When I'm on the night shift, all the department heads can't sleep.

When Lin Ye arrived at the emergency room, the digital clock on the wall had just ticked past 6:15.

Nurse Zhu was looking down at the triage information when she caught a glimpse of the bag in his hand: "Going home to get supplies?"

"My mom forced it on me." Lin Ye gently moved the bag to the side, deliberately avoiding the clean triage counter, afraid of getting the worktable dirty.

"Put it in the rest area first, don't put it next to the triage desk." Nurse Zhu tilted her head behind the nurses' station. "If a child runs around and pounces on it, the apple will be scattered all over the floor, and you'll have to pick it up all over the emergency room."

Lin Ye responded and walked towards the back with the bag. Just as he put the food container into the small refrigerator, Qin Hai came out of the clinic with a schedule in his hand.

"I'll be on duty at 6:20." Qin Hai glanced at the clock on the wall. "Five minutes to go, the timing is perfect."

Lin Ye buttoned up the collar of his white coat: "Director Qin."

Qin Hai gently patted the shift schedule onto the medical record folder, his expression serious: "Tonight's shift work involves more than just observing consultations. Answering calls, referral procedures, and handover to 120 (emergency services)—any omission or missing page of information could cause serious problems."

Lin Ye nodded, keeping these words of advice firmly in mind.

The moment those words were spoken, the landline at the nurses' station rang.

Nurse Zhu reached out and took the phone, listened briefly, and then turned to Qin Hai to report: "The emergency department of the Second People's Hospital of Chengxi said that there is a pneumonia patient who needs to be transferred."

Qin Hai did not take over immediately, but instead looked at Lin Ye, signaling him to take over.

Lin Ye walked over, took the stethoscope, and with his other hand, flipped open the referral registration book, ready to record information at any time.

The person on the other end of the phone was a male doctor, and his voice sounded a bit urgent. In the background, you could hear the beeping of a monitor and someone shouting, "Is the oxygen cylinder pressure high enough?"

"Is this the emergency room at the First Municipal Hospital? We have a 66-year-old male patient here who has had a fever and cough for three days. A chest CT scan showed pneumonia, and his blood oxygen saturation remains low even after oxygen therapy. We would like to transfer him to your department for further treatment."

"Current vital signs."

There was a brief pause on the other end of the phone: "Temperature 38.6℃, heart rate over 110, blood pressure... just measured 96-96."

"What was your lowest previous peak blood pressure?"

"This... let me take a look."

The sound of pages turning came clearly from the receiver. Lin Ye didn't urge him; his pen lightly tapped the blank space in the register.

"The lowest was 88 or 852, but it came up after the IV fluids."

"Respiratory rate?"

"Around thirty times."

"What method of oxygen therapy was used? How many liters of oxygen were used? How much oxygen saturation was achieved after oxygen therapy?"

The male doctor on the other end of the phone paused again, seemingly asking the nurse next to him. After a few seconds, he replied, "Nasal cannula: 4 liters; oxygen saturation: 90-92, occasionally dropping to 89."

Nurse Zhu, who was originally filling out the triage card with her head down, slowed down her writing when she heard the unstable blood oxygen data.

Lin Ye continued, "Are there any blood gases? Oxygen partial pressure, carbon dioxide, lactic acid?"

"The blood gas analysis showed lactate at 3.4, carbon dioxide levels were not high, and oxygen partial pressure... I don't have the report on hand."

"How is your consciousness?"

"He was able to answer when he first arrived, but now he's a bit irritable. His family said he's been less clear-headed since the afternoon."

Lin Ye wrote in the register: Irritable, confused since the afternoon.

The doctor on the other end of the phone couldn't help but urge, "We've had the patient's medical records taken by the family, and we've also taken pictures of the X-rays. You can take a closer look when you arrive at the hospital. Our ambulance is ready."

Lin Ye looked up at Qin Hai beside him.

Qin Hai stood quietly to the side, without saying a word, only slightly raising his chin to indicate that he should continue to control the process.

"We are not refusing patients," Lin Ye said calmly. "Patients need continuous monitoring during transport. The reception area and treatment plan upon arrival at the hospital—whether it's a regular clinic, an observation area, or a red zone—must be determined in advance. If we wait until the patient arrives to review and complete the necessary information, it will delay the patient's treatment time."

There was a two-second silence on the other end of the phone, then the hurried tone softened: "Okay, keep asking, we'll cooperate and verify."

"Complete blood count, white blood cells, hemoglobin, and platelets."

"White blood cell count is slightly over 15, neutrophil percentage is high, hemoglobin is 96, and platelet count is normal."

Lin Ye's pen suddenly stopped beside this set of data, and a hint of doubt flashed in his eyes.

What was your hemoglobin level before?

"The family brought last month's medical examination report, which cost around 130 yuan."

In just three days, hemoglobin levels dropped from over 130 to 96, which cannot be reasonably explained using the course of ordinary pneumonia.

"Is there blood in your sputum? Is there any hemoptysis?"

The person on the other end of the phone was clearly taken aback.

"The cough was quite severe, and the family said there was some blood in the phlegm, so we treated it as if the cough had caused a rupture."

"How much blood was coughed up? Was it bright red or dark red? Was there any frothy blood-tinged sputum?"

"I didn't ask about that in detail. The nurse just said there was blood on the tissue, but not much."

Lin Ye wrote down "blood streaks in sputum, amount unknown" and then asked, "What about kidney function? Creatinine, blood urea nitrogen?"

The sound of someone searching for medical records came through the phone again.

"Cretin... 268."

At that moment, Nurse Zhu looked directly at him, her eyes filled with surprise. Qin Hai's gaze also instantly fell on the receiver.

Lin Ye continued writing, his pen still twirling, "What was your kidney function like in the past?"

"The family said they didn't have kidney disease before. The creatinine level on the medical report seems to be in the 80s."

"Have you had a urinalysis?"

"Urinalysis..." The male doctor paused for a longer time, "Wait a minute, let me ask the nurse to look. Isn't it in the photo we sent you earlier?"

Nurse Zhu opened the referral photos sent by the other hospital on her computer and scrolled down a few.

"Chest CT scan, complete blood count, CRP, procalcitonin, and half of the biochemistry scan was done." She dragged the mouse back. "No urinalysis, and only the top half of the kidney function scan was done."

Lin Ye stared at the truncated lab report on the screen, the creatinine column missing from the bottom right corner.

A line of light blue text flashed before his eyes very quickly.

[Risk Area: Increased risk associated with pulmonary-renal syndrome.]

[Key gaps: urinalysis, kidney function, hemoptysis volume, hemoglobin changes, and chest CT imaging features.]

The notification flashed by in an instant.

Lin Ye didn't pause and continued speaking into the phone, "Have you asked about the color of your urine? How's your urine output been these past two days?"

This time, instead of the sound of turning over paper, I heard a distant shout on the other end of the phone: "Ask the family how their child's urination has been these past two days!"

The voices of several people mingled together, and after half a minute, the male doctor picked up the phone again.

"The family said the urine was scanty and dark in color, like strong tea. They thought it was because the child had a fever and wasn't drinking enough water."

"Have you found the results from the urinalysis?"

"Found it." The other party took a deep breath. "Three pluses for occult blood in urine, two pluses for protein in urine."

Lin Ye noted down these two sets of key abnormal indicators one by one.

Next to the originally simple note "referral for pneumonia", a large portion of the page was filled with abnormal signs and test data, with layers of doubts piling up.

Qin Hai then reached out and took the receiver.

"I'm Qin Hai from the emergency department of the First Municipal Hospital." As he spoke, he wrote the red zone bed number on a sticky note. "Please pick up the patient from the red zone. Continuous oxygen administration and monitoring in the ambulance, with blood pressure and oxygen saturation recorded every five minutes. Bring the original blood gas, kidney function, and urinalysis reports with you in the ambulance. Don't just send screenshots of the chest CT images; copy them all if possible."

The person on the other end of the phone responded very quickly.

Qin Hai added, "If your oxygen saturation drops below 88, your consciousness deteriorates, or you cough up more blood on the way, call ahead. Don't wait until you get to the door to tell me."

He hung up the phone and put the receiver back on the landline.

"Nurse Zhu, reserve a bed in the red zone, and prepare oxygen, monitors, and blood gas analyzers. Call the Department of Respiratory and Critical Care Medicine, and also the Department of Nephrology. Find the on-call number for the Department of Rheumatology and Immunology, and contact them after they arrive at the hospital and have been examined."

Nurse Zhu had already stood up: "I know."

Halfway there, she turned back and reminded Lin Ye, "Write all the information in the registration book carefully. Verify the name, gender, age, and the hospital from which you were transferred one by one. Don't just simply mark it as pneumonia."

"Um."

Lin Ye lowered his head and finished completing the registration book.

Transferred to: Emergency Department of Chengxi No. 2 Hospital.

Male, 66 years old.

Initial report: Fever and cough for three days, referred for pneumonia.

Additional information: Low oxygen, lactate 3.4, restlessness, decreased consciousness, blood streaks in sputum, decreased hemoglobin, creatinine 268, occult blood in urine 3+, protein in urine 2+, dark tea-colored urine.

At the end of his writing, he specifically added a note to the referral information section: "The first batch of referral screenshots from other hospitals is missing the urinalysis and complete kidney function report pages."

Qin Hai watched from the side and said, "The most common problem in clinical practice is the lack of crucial data. If we only discover the loophole when the patient is wheeled to the door, the rhythm of admissions in the red zone will inevitably be disrupted, delaying treatment."

Lin Ye put the pen cap back on.

The red zone has already started moving.

Nurse Zhu pushed the monitor over, and as she passed the triage desk, she casually pointed to a young man coughing and feverish on the outside chair: "You sit over there first, and put on your mask properly. Don't block the passage, the red zone needs to pick up the ambulance."

Another nurse took out a blood gas analyzer and several blood collection tubes from the treatment room, placed the labels on the treatment tray, and checked them when the patient arrived. The oxygen inlet was turned on and tested, and a faint hissing sound came from the bedside.

Lin Ye put the referral registration book back on the table, and his phone vibrated in his pocket.

He glanced at it briefly; it was a WeChat message from Ma Hao.

Are you busy tonight? If the ER can quiet down for a while, could you please wish me good luck for my shift on Saturday?

Before Lin Ye could reply, the intercom at the nurses' station rang again.

Nurse Zhu had just pushed the monitor to the entrance of the red zone when she heard the phone ring. She turned around and quickly went back to answer it.

"The ambulance said it will be there in three minutes."

She covered the receiver and turned to Qin Hai: "On the way, my oxygen saturation dropped to 87, and I coughed up a mouthful of dark red, foamy blood."

Qin Hai walked towards the red zone: "Prepare the attraction devices as well."

Lin Ye followed closely behind. Just as he reached the entrance of the red zone, he saw the warning lights of the ambulance flashing through the glass doors of the emergency room, dazzling and urgent.

The paramedic on the other end of the line hadn't hung up yet; his voice sounded muffled by the noise of the equipment and people inside the vehicle.

"The family found the original urine test result, the one we just talked about on the phone. It showed three pluses for occult blood and two pluses for protein. The patient is hard to wake up right now, and they're almost at the door."

The automatic doors at the emergency room entrance are opening to both sides.