9: Chapter 9 Danger Level: High Risk

Around 10:40 AM.

A new patient arrived in the Yellow Zone.

A man in his mid-thirties walked in, supported by his wife.

The man was of medium build, wearing a blue polo shirt. His complexion looked alright, but there was a thin layer of sweat on his forehead.

His wife was a thin woman wearing glasses. She looked quite refined, but her expression was frantic.

"Doctor, my husband started feeling discomfort in his chest this morning. It's a dull tightness, and he's a bit nauseous. Please take a look."

The one receiving them was an Associate Chief Physician from the Emergency Department.

Zhou Ze.

Forty-six years old, he had worked in the Emergency Department for fifteen years. He was highly experienced and the most senior doctor in the department besides Director Li Sen.

Lu Chen had only seen this man once before, during the Monday morning meeting.

At that time, Zhou Ze was sitting in the second row of the Conference Room, leaning against the back of his chair with his eyes half-closed. He barely spoke throughout the meeting.

The impression he gave Lu Chen was summed up in one word: seasoned.

After taking the patient, Zhou Ze began the routine consultation.

"When did it start?"

"This morning, around seven o'clock. After I got out of bed, I felt a tightness in my chest."

"Where is the tightness? Point it out to me."

The man used his hand to gesture to the center of his chest.

"Right in this area. It's not very painful, just tight. It feels uncomfortable when I breathe."

"Did it radiate to your left arm or jaw?"

"No."

"Any cold sweats?"

"A little bit, not much."

"Any previous heart problems?"

"No, my annual physicals are always normal."

"Do you smoke?"

"I don't."

"What about drinking?"

"Occasionally a little, but not much."

Zhou Ze recorded the details in the medical record while questioning him, then performed a simple physical examination.

He placed the stethoscope on the patient's chest to listen, then measured his blood pressure.

"Blood pressure is normal. Heart rate is 82—a little fast, but nothing major."

Zhou Ze took off the stethoscope and hung it back around his neck.

"It's not a big problem. It should just be Chest wall neuropathic pain. Combined with the work stress and lack of sleep you mentioned, Autonomic nervous system dysfunction is a possibility."

He wrote down the preliminary diagnosis in the medical record.

"We'll do an Electrocardiogram first to rule things out. If the Electrocardiogram is normal, I'll prescribe some medicine for you to take home and rest for a few days."

Hearing the words 'not a big problem,' the tension on the man's wife's face visibly relaxed.

"That's good, that's good. We thought it was a heart problem; we were scared to death."

Zhou Ze smiled.

"Don't be too nervous. You're young; the heart doesn't run into trouble that easily. Take him to get the Electrocardiogram first, and bring the results back when you're done."

The Nurse took the patient to get the Electrocardiogram.

Lu Chen was standing by the adjacent bed, changing the IV fluids for another patient.

He had heard Zhou Ze's entire consultation from beginning to end.

But he didn't say anything.

Because from where he stood to that patient, the distance was less than three meters.

The Eye of Truth had activated the moment the patient walked in.

And the diagnosis given by the system was completely different from Zhou Ze's judgment.

[Eye of Truth scan complete]

[Patient Information: Male, 36 years old]

[Chief Complaint: Chest tightness and discomfort accompanied by nausea for 2 hours]

[Eye of Truth Diagnosis: Acute inferior myocardial infarction (early stage), Subacute thrombosis of the distal right coronary artery, lumen narrowing by approximately 85%, focal ischemic changes have begun to appear in the myocardium]

[Danger Level: High Risk]

[Current symptoms are atypical; routine Electrocardiogram may show a false negative]

[Recommendation: Immediately complete Myocardial Enzyme Spectrum and Troponin tests; perform Coronary angiography if necessary]

[Warning: Without timely intervention, the patient has a high probability of suffering a massive myocardial infarction within 3 to 6 hours, which may lead to Cardiogenic shock or even sudden death]

Lu Chen's movements while changing the IV fluids paused for a moment.

Acute inferior myocardial infarction.

Early stage.

Atypical symptoms.

Routine Electrocardiogram may show a false negative.

These keywords crashed into his mind, making his back tighten slightly.

This patient was far from as simple as Zhou Ze had judged.

If they only treated it as "neuropathic pain," waited for a seemingly normal Electrocardiogram result, and then prescribed some medicine to send him home...

Then this person might very well collapse on the way home.

