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

The automatic doors at the emergency room entrance slid open to both sides.

The flatbed truck wheels rolled over the metal groove at the bottom of the door with a thud. The old man on the truck was half-reclined, an oxygen mask over his face, his chest rising and falling rapidly and shallowly.

The paramedic, holding an oxygen tank with one hand and the edge of the stretcher with the other, spoke in a muffled voice through his mask: "His blood pressure dropped to as low as 87 on the way here. He just coughed up some dark red frothy phlegm. He can open his eyes when I call his name, but he can't speak."

Lin Ye followed the stretcher toward the red zone, his gaze sweeping over the monitor clips, oxygen tubes, foreign hospital document folders, and the deformed plastic folders clutched by family members.

Qin Hai was already standing beside the bed in the red zone, raising his hand to lower the bed rail: "Connect the monitoring, connect the oxygen first. Keep the suction device on standby, don't wait until you cough it up before you find it."

Nurse Zhu stopped the people at the entrance of the red zone by half a step: "Family members, please stand here first. Take out your ID cards, medical insurance cards, and all your documents. Don't crowd around the bed; the doctors and nurses need to pass by."

When the elderly man was moved onto the resuscitation bed, his oxygen mask was fogged up. He made a gurgling sound in his throat, turned his head to the side, and a little dark red phlegm spilled from the corner of his mouth.

The nurse next to him had already handed him the suction tube, and Qin Hai stepped aside to make room: "Turn your head to one side, and let me suction your mouth."

As soon as the tube was inserted, a small wisp of dark red foam swirled into the suction bottle. The old man frowned, his Adam's apple bobbed, but he ultimately couldn't utter a complete sentence.

The monitor was connected, and the numbers quickly appeared.

My heart rate is over 120, blood pressure is 92/56, blood oxygen saturation fluctuates between 86 and 88, and my respiratory rate is over 30.

Qin Hai stared for two seconds: "Do the bedside blood gas analysis first. If the original indwelling needle is still usable, keep it and open another intravenous access."

The nurse responded, her hands never stopping. The sounds of tearing tape, the soft click of blood collection tubes hitting the treatment tray, and the short alarms from the monitor mingled together in that small area of ​​the red zone.

Lin Ye took the handover form from the paramedic, checked the time, and then looked at the records from the journey. The other hospital said on the phone that blood pressure and blood oxygen levels should be recorded every five minutes. The form was filled out neatly, and several times the blood oxygen level dropped from 90 to 87. Next to it, a line was added in black pen: "Coughed up dark red frothy sputum once."

He tucked the handover form into the medical record folder, then looked up and asked the paramedic, "Did he vomit on the way? Was there any large amount of blood?"

"He didn't vomit." The paramedic breathed a sigh of relief. "It wasn't a spurt, just a cough, lots of foam, and dark in color."

Lin Ye nodded and added that sentence to the hospital record.

The old man's wife stood outside the red zone gate, holding a folder of documents in her arms. Nurse Zhu asked her to take out her ID card, and she frantically rummaged through it for a while, first pulling out a physical examination report from last month, and almost dropping the original urinalysis report on the ground.

Lin Ye reached out and caught the paper; the corner of the paper was already soaked with sweat.

On the original urinalysis report from another hospital, the columns for occult blood and protein in urine were circled in red. The page with kidney function was also there, showing creatinine at 268 and elevated blood urea nitrogen. Flipping further, there was last month's physical examination report, with creatinine in the 80s and hemoglobin in the 130s.

The original documents have now been obtained for the several gaps that were raised over the phone.

He arranged the original documents in order and pasted them at the front of the medical record folder, casually leaving half a corner of the page sticky on a sticky note.

Nurse Zhu took the remaining document bag from the family member and handed it to Lin Ye: "Keep the rest for now. The family member's hands are shaking, and they might spill it all over the floor later."

Upon hearing the words "shaking hands," the elderly woman realized that her own hands had been trembling. She wiped the back of her hands on her clothes, her eyes glued to the emergency bed: "Doctor, the Second Hospital said it's pneumonia, why are there so many people here?"

Qin Hai didn't turn around; his gaze remained fixed on the monitor. "First, stabilize the oxygenation. Whether it's simple pneumonia or not, we need to check the blood gases, X-rays, and other relevant documents. Don't crowd around the bed; we'll let you know if anything happens."

The blood gas analyzer beside the bed quickly spat out a narrow strip of paper. The nurse tore it off and handed it to Qin Hai; the paper was still warm from the machine.

After reading it, Qin Hai frowned slightly: "The oxygen partial pressure is still low, and the lactic acid level is 3.8."

He handed the note to the on-duty doctor from the Department of Respiratory and Critical Care Medicine who had just arrived.

The pulmonologist first checked the blood gas, then the monitor, and listened to the breath sounds on both sides of the bed. As soon as the stethoscope was removed, the old man coughed again.

This time he didn't cough up a lot of blood; there was just a little dark red stain on the inside of his mask.

The pulmonologist gently lifted the edge of his mask to take a look, his expression darkening. "It doesn't look like ordinary blood in the sputum. It's fine for intensive care and monitoring as severe pneumonia, but if there's hemoptysis, a drop in hemoglobin, and diffuse ground-glass opacities on the X-ray, then we need to consider alveolar hemorrhage."

After he finished speaking, he turned to Lin Ye and asked, "Where are the complete images from the other hospital's CT scan?"

Lin Ye pulled out a CD and a QR code from the document bag: "Both are here. The CD just arrived with the car, and the QR code is on the back of the film bag."

"Take it to the computer for viewing the images." The pulmonologist pointed to the small workstation next to the red zone. "Don't just look at the screenshots on your phone."

Lin Ye responded and turned to hand the disc to the nurse on duty, asking her to open it at the workstation. The disc drive whirred and made a low humming sound, and the screen froze for a few seconds before starting to read the disc.

The on-call nephrologist has also arrived.

The nephrologist didn't ask about the patient's medical history first. He took the original document from Lin Ye, flipped to the pages about kidney function and urinalysis, glanced at them, and then checked the dates on last month's physical examination report.

"Last month it was over 80, now it's 268. There's blood in the urine and protein in the urine, so this can't be explained by fever and dehydration alone." The nephrologist put the paper back in the medical record folder. "Collect a urine sample for retesting, and do a urine sediment test. Keep a clear record of your fluid intake and output, as we'll need to monitor your kidney function later."

Qin Hai nodded, then turned to instruct the nurse: "Collect a urine sample first, attach the intake and output sheet to the foot of the bed, and record the urine volume each time."

Lin Ye noted down the nephrology department's arrival time, the results of the original document verification, and the supplementary examination items. When he wrote "cannot be explained solely as dehydration," he crossed those words out and changed it to "acute kidney injury requires further evaluation."

No one in the red zone noticed his little action.

At the workstation, the CT images from the other hospital finally finished loading. The pulmonologist sat down in front of the screen, scrolling down the mouse wheel, flipping through the axial images layer by layer. At first, he didn't say anything, only adjusting the window width and level a couple of times, then pushed his chair back half an inch.

"Director Qin, come and take a look."

Qin Hai walked over.

Lin Ye stood to the side, not too close, and could only see hazy images of the lungs on the screen. It wasn't the unilateral consolidation shown in textbooks, nor was it a clearly defined shadow like in ordinary inflammation.

The pulmonologist clicked on several areas with the mouse: "Diffuse ground-glass opacities in both lungs, the distribution doesn't resemble simple lobar pneumonia. Considering the hemoptysis, poor oxygenation, decreased hemoglobin, and the urinalysis and creatinine levels on the kidney side, we need to consider pulmonary-renal syndrome and diffuse alveolar hemorrhage. We can't ignore the infection; pathogen screening and culture should continue as usual."

The nephrologist listened from the back, then looked down and flipped through the medical report again: "Call the rheumatologist down. Anti-GBM antibody, ANCA, complement, these need to be tested together."

Qin Hai didn't hesitate: "Nurse Zhu, dial the on-call number for the Rheumatology and Immunology Department and get it connected to me."

Nurse Zhu responded at the nurses' station, still holding the freshly labeled blood collection tubes in her hand. She dialed the number, but didn't turn on speakerphone; she simply held the receiver to her ear and first gave the department and bed number.

"Emergency red zone, Director Qin, please find the on-call doctor in the rheumatology and immunology department."

After hearing something said on the other end of the phone, Nurse Zhu glanced at the respiratory physician in the red zone and handed him the receiver: "Connected."

Qin Hai took the stethoscope: "Emergency red zone, 66-year-old male, hypoxia, hemoptysis, creatinine over 200, positive for occult blood and protein in urine, respiratory and renal endoscopists are at the bedside. He's already in the red zone, and the scans are ready. Please come down and take a look."

After he finished speaking, there was a two-second silence on the other end of the receiver.

Qin Hai hung up the phone quickly: "The rheumatology and immunology department on duty said they'll be there in ten minutes."

The elderly woman, standing by the door, heard that another department had been added, and took a half-step back, then moved back: "Isn't it pneumonia? Why are nephrology and rheumatology/immunology here too?"

The respiratory physician stood up from his computer, his words neither deliberately frightening nor downplaying their impact.

"Currently, it appears to be more than just a simple lung infection. The lungs are lacking oxygen, there is blood in the sputum, and kidney function has suddenly deteriorated. We are consulting with several departments together to avoid missing any diseases that can damage both the lungs and kidneys simultaneously."

The elderly woman leaned against the doorframe with one hand and pressed the other against her chest, her voice suddenly lowering: "Then...can he still wake up?"

Qin Hai continued, "We're still assessing the situation, so I can't give you a guarantee. Make sure you have all your family's contact information ready, as we might need to sign the necessary consent forms for hospitalization and intensive care later."

She nodded quickly and reached for her phone. The screen lit up, showing several missed calls, each labeled "Son".

She pressed the call button twice before she could get it right: "Come to the First Municipal Hospital quickly, your dad doesn't have ordinary pneumonia... I can't explain it clearly, the doctor called several departments and they all came."

The monitor next to the bed in the red zone beeped twice more.

My blood oxygen saturation fluctuated around 90 before dropping to 88.

The pulmonologist had returned to the bedside, leaned down and patted the old man's shoulder: "Sir, can you hear me? Open your eyes."

The old man's eyelids twitched, and he managed to squeeze out a muffled sound.

Qin Hai glanced at the time: "Record the changes in consciousness after discharge. Once the rheumatology and immunology department arrives, go directly into the red zone; don't make anyone wait at the entrance."

Lin Ye lowered his head and added the time.

At that moment, a series of hurried footsteps came from the corridor outside the red zone.

Nurse Zhu peeked out and then stepped aside to make way for the entrance to the red zone.

"We've arrived at the Rheumatology and Immunology Department."

Before the newcomer could even stand still, the respiratory physician had already hovered the mouse over the CT scan showing diffuse ground-glass opacities in both lungs and tapped the screen with his fingertip.

"Look here first."