When Taeho and Doctor Chen ran into the ICU, a shrill alarm was blaring from the monitor. Two nurses who had arrived first were moving busily.
Doctor Chen asked, gasping for breath.
“How’s the situation?”
“Blood pressure has dropped to 80 over 50, and heart rate is in the 40s. He’s unconscious.”
Sarah, the nurse in charge, reported urgently.
Taeho approached the bedside and examined Lee Junho. His face was even paler, and his breathing was shallow and irregular.
Doctor Chen immediately ordered emergency treatment.
“Give 0.5 milligrams of atropine IV first, and if there’s no effect, prepare an epinephrine drip. And call the respiratory therapist right now.”
“Yes!”
The nurses’ hands grew even busier.
Just then, Chief Lee Junbeom came running into the room, panting. From the look of him, it seemed he had bolted out after catching a brief nap in the call room.
“What happened? Junho.”
Even without an explanation, Lee Junbeom grasped the situation at a glance, and his face turned corpse-pale.
Taeho knew there was no more time.
“Doctor Chen, this may be our last chance. We don’t have time to wait any longer for MRgFUS.”
“Doctor Kang. Can you really be certain MRgFUS will work?”
“Right now, the drug concentration in Junho’s cerebrospinal fluid is only 2% of the blood concentration. But if we selectively open the blood-brain barrier with MRgFUS, we should be able to increase the drug delivery rate by more than twentyfold.”
Rema displayed the probability of success in numbers before Taeho’s eyes.
—Success probability: 73%, risk of side effects: under 12%.
With odds like that, they had to try it immediately. Taeho was certain.
Doctor Chen examined the data carefully once more. He asked Doctor Johnson, who had come over after hearing the call.
“Doctor Johnson, what do you think?”
Doctor Johnson also knew very well that there was nothing else they could try. He answered with a worried expression.
“I think that’s a decision the chief has to make. Getting IRB approval immediately is an issue too.”
Most of the responsibility would fall on Doctor Chen, the attending physician. That was why Doctor Chen hesitated.
Taeho spoke in a determined voice.
“Even at this very moment, the patient’s brain cells are continuing to be destroyed. We don’t have time to wait until tomorrow morning. There’s the Compassionate Use Emergency Protocol, isn’t there? As far as I know, in a life-threatening situation, approval can be obtained within twenty-four hours.”
Doctor Chen turned to him in surprise.
“How do you know about that protocol?”
“Korea has a similar system. And I know it exists in FDA regulations as well.”
Rema was displaying the relevant regulation before Taeho’s eyes.
“FDA 21 CFR 56.104(c). In a life-threatening emergency, the procedure can proceed immediately with emergency approval from the IRB chair.”
Doctor Chen fell into deep thought. Doctor Johnson whispered cautiously.
“If you decide to do it, Chief, I’ll follow your lead.”
At that moment, Rema’s warning tone rang in Taeho’s ear. Startled, Taeho shouted.
“Doctor Chen, the patient’s pupillary response is worsening further! The cerebral edema is rapidly getting worse!”
Everyone looked at the monitor. Lee Junho’s intracranial pressure really was continuing to rise.
Taeho urged him once more.
“There really is no time now, Chief. Please decide. You need to call the IRB chair right now.”
“Doctor Chen. Please do it. Please save my son.”
Lee Junbeom spoke in a trembling voice.
Doctor Chen finally took out his phone.
“It’s one in the morning. I’ll contact the IRB chair. Doctor Kang, you’ll have to explain it yourself.”
“Of course, Doctor Chen. And we need to contact radiology as well. Ask them to prepare the MRgFUS equipment. There’s no time, so they have to be getting ready.”
“Doctor Johnson, contact Doctor Kim in radiology right now.”
“Yes!”
Doctor Johnson ran outside, and Doctor Chen took out his phone and contacted the IRB chair.
Chief Lee Junbeom took his son’s hand.
“Junho, Junho…”
***
Doctor Foster arrived at the hospital. She was a woman in her seventies, a veteran who had worked in medical ethics for thirty years.
“Doctor Chen, please explain the situation.”
Doctor Chen briefly explained Lee Junho’s condition and Taeho’s proposal. Doctor Foster listened with a grave expression.
“You must be Doctor Kang. Would you explain it yourself?”
“Doctor Foster, I compared and analyzed patient Lee Junho’s blood test and cerebrospinal fluid test results.”
Taeho showed her Lee Junho’s blood test results and cerebrospinal fluid test results as he spoke.
“The interferon concentration in his blood is within the therapeutic range, but the concentration in his cerebrospinal fluid is only 2%. This is the fundamental reason the treatment has failed until now.”
Doctor Foster checked the numbers on the reports and asked.
“So you’re proposing opening the blood-brain barrier?”
“That’s correct.”
Taeho answered calmly.
Doctor Chen added in support.
“Doctor Kang’s analysis is accurate. We were missing the issue of the blood-brain barrier.”
Taeho continued.
“Doctor Foster, MRgFUS is being used successfully in Alzheimer’s treatment. According to a 2019 paper in the Journal of Controlled Release, the drug delivery rate increased twentyfold after opening the blood-brain barrier. And a 2020 review in Nature Reviews Drug Discovery also mentions its potential application in infectious brain diseases. Of course, there are no cases of direct application to SSPE. But the pathological mechanism is the same.”