Or never wake up again after taking a nap at home.

Lu Chen's hand gripped the IV tubing as his mind raced.

Director Li Sen's words echoed in his ears.

"Without explicit authorization from me or another superior physician, you cannot perform any operations on any patient that exceed an intern's permitted authority."

He wasn't going to perform surgery.

He wasn't even going to write medical orders.

He just wanted to remind Zhou Ze that there might be a problem with this patient's diagnosis.

Reminding a superior physician should be within an intern's permitted authority, right?

Lu Chen put down the IV tubing and walked toward Zhou Ze.

"Doctor Zhou."

Zhou Ze was writing another patient's medical record and didn't even look up.

"What is it?"

"That patient with chest tightness just now, the 36-year-old one—I think we might need to check his Myocardial Enzyme Spectrum and Troponin."

Zhou Ze's pen paused.

Then he looked up and glanced at Lu Chen.

"Are you the new intern?"

"Yes, I'm Lu Chen. I just rotated over from the General Surgery Department this week."

"What did you just say? Say it again."

"That patient with chest tightness—I don't think it's neuropathic pain. Although his symptoms are atypical, there are a few details worth noting."

Zhou Ze put down his pen and leaned back in his chair.

The look in his eyes changed.

It wasn't anger, but it wasn't friendly either.

It was that specific scrutinizing gaze a veteran has when being questioned by a junior.

"Tell me, which details?"

Lu Chen said, "He said his chest was tight but not very painful, and the location was retrosternal, not on the chest wall."

"He said he sweated a little. Although he said it wasn't much, I saw just now that the sweat on his forehead was a cold sweat, not a heat sweat."

"It's June, the indoor air conditioning is set to 23 degrees, and he's wearing a short-sleeved polo shirt. Breaking out in a cold sweat isn't right."

"Also, he mentioned nausea. One of the early symptoms of an inferior myocardial infarction is nausea and upper abdominal discomfort, which is easily mistaken for a gastrointestinal issue."

After Zhou Ze finished listening, he was silent for a few seconds.

Then he gave a small laugh.

It wasn't a laugh of appreciation, but one tinged with a bit of helplessness and dismissal.

"Little Lu, is it? You've taken Cardiology Department courses in medical school?"

"I have."

"Then you should know what the most important diagnostic criteria for an acute myocardial infarction are."

"Electrocardiogram and cardiac biomarkers."

"Correct, the Electrocardiogram."

Zhou Ze extended a finger and tapped the desk.

"I've already sent him for an Electrocardiogram. When the results come out, if there's ST-segment elevation, it's an infarction. If not, it isn't."

"But Doctor Zhou, Electrocardiogram changes in an inferior myocardial infarction might not be obvious in the early stages, especially within two to three hours of onset. A routine twelve-lead Electrocardiogram might show a false negative."

"That's why I suggest checking the Myocardial Enzyme Spectrum and Troponin at the same time."

Zhou Ze's smile vanished.

His gaze turned somewhat cold.

"Student Lu Chen, I've worked in the Emergency Department for fifteen years. How many days have you been here?"

"Five days."

"Five days."

Zhou Ze repeated the number.

"You've been in the Emergency Department for five days, and you're coming to teach me how to diagnose a myocardial infarction?"

Lu Chen: "I'm not teaching you; I'm simply making a suggestion."

"I've heard your suggestion, and my judgment will not change because of it."

Zhou Ze picked up his pen again and lowered his head to continue writing the medical record.

"This patient's symptoms do not support a diagnosis of acute myocardial infarction. Chest wall neuropathic pain combined with Autonomic nervous system dysfunction is the most reasonable explanation. We'll know once the Electrocardiogram results are out."

"Go back to your work and stop interfering with patients who are not within your scope of authority."

His tone in that last sentence was quite heavy.

Lu Chen stood there without moving.

There wasn't much of an expression change on his face.

No anger, no feeling of being wronged, and none of that submissive look one has after being scolded.

He was just very calm.

But in Zhou Ze's eyes, his calmness seemed more like a silent confrontation.

"What are you still standing here for?"

"Doctor Zhou, I still suggest adding the Myocardial Enzyme Spectrum test."

Zhou Ze's brow furrowed completely.

He put down his pen, stood up, and looked at Lu Chen.

"Lu Chen, did you not understand what I said?"

"I understood."

"You understood and you're still arguing with me?"

"Because this patient really could have a myocardial infarction."