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

The lead door of operating room number nine opened to both sides.

The deputy director of orthopedics and the chief vascular surgeon casually ripped off their surgical gowns and threw them into a yellow waste bin, their foreheads and necks covered in a layer of oily sweat.

The damage control surgery was performed with extreme restraint. The bone ends were not repaired, and the remaining muscle tissue was not sutured. The bleeding deep femoral artery and vein were simply ligated. After rinsing off the machine oil with hydrogen peroxide, the wound was filled with thick dressings and pressure bandaged. The entire surgery was completed within forty minutes.

"The wound is temporarily under pressure; please do not remove it."

The vascular surgery on-call doctor picked up his teacup, took a sip of cold water, and then gave instructions to Lin Ye.

"Transfer to EICU now, and quickly wash out the acid and potassium. As long as the environment doesn't collapse in the next two days, we can perform a second debridement the day after tomorrow."

Lin Ye responded and, together with Fang Rui, pushed the stretcher toward the intensive care unit.

EICU bed number two.

Transfer to bed, connect to ventilator, connect to central venous access, and align dialysis tubing.

The bedside hemodialysis machine completed its power-on self-test, and the roller pump began to rotate smoothly.

On the multi-parameter monitor, data was displayed line by line: heart rate 105, blood pressure at 98/62 mmHg due to the micro-pump norepinephrine, and blood potassium dropping back to 5.6 mmol/L after continuous filtration.

Fang Rui leaned against the instrument rack at the foot of the bed and wiped the sweat from his forehead with his sleeve.

"Teacher Lin, at least her life was saved."

After signing the handover form, the attending physician pulled out a chair and started typing on the keyboard.

"The patient has suffered a major crush injury, and the internal environment is still acidic. However, since CRRT has been started, the subsequent crystalloid fluid resuscitation combined with furosemide flushing will prevent myoglobin from blocking the renal tubules. The overall situation is stable."

The monotonous, dull sounds of machinery filled the ward as several medical staff members packed up their instruments.

At the foot of the bed, Nurse Zhao was bending over to record the patient's intake and output for the previous hour.

She picked up the anti-reflux drainage bag to check the markings, her pen hovering over the line on the record sheet, her gaze lingering on the bag for a couple more seconds:

"Lin Ye, come take a look over here."

Lin Ye walked over.

Two hundred milliliters of drained urine were collected at the bottom of the plastic bag.

Urine from rhabdomyolysis and severe crush injuries typically contains high concentrations of myoglobin, and its color resembles light soy sauce or strong black tea. Logically, after being hydrated with several thousand milliliters of warm saline solution in the emergency room, the color should gradually lighten from dark brown, even if it doesn't completely fade.

However, the urine in the bag was completely opaque, with a deep, bright red color like freshly squeezed tomato juice, and a layer of fine, dark particles clung to the bag walls.

The attending physician was typing on the keyboard.

"The I-beam weighing hundreds of kilograms has been pressing on you for so long, causing necrosis of the entire thigh muscle. How could your myoglobin levels be low? Nurse Zhao, administer 20 mg of furosemide via bolus injection. Once your urine output increases, it will clear up the problem."

"Don't use furosemide yet."

"What's wrong?"

The attending physician stopped what he was doing.

Lin Ye didn't respond. He quickly walked to the bedside and reached out to open the driver's eyelids.

The beam of the spotlight swept across the eyeball.

The sclera had a very faint, but definitely not normal, lemon-yellow tint.

The fluorescent lights shone down from above, and the driver's ears and cheeks appeared slightly sallow and dull.

Acute jaundice in trauma patients?

It has only been three hours since they were excavated from the tunnel ruins. Even if there was a closed injury to the liver or a tear in the bile duct, it would be impossible for bilirubin to precipitate into a visible yellow stain throughout the body within three hours.

In the deepest part of my vision, that line of tiny words jumped silently:

【01:45:12】

【01:45:11】

The time limit is more than an hