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

The No. 3 emergency bed creaked as it was pushed. Li Xu, a drunk young man in his twenties, was curled up on the mattress like a shrimp thrown ashore, his hands clutching his stomach and uttering meaningless screams.

"Doctor! Quickly give him a painkiller injection, his gastroenteritis has flared up, and he can't stand the pain!" Two blond companions, reeking of alcohol, were jumping up and down by the bedside, frantically giving the emergency room "diagnoses."

Fang Rui endured the pungent smell and walked forward with a frown. He skillfully pulled the blood pressure cuff over and strapped it on Li Xu, while simultaneously hanging the stethoscope around his neck.

"Hey doctor, why don't you give him the injection first? Why are you taking his blood pressure!"

The blond-haired young man panicked and reached out to grab Fang Rui's arm.

"Don't touch me!" Fang Rui turned his head sharply. Although he was just a resident trainee, the aftereffects of the pericardiocentesis he had just experienced still lingered. His shout carried an undeniable air of authority. "Am I the doctor or are you? In the emergency room, if you prescribe painkillers before determining the cause of the illness, you could mask the true condition and it could be fatal. Are you going to take responsibility?!"

The blond-haired young man was taken aback and reluctantly withdrew his hand.

In the nurses' station not far away, Lin Ye leaned back in his chair, twirling a ballpoint pen in his hand. Watching this scene, a slight smile appeared on his lips.

Fang Rui, that kid, has finally developed the temperament and composure that a doctor in the emergency ward should have.

Avoiding being swayed by family members is the first step in avoiding pitfalls in the emergency room.

At bed number three, Fang Rui's expression did not ease even though he had managed to calm the family members.

The numbers on the monitor popped up: blood pressure 105/65 mmHg, heart rate 118 beats/min.

Blood pressure was still within the safe range, but heart rate was noticeably fast. However, for someone who had been drunk and vomited violently, this heart rate was barely acceptable.

"Li Xu, right? Can you hear me? Where does your stomach hurt?" Fang Rui reached out to unbutton Li Xu's shirt, which was covered in vomit residue.

"It hurts... Ah! My stomach hurts! It hurts all over!" Li Xu was unable to cooperate at all. As soon as Fang Rui's hand touched his abdomen, he struggled violently as if he had been electrocuted. His abdominal muscles were taut, like a hard wooden board.

Fang Rui pressed his fingers on Li Xu's abdomen a few times, and his expression changed instantly.

My abdominal muscles are tense and I can't stand being pressed! This is definitely not just a common case of acute gastroenteritis or stomach cramps caused by alcohol!

Fang Rui's mind raced through several classic chapters on "acute abdomen" from medical textbooks, and his heart pounded. He took a deep breath, turned around, and strode back to the nurses' station, his eyes filled with the eagerness of someone who had "caught a big fish."

"Teacher Lin!" Fang Rui said rapidly, his hands gripping the table. "Bed number three is not an ordinary case of intoxication. The patient's abdominal muscles are extremely tense, with obvious tenderness and rebound tenderness, resembling a board! Moreover, the pain is extremely intense, and the heart rate is also too fast."

Lin Ye stopped twirling her pen, looked up at him, and asked, "What are your considerations?"

"I highly suspect acute gastrointestinal perforation (gastric perforation) or severe acute pancreatitis!" Fang Rui confidently stated his diagnosis. "Professor Lin, I'm going to immediately order an emergency abdominal X-ray (standing position) and check his blood routine, amylase, and lipase levels. To prevent him from going into shock from the pain during the examination, I'd like to prescribe an injection of phloroglucinol for spasmolysis and pain relief, and then immediately transfer him to the radiology department!"

Fang Rui finished explaining the entire process of physical examination, differential diagnosis, and treatment in one breath, looking at Lin Ye with expectant eyes.

For a resident trainee who has just started clinical practice, being able to accurately identify a high-risk acute abdominal condition like "gastric perforation" among a group of noisy drunkards without being misled by appearances is definitely a textbook example of skill.

However, Lin Ye did not nod in approval as he had expected.

Lin Ye's gaze passed over Fang Rui's shoulder and landed on Li Xu, who was still rolling around on the bed, his brows furrowing slightly.

"Fang Rui, your thinking is good; you weren't fooled by the distraction of 'drunkenness.'" Lin Ye stood up, his voice calm yet carrying a palpable pressure that made one's nerves taut. "However, don't give him the painkillers yet, and don't prescribe the tablets either. Think again, what did you overlook?"

Fang Rui was stunned.

What was missed? The physical examination was done, the indications for acute abdomen were found, auxiliary tests were ordered, and even pre-transfer analgesia was considered. Where was anything missed?

"Come on, take me there."

Lin Ye strode toward bed number three.

Fang Rui followed behind, completely bewildered.

Walking to the bedside, Lin Ye didn't immediately touch Li Xu's stomach, but instead turned to look at his two blond companions.

"Stop talking nonsense and answer me one question. If you want to save his life, tell the truth. Did his stomach hurt first, or did he vomit first?"

The blond-haired young man was overwhelmed by Lin Ye's aura and quickly tried to recall what he had seen.

"Yes, he vomited first! He drank about a pound of baijiu (Chinese liquor) and vomited several times. The last time he vomited particularly badly, even bringing up bitter bile. Then, just as he stood up, he suddenly yelled 'Ouch!' and collapsed to the ground, clutching his stomach, saying his stomach was going to burst..."

Lin Ye's eyes instantly became extremely sharp.

"Vomiting first, then pain, and it was a sudden, tearing pain after violent dry heaving." Lin Ye turned to look at Fang Rui. "If it were a perforated stomach, there would usually be severe ulcer pain first, followed by nausea and vomiting. The order is reversed."

Fang Rui's heart skipped a beat.

Lin Ye reached out and, avoiding Li Xu's stomach, ripped open Li Xu's collar.

He pressed his index and middle fingers together, accurately placing them on the suprasternal notch above Li Xu's collarbone and on the skin on both sides of his neck, applying slight pressure.

"Fang Rui, come here." Lin Ye stepped aside. "Put on your gloves and touch the spot I just pressed."

Fang Rui quickly put on gloves and placed his hands on it.

The moment Fang Rui's fingertips touched Li Xu's neck skin, his eyes widened in shock.

It was an extremely strange sensation! Beneath Li Xu's skin, it was as if countless tiny bubbles were hidden. With each press of the fingers, a faint but clear sensation, similar to crushing instant noodles or stepping on snow, was felt.

"A 'twisting' sound?!" Fang Rui gasped, his voice trembling. "Subcutaneous emphysema?!"

"Yes." Lin Ye ripped off the stethoscope and quickly placed it on Li Xu's left chest. "The breath sounds in the left lung are extremely weak, almost nonexistent. A large amount of air has leaked into the chest cavity and mediastinum, and has traveled all the way up to the neck along the interstitial spaces."

Lin Ye stood up.

"It wasn't a perforated stomach. The violent vomiting just now caused the pressure inside the esophagus to spike, tearing the lower part of the esophagus apart! Everything in the stomach and the gas leaked into the chest cavity!"

Spontaneous esophageal rupture (Boerhaave syndrome)!

Fang Rui felt his back instantly soaked with cold sweat.

This is ten times more deadly than a stomach perforation! It is a devastating acute condition with an extremely low incidence but an extremely high mortality rate.

If not surgically repaired in time, the leaked stomach acid and food residue can cause severe mediastinal infection and purulent pleurisy within hours, with a mortality rate of almost 100%.

If Lin Ye hadn't stopped him, he would have given the patient painkillers and then taken him to get an "abdominal X-ray in an upright position" that wouldn't even show the mediastinum in the chest... The intense pain would have been masked by the medication, and the X-ray might have only shown a faint abdominal abnormality.

By the time they realize something is wrong, the patient may have already died in the observation ward!

"Don't just stand there!" Lin Ye's roar pulled Fang Rui back from the brink of disaster. "Use the general practice green channel! Immediately perform a combined chest and abdominal CT scan, and notify the second-line cardiothoracic surgeon to wait for the results outside the CT room! Sister Zhao, open two more large-diameter intravenous lines, start antibiotics and proton pump inhibitors directly, no food or water, and insert a gastrointestinal decompression tube!"

The emergency treatment area is now operational again.

As the stretcher rushed toward the CT room under the escort of security guards, Fang Rui stood there, panting heavily, his face even paler than that of the drunken patient.

Lin Ye walked over and looked at the frustrated resident trainee. His gaze was clear and unwavering, without any hint of a countdown.

This means that before the real crisis arrived, Lin Ye personally dismantled this hidden mine in the fog, relying on his pure clinical experience and thinking.

"Do you feel frustrated?"

Lin Ye leaned against the emergency table.

Fang Rui lowered his head in shame: "Teacher Lin, I almost killed him. I was so focused on his stomachache and seeing him clutching his stomach that I didn't even think to touch his neck or listen to his chest..."

"You've done better than most first-year residents. You withstood the pressure from the family, ruled out ordinary intoxication, and saw abdominal muscle tension, but that's the pitfall of the emergency department. A patient complaining of pain in a certain area doesn't necessarily mean the root cause is there. The radiation and repercussion of bodily pain often give false signals. A rupture in the lower esophagus, with leaking fluid irritating the diaphragm, will cause pain to radiate to the upper abdomen, perfectly disguising it as a perforated stomach or pancreatitis."

Lin Ye straightened up and patted Fang Rui's chest.

"Today I'll teach you the second fundamental rule of emergency room physical examinations." Lin Ye's voice was particularly clear in the noisy emergency room lobby. "No matter where the patient complains of pain, during an emergency physical examination, your gaze must be one inch upward and one inch downward. Never let the patient's subjective feelings limit your overall perspective as a doctor."

Fang Rui raised his head, looked into Lin Ye's eyes, and deeply engraved those words into his mind.