Chapter 52: What is this? (2)

Anatomical variation.

It was a term used to describe findings that occur with a certain probability.

Most of the time, "certain probability" meant a frequency of around 10% or less.

In other words, when performing surgery or procedures, it meant that one had to be prepared to some extent.

Moreover, many surgical techniques were designed with anatomical variations in mind.

‘This... What are the odds of this happening?’

[The probability of the left and right coronary arteries branching from a single vessel from the aorta is less than 0.1%.]

‘And among those, the probability of the right branch being so short and another branch coming out from the left branch?'

[Based on the data I have, it has never been statistically recorded.]

‘I don’t think I’ve ever seen it in case reports either.’

[No, I have seen it once. Just once.]

‘Ah... Is that so?’

In other words, it meant that they were dealing with an extremely, extremely rare case.

Even Seohyuk, who was only assisting from behind, was flustered to this extent, so Lee Hyun-jong, who was directly performing the procedure, felt like he was about to die.

‘Should I call the thoracic surgery team now?’

He pulled back the guide wire he had inserted with confidence and considered the thoracic surgery option.

He had started by inserting the guide wire into the right coronary artery branch from a single vessel.

It turned out to be less than 5 cm.

‘Ah... This is awkward.’

Who was Lee Hyun-jong?

He was the one who, once upon a time, firmly believed that the chest must always be opened by thoracic surgeons and brought cases into the internal medicine domain, arguing that stents could be placed without opening the chest.

He even drew a comic where he, armed with a bow, aimed at myocardial infarctions while thoracic surgeons, armed with scalpels, chased them, promoting cardiology on a large scale.

‘Enemies, true enemies.’

In fact, thoracic surgery professors did not greet Lee Hyun-jong well even after he became the director.

It was an inevitable situation, given their professional rivalry.

‘What should I do?’

Moreover, the situation was medically too late.

He was regretting not opening the chest when he confirmed that there was only one vessel earlier.

“Director.”

At that moment, Seohyuk spoke up.

“Hmm?”

“I’ll call the thoracic surgery team first. If they are told there’s a possibility of a thoracotomy, they might come.”

“Ah, if you do that, they will come. But...”

The situation was not good.

From the thoracic surgery team's perspective, it would feel like they were being handed a dead patient.

“Still, we have to call them. It’s too dangerous.”

“That’s... true.”

“And.”

“And?”

“I’ll call and then tell you immediately.”

“Okay.”

Lee Hyun-jong was just pulling the guide wire back to the point where the coronary artery branches from the aorta.

He hadn’t completely pulled it out of the aorta because he was considering whether to try again.

Just then, it seemed Seohyuk had something else to say, which piqued his interest.

Seohyuk glanced at Lee Hyun-jong, who was listening intently, and asked the nurse to make a call.

As with any hospital, the catheterization lab had a direct line to the thoracic surgery on-call doctor, so the connection was immediate.

“Yes, sir. I’m Seohyuk, a first-year resident in internal medicine.”

“First-year? Why? Did an accident happen?”

The thoracic surgery team was familiar with the catheterization lab’s number.

Therefore, they would never ignore a call, even from a first-year resident.

“It’s not a CPR situation yet, but there’s an anatomical variation, which is dangerous.”

“Variation? What... One vessel?”

“Yes.”

“But you didn’t go inside, did you? With the wire?”

The person on the other end was a fellow.

In cases of a single vessel, it was generally handled by thoracic surgeons rather than internists.

That’s why the voice was a bit higher.

“Yes. The lesion was expected to be not far from the vessel, so I went in.”

“No, what... Oh.”

The fellow, who was about to get angry, suddenly remembered someone’s face.

“Is it Professor Lee Hyun-jong?”

“Yes.”

“Damn... I see. I’ll go to the operating room. Just tell them to do nothing. How is the patient’s vital signs? Are they stable?”

“They are stable now, but the patient already has a right ventricular infarction, so the blood pressure is low.”

“Got it. I’ll come right away. Just tell them to do nothing.”

“Okay.”

Seohyuk nodded, thinking that even if he told Lee Hyun-jong, he wouldn’t listen.

Then he turned to look at Lee Hyun-jong, who had been listening intently.

Looking at his face, he wondered if he should really keep saying this.

[The analysis is complete. The anatomy of this patient matches exactly with the case I have. The results are the same even when compared with the fluoroscopic image on the screen.]

But just as he was hesitating, Baruda gave him tremendous courage.

Of course, that didn’t mean he could suddenly speak.

‘Is it really okay?’

[Seohyuk. In a similar case, the patient died after the chest was opened. If interventional treatment had been possible, the patient might have survived. Think about it. A thoracotomy takes a lot of time.]

‘That’s true...’

Just preparing for surgery would take at least 30 minutes.

Surgery wasn’t something you could just jump into with a scalpel.

Anesthesia, sterilization, and draping were all required.

[You need to make a quick decision. Time is passing while you’re hesitating.]

That meant the patient was dying.

Although Seohyuk wasn’t a doctor with a crazy sense of mission,

he wasn’t below average either.

So he finally spoke up.

“Director, may I speak about the case?”

The words were his, but the opinion was Baruda’s.

Lee Hyun-jong, who was still considering whether to proceed, immediately nodded.

For a professor to take advice from a first-year resident.

It would be impossible with any other professor.

But Lee Hyun-jong was a very flexible thinker.

He had broken the traditional medical mindset that had been passed down for decades, so it was natural.

“Go ahead. I called the thoracic surgery team, but... You know, the probability of death from a thoracotomy in this situation is over 50%.”

“Yes, Director. In the 1994 University of California, Irvine (UCI) Hospital case, we can see an exact anatomical variation like this.”

“1994 UCI?”

“Yes.”

“Go on.”

UCI was a quite excellent university located in Irvine, just below Los Angeles.

However, UCI Hospital itself was not a hospital that could be called excellent.

In fact, it was overshadowed by nearby medical centers in terms of local resident acceptance.

Of course, as a university hospital in the United States, it maintained a certain level of quality.

“At that time, the patient was brought to the emergency room with right ventricular infarction and decreased consciousness.”

“This case is the same.”

“Yes. But at that time, interventional procedures, such as stenting, were very rare, so the patient was immediately moved to the operating room for a thoracotomy and bypass surgery.”

“What happened?”

“A lot of time had already passed by the time the patient was brought in, and they went straight into surgery without other tests, so they didn’t recognize the anatomical variation.”

“Ah... They must have been confused there too.”

Of course, they would have been.

Even with the current advanced medical technology, it would be confusing.

How much more so back then.

Naturally, they would have assumed the problem was with the right vessel, only to find out that another vessel was supplying the right heart.

“Yes. After the patient died, an autopsy was performed with the family’s consent, and the anatomical structure confirmed at that time is exactly the same as this patient’s.”

“So this is a possible variation, not a mutation...?”

“Yes. It’s a very rare variation, but it is a variation.”

“Then where should I go in?”

Lee Hyun-jong advanced the guide wire a bit again.

Then he saw a branch heading to the right and another branch heading to the left.

Unlike typical variations, the left branch split into two.

It was a structure so complex that it seemed someone was intentionally trying to torment the patient.

“The branch heading upward from the left fork.”

“Upward? Not downward?”

“They twist a bit after a short distance. The thick part you see on the image is exactly that point.”

“Hmm.”

This meant that he had to insert the wire in the opposite direction.

Lee Hyun-jong almost reflexively looked at the clock behind him.

The procedure had already been going on for over 20 minutes.

It meant the patient was slowly but surely dying.

Given the already existing infarction, if more time was wasted, the patient would definitely be lost.

‘It looks like it’s downward...’

But hadn’t he been fooled once before, thinking it was on the right?

There was no guarantee it wouldn’t happen again.

‘The way he cited the case is so convincing...’

If he had just said it was a published case, it might have been ignored.

But mentioning the specific year 1994 made it hard to ignore.

Moreover, his trust in Seohyuk was immense.

‘Well... At this point, trying is the best chance to save the patient.’

If it had been arranged to go to thoracic surgery from the beginning, it would be different.

But now, it wasn’t.

So, with a “let’s see what happens” attitude, Lee Hyun-jong pushed the guide wire in.

One fortunate point was that his skill in manipulating the guide wire was almost divine.

He had no hesitation in navigating the narrow coronary artery.

Swoosh.

The guide wire, as expected, headed upward and hit the wall once.

Thanks to the smooth tip and Lee Hyun-jong’s gentle touch, no mishap occurred.

Of course, the biggest reason was Seohyuk.

“There, it bends there.”

He had timely informed about the anatomical structure.

“Really. Good. Then there’s no need to hesitate. Let’s...”

Lee Hyun-jong pushed the guide wire down and soon confirmed the blocked point.

The vessel, stained by the contrast agent injected earlier, was clearly cut off where the guide wire stopped.

This meant it was blocked there.

“Here’s the stent.”

Seohyuk handed the stent to Lee Hyun-jong, whose face was beaming with joy.

Lee Hyun-jong pushed the stent along the guide wire and laughed.

“Hey, we did it. The patient is saved.”