Doctor Johnson, who was listening nearby, could not believe his ears. The Korean doctor he had looked down on so much knew these papers and was even citing them!
Doctor Foster showed interest in Taeho’s words.
“Have you read all those papers?”
“Yes. In addition, a paper published this year in Nature Reviews Neurology reports that MRgFUS can deliver drugs to deep regions of the brain without risk of infection. It avoids all the risks of infection and bleeding associated with traditional brain surgery.”
Doctor Johnson spoke with a distorted face and a startled expression.
“You reviewed even literature that recent?”
Was that even humanly possible?
Doctor Johnson was not the only one thinking that. Every medical professional in the room stared at Taeho with wide eyes.
Taeho nodded. Of course, Taeho did not mention that Rema had found the materials for him in an instant and that he had read them thanks to it.
“And among the 120 cases performed at Mount Sinai over the past two years, serious side effects occurred in less than 3%.”
“Jeez!”
“Wow!”
All the medical staff who had been listening with bated breath could only click their tongues in amazement. A Korean doctor who knew all the relevant papers inside out and knew more about the hospital than Mount Sinai’s own doctors!
Doctor Foster, who had been standing with her arms crossed, nodded in acknowledgment.
“You’ve prepared quite thoroughly. How did you calculate the probability of success?”
“I can’t present an exact figure. But given his current condition, I believe it is at least worth attempting.”
Taeho answered, pointing to the vital signs monitor.
Chief Lee Junbeom cut in with a trembling voice.
“Doctor Foster, please give my son one last chance.”
Doctor Foster remained silent for a long time, then spoke.
“Doctor Kang’s analysis appears scientifically valid. And this case is clearly a life-threatening emergency. I will approve it under Compassionate Use.”
A sigh of relief passed through the hospital room.
“But there is a condition. Every step of the process must be recorded in real time, and if any problem occurs, it must be stopped immediately.”
“Of course.”
Doctor Chen answered quickly, then checked the time.
“It’s three in the morning now. When can we start?”
“The equipment is ready. Once the patient is transferred to the MRI room, we can begin immediately.”
Doctor Johnson, who had contacted radiology, answered.
Doctor Foster said as she filled out the paperwork.
“Then we will begin in thirty minutes.”
Taeho looked back at Lee Junho again.
‘Junho, hang in there just a little longer.’
***
Lee Junho was transferred from the ICU to the MRI room. Doctor Chen directed the transfer as the attending physician, and Chief Lee Junbeom followed alongside them, watching over his son.
When they arrived at the MRI room, Doctor Kim was waiting with his team. The radiologic technologists had already set up the MRgFUS equipment perfectly.
When Taeho lightly touched his glasses, Rema’s voice sounded in his ear.
—I am analyzing Lee Junho’s vital data in real time. Intracranial pressure continues to rise.
Doctor Kim reported to Doctor Chen, the attending physician.
“Doctor Chen, we’re ready, but this is our first time applying MRgFUS to SSPE as well.”
Doctor Kim looked as though he felt an enormous burden.
Just then, Rema displayed the real-time data.
—Recommended output: 0.6 MPa (peak acoustic pressure)
—Focus location: white matter region of the left temporal lobe
—Caution: 2 mm from the language center, careful approach required
Taeho slipped in carefully.
“After reviewing the relevant papers, I found that in young adults, the elasticity of the brain tissue is good, so effective opening is possible even at an appropriate output. Of course, for the specific numbers, it would be best to follow Doctor Kim’s professional judgment.”
Hearing Taeho’s words, Doctor Kim seemed to gain confidence and looked at Doctor Chen.
“Doctor Chen, since he’s an adult male, how about starting at around 0.6 MPa and adjusting while monitoring in real time?”
“Good. Please proceed.”
Doctor Chen gave his approval.
Doctor Kim began the scan.
“We’ll check the MRI images first.”
Soon, Doctor Kim tilted his head slightly and reported to the attending physician.
“Doctor Chen, the viral invasion is concentrated at the boundary between the left temporal lobe and frontal lobe.”
“Hmm…”
Doctor Chen stared hard at the image, deep in thought.
Beside him, Taeho gripped the rim of his glasses and pushed them up, and Rema analyzed the image.
—Analysis complete: the center of inflammation is 2.3 mm from Broca’s area
—Safe zone: posterior region of the left temporal lobe
—Focus angle: 15-degree tilt recommended
Taeho cautiously offered his opinion.
“I think it would be effective to focus on the area where the inflammation is most severe first. However, this area appears to be about 2 to 3 millimeters away from the language center. If the focus angle is adjusted slightly, it should be safe.”
“That’s a good idea.”
Doctor Chen, who had been listening, nodded.
Chief Lee Junbeom spoke with a worried expression.
“Doctor Chen, is there no risk of damaging the language center?”
“Chief, we have secured a safe distance, and Doctor Kim is highly experienced, so it should be all right. Let’s begin the procedure.”
Doctor Chen reassured him.
The procedure began.
As everyone watched the procedure with bated breath, Rema sounded a warning.
—Danger! The temperature is rising faster than expected.