MRI room.

During the MRI scan, Ha-yoon had to prepare an IV. Similar to when they did the CT scan, Suhyuk diligently accompanied her instead of staying behind.

The MRI itself took a long time due to the imaging process.

“Hmm.”

“So far, it just shows bleeding… Hmm?”

As the images were being captured and transmitted, something unusual caught their attention. Baruda was the first to notice it.

“There are two instances of cerebral infarction. They are small, but they are indeed infarctions.”