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

Fang Rui took the admission slip from the triage nurse. The slip stated that he experienced chest tightness and difficulty swallowing after eating, but his vital signs were stable.

"Can you speak? Are you breathing?"

"He can talk, but he keeps spitting into the paper cup. I didn't hear him breathing."

Lin Ye remained by the examination table at the entrance of the treatment area, still holding Shen Yan's observation record in his hand.

"First, examine his airway. After you've examined it, tell me what information will determine where he goes."

He Guodong has been helped to the treatment bed.

He was 43 years old, leaning forward, holding a paper cup in his hand, and spitting out saliva that had accumulated in his mouth.

His wife followed him to the bedside, unscrewing the bottle of mineral water to hand it to him.

"Don't drink it yet." Fang Rui took the water and placed it on the farthest side of the bedside table. "Is your breathing easy? Has your voice changed?"

"Breathing is fine." He Guodong raised his hand and pointed to the back of his sternum. "It's just stuck here, I can't swallow it."

"What did you eat? How long ago was it?"

"Beef, about twenty minutes."

His wife added, "He just drank two sips of water and threw it all up." Fang Rui asked He Guodong to open his mouth and then leaned closer to listen to his voice and breathing.

The nurse took over the monitor; the blood oxygen level was 98, and the blood pressure was 132-138.

There are no obvious abnormalities in the airway at present.

Fang Rui asked the nurse to raise the head of the bed and prepare an insufflation device next to the bed.

Have you ever choked on food before?

"I sometimes choke on dry food, but a sip of water helps," He Guodong said with some difficulty. "It's never been this bad, though."

Have you had a gastroscopy? Do you have any problems with your esophagus or stomach?

"No, I've never checked."

"What medications do you usually take? Anticoagulants, or medications that improve blood circulation?"

He Guodong shook his head: "I won't eat any."

His wife brought the bottled water back: "It used to be fine after just one sip, why don't we try it again?"

"We can't try again." Fang Rui tightened the bottle cap. "The water can't even go down. If we pour any more in, it'll just back up."

"So what do we do now?"

"I'll arrange the inspection." Fang Rui raised the headboard a little higher. "First, we'll confirm the location of the blockage, then decide how to handle it."

He Guodong was able to answer questions completely, and his blood pressure and blood oxygen levels on the monitor were stable.

But as soon as he tried to swallow, he spat the saliva that had accumulated in his mouth into the paper cup.

Fang Rui noted down the onset time and swallowing situation, and filled in the imaging application in the examination column.

He walked to the examination table with the records in hand: "Airway is stable, no difficulty breathing, blood oxygen 98. Can't swallow water or saliva. I'd like to take an X-ray first to see where the blockage is, rule out perforation, and then decide whether to call the gastroenterology department."

Lin Ye gestured for him to put the application form down and led him back to the bedside.

He Guodong was spitting the saliva he had just accumulated into a paper cup.

"He can't even swallow saliva, so complete esophageal obstruction is highly suspected."

Lin Ye covered the sounds and breaths.

"First, withhold food, establish intravenous access, prepare suction at the bedside, and immediately contact the gastroenterology department for emergency endoscopy. Whether additional imaging is needed should be determined by a specialist based on the risk of injury and foreign body. Keep the request form for now; routine imaging cannot be delayed at this stage."

Fang Rui pulled the application form out of the record and put it back in the drawer.

"Understood. We'll start with fasting, establishing a pathway, and suctioning. I'll contact the gastroenterology department. We'll decide on imaging once they arrive."

The nurse began establishing intravenous access.

Fang Rui marked the items to be reported on the record and dialed the gastroenterology department.

"Emergency treatment area, He Guodong, beef is stuck in his esophagus, he can't even swallow water, someone come here."

"Wait a minute, repeat the patient's name and location."

"He Guodong, 43 years old, emergency treatment area." Fang Rui slowed his speech. "The beef has been lodged in his throat for about 20 minutes. His airway is stable, but he is unable to swallow saliva."

"Understood, the doctor will be there right away. Fasting is required, and intravenous access must be established."

Fang Rui hung up the phone and filled in the consultation time at the top of the record.

The wife immediately pressed, "Does it require a gastroscopy? Won't it rupture the esophagus?"

"The gastroenterologists will come to assess you first. They will discuss the specific procedures and risks with you."

His wife was still worried: "His blood pressure is fine, why does he need an emergency endoscopy?"

"Your blood pressure is stable, which means your circulation isn't currently the problem." Fang Rui pointed to the paper cup that was just full in his hand. "The obstruction is quite severe. If your voice changes, you can't breathe, or your chest pain gets worse before the gastroenterologist arrives, call for help immediately."

The wife moved the chair to a spot where it wouldn't block the aisle, and after sitting down, she continued to watch her husband's breathing.

He Guodong pressed his chest and spat again.

The nurse at the bedside changed the paper cup to a clean one. Before the gastroenterologist arrived, Fang Rui leaned over and asked, "Besides the feeling of tightness in your chest, do you experience any sharp, cutting pain? Is there any blood in your vomit?"

"It doesn't hurt, it's just a feeling of blockage." He Guodong pointed behind his sternum. "I'm spitting out saliva."

Fang Rui examined the neck and chest, but did not feel any abnormal emphysema, and the saliva in the paper cup was not bloody.

The wife sat down on the edge of the bed, took out a tissue, folded it, and placed it next to her husband.

"He used to choke when he ate too fast, but it would go down when he drank water. We all thought it was because he ate too quickly."

"How long did it take to recover before?"

"It only took a few minutes, the longest it took was no more than ten minutes. Knowing it would be this congested, we came to check earlier."

"Does it only happen with solid foods like meat, or can it also happen with water?"

"The water has remained fine."

Have you been losing a lot of weight lately? Have you choked on water?

"My weight hasn't changed, and I don't choke when I drink water, but this time it was scary when I got stuck."

Fang Rui added these, along with the previous attack times, to the record.

When the gastroenterologist arrived, he went to the bedside first, and Fang Rui handed over the records.

"The beef had been lodged in his throat for nearly forty minutes, but his airway was stable. He has a history of intermittent difficulty swallowing solid food, has never had an endoscopy, and has not taken any anticoagulants."

The gastroenterologist checks the intravenous access.

"Continue with the fasting period. Transfer to the endoscopy area and prepare for emergency endoscopy. We will discuss the specific plan and risks with the family there."

The wife stood up: "Go now?"

"The sooner it is dealt with, the better."

The gastroenterologist instructed the nurses to bring the bedside suction device along with the bed.

The transporter pushed in a transfer bed.

When He Guodong propped himself up, he felt a tightness in his chest. The nurse by the bedside helped him catch his breath before assisting him to slowly move over.

Fang Rui handed the handover form to the gastroenterologist, and after confirming that the doctor had signed for it, he followed the transport bed to the corridor entrance. Only after the transport bed had turned into the corridor did Fang Rui return to the emergency area.

He placed the signed receipt next to Lin Ye.

"The gastroenterology department has admitted him; he has been taken to the endoscopy treatment area."

Lin Ye flipped to the delivery date and filed the delivery slip.

Diagonally opposite the examination table, Shen Yan's monitoring bed was still lit.

Fang Rui followed Lin Ye's gaze.

"She's still under observation. I'll go for the reassessment, first checking her voice, swallowing, and neck movement. I'll explain the next steps when I get back."

"Okay, go ahead."

Fang Rui carefully placed He Guodong's signed receipt, picked up Shen Yan's observation record, and walked towards the monitoring bed diagonally opposite.

The nurse at Shen Yan's bedside is taking her blood pressure.