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

By the time Lin Ye caught the monitor, Nurse Zhu had already helped the patient to a stable position on the first resuscitation bed.

The 43-year-old man was named Chen Weian. He was still wearing a shirt, and the collar was soaked with a dark ring of sweat.

He refused to lean against the headboard and instead rested his hands on his knees.

"Stay in this position." Lin Ye leaned down. "Why does your chest hurt?"

"It feels like being pricked with needles, or like someone is scraping back and forth with something." Chen Wei'an raised his hand and pressed on the left side of his sternum. "It hurts when I inhale, and it hurts even more when I cough. It's even more unbearable when I lie down."

"Should we go towards the shoulders or back?"

"There's a little bit on my left shoulder and around my neck too."

Nurse Zhu was put into in-hospital monitoring.

Heart rate 106, blood pressure 120.74, blood oxygen 98.

When did the fever start?

"The night before last. My temperature reached a high of 38.2 degrees Celsius, and I took fever reducer." Chen Wei'an licked his dry, chapped lips. "I caught a cold last week, had a sore throat, and got better for two days. This afternoon, my chest started hurting, and I thought it was a stitch in my side."

"Do you have a history of heart disease, high blood pressure, or diabetes?"

"No, none of them."

Have you recently suffered any injuries, been bedridden for extended periods, or experienced swelling in one leg?

Chen Wei'an shook his head.

Lin Ye made him take a slow breath.

Chen Wei'an frowned and leaned his body forward more as he took a breath.

Chest pain changes with breathing and can be relieved by leaning forward, which does not match the symptoms of a sudden blockage of a coronary artery.

Elevation on a pre-hospital electrocardiogram cannot be explained away by symptoms alone.

"Redo the 12-lead test, recheck the electrode positions." Lin Ye turned to Nurse Zhu. "We won't use either of the two pathways, just keep one open. Send the blood sample according to the order we just gave you, and expedite the troponin test."

Nurse Zhu attached the electrode pads, and the electrocardiograph quickly started feeding data.

Chen Wei'an stared at the piece of paper that was being spat out.

"Is it a heart attack?"

"We can't draw conclusions yet." Lin Ye pressed down on the edge of the paper. "Let's first rule out the most dangerous possibilities."

The new map is clearer than the one before.

Apart from aVR and V1, most leads showed slight ST segment elevation, with an upward morphology, extending beyond the area supplied by a single coronary artery. The PR segment in several leads was also depressed.

Unlike typical ST-segment elevation myocardial infarction.

Lin Ye picked up the stethoscope.

"Move forward a little, but don't speak yet."

Chen Wei'an did as instructed.

A faint, rough friction sound mingled with my heartbeats from the lower part of my left sternal border, but was quickly drowned out by my breathing.

Lin Ye moved to a different spot and listened again, but the voice was still there.

"Director Zhou, patient number one has chest pain." He looked up at Zhou Min, who had entered the resuscitation area. "Extensive ST-segment elevation, with PR-segment depression. The pain is related to breathing and position. I can hear a pericardial friction rub. Blood pressure is stable, and there are no signs of shock yet."

Zhou Min took the two electrocardiograms and looked at them under the light for a few seconds.

"Has a bedside ultrasound been performed?"

"The machine has been brought over."

"First, check for fluid accumulation and right ventricular compression. Myocardial infarction cannot be ruled out based on the waveform alone; we need to continue monitoring with calcification and Holter monitoring."

Lin Ye nodded and moved the ultrasound machine next to the bed to Chen Weian's left side.

When the probe was placed against the chest wall, the outline of the heart appeared on the screen, surrounded by a narrow dark area.

"Where is this place?"

Chen Wei'an endured the pain, his eyes fixed on the screen.

"There's a small amount of fluid outside the heart." Lin Ye adjusted the cut surface. "Let's see if it's pressing on the heart."

There was no collapse of the right atrium during systole, nor did there be any collapse of the right ventricle during diastole.

The inferior vena cava does not dilate permanently and can narrow during inspiration.

Lin Ye looked at it again before freezing the image.

"The fluid accumulation is not significant, and there are no signs of obstruction at the moment."

Zhou Min reached out and examined the cut surface.

"Okay. Check his blood pressure every fifteen minutes, and don't let him lie flat yet. Continue monitoring until the cardiologist arrives."

Chen Wei'an grasped the key words "suppress".

What does "pressurization" mean?

"If the fluid buildup increases rapidly, it will compress the heart, and your blood pressure may drop." Lin Ye wiped the probe clean. "You don't have these symptoms now, but we need to keep an eye on you. The chest pain, along with this ECG and pericardial friction rub, strongly suggest acute pericarditis."

"Do I need surgery?"

"At present, puncture is not necessary. We will only upgrade the treatment if the blood pressure drops, breathing becomes worse, or ultrasound shows an increase in fluid accumulation."

Chen Wei'an slowly exhaled.

When the cardiology doctor on duty arrived, Nurse Zhu had just written down the second blood pressure reading: 118 and 72.

Lin Ye put the two electrocardiograms and the bedside ultrasound images onto the same screen.

"Chest pain for three hours, preceded by fever and sore throat. The pain worsens with deep breathing and lying flat, and is relieved by leaning forward. Extensive ST segment elevation with PR segment depression, and a pericardial friction rub was heard. Bedside ultrasound showed a small amount of pericardial effusion, no right ventricular compression, and stable hemodynamics. Troponin levels are still positive."

After listening to the patient's voice, the cardiologist leaned over and asked a few more questions about the changes in pain, then listened to the patient's heart and lungs again.

"For acute pericarditis, admit the patient to the cardiology ward for monitoring, check inflammatory markers, myocardial enzymes, and perform a formal echocardiogram. Treatment should be started after the patient returns to the ward to assess kidney function and gastrointestinal risks; do not administer antithrombotic drugs in the emergency room first."

"What about beds?" Lin Ye asked.

"I'll coordinate. A small amount of fluid can wait for a regular intensive care unit. If symptoms such as low blood pressure, jugular vein distension, or worsening difficulty breathing occur, call me and Director Zhou immediately."

Upon hearing "admit to the hospital," Chen Wei'an first reached into his pocket.

"I need to call home. My wife thinks I'm just here for an electrocardiogram."

"Call first." Lin Ye handed him the phone. "Tell her not to crowd around the emergency bed, but to bring her ID card and medical insurance card and find someone at the emergency room nurses' station."

As soon as the call connected, Chen Wei'an lowered his voice.

"Don't panic, the doctor said surgery isn't needed immediately. There's some fluid buildup outside the heart, so you'll need to be hospitalized for monitoring."

He repeated "It's stable now" twice, after the other person said something.

Nurse Zhu walked over with the test results.

"Crotonin is normal, white blood cell count is 11,000, C-reactive protein is elevated. Kidney function is normal."

Lin Ye handed the results to the cardiologist.

"This matches the current assessment." The other party signed the consultation form. "Admit the patient for acute pericarditis. I'll get the nonsteroidal anti-inflammatory drugs and colchicine from the department. Continue monitoring the electrocardiogram and pericardial effusion."

The notification to transfer to another bed came very quickly.

After Nurse Zhu and the cardiology ward nurse checked Chen Weian's name, wristband, monitoring records, and intravenous access, Chen Weian remained in a semi-sitting position.

Lin Ye handed over the handover form.

"Small amount of pericardial effusion, no signs of tamponade. Keep the patient in a semi-sitting position during transport. If blood pressure drops or breathing worsens, stop transporting the patient immediately, call for help at the nearest facility, and notify the cardiology department and emergency department."

"clear."

The nurse taking over the bed connected the portable monitor.

As the emergency bed was pushed to the door, Chen Weian glanced back at Lin Ye.

"Doctor, what would happen if we treated it as a heart attack today?"

"The risks that need to be assessed still need to be assessed." Lin Ye fastened the bed rails tightly. "But every step must be based on evidence. Go to the hospital first, don't scare yourself by checking your phone."

The door closed behind him, and bed number one became empty again.

Lin Ye returned to the nurses' station, while Xu Xiao's heart was still in sinus rhythm.

The other party was about to reply to a colleague's message when the computer hadn't arrived yet.

"If there's a bed tomorrow, transfer him to the cardiology department." Lin Ye pressed his handover form back onto the splint. "Get enough sleep tonight."

Xu Xiao put his phone face down: "Okay."

Nurse Zhu pushed the disinfection cart back to bed number one, changed the sheets, and replenished the items by the bedside.

Lin Ye erased Chen Weian's name from the shift handover board and reassigned bed number one to the motorized position. The clock on the wall had already reached shift handover time.

The attending physician opened Xu Xiao's records.

What's the focus tonight?

"After cardioversion, the heart rhythm has remained sinus rhythm. Continue monitoring. If palpitations, chest pain, or changes in blood pressure recur, have an ECG repeated immediately. Transfer to the cardiology ward tomorrow morning if a bed becomes available."

The attending physician circled these items.

"Okay, you can go home now."

After signing the last name, Lin Ye changed out of his white coat. As he walked out of the emergency room, it wasn't completely dark yet. The evening breeze brushed against his forehead, and he realized that he hadn't eaten anything since noon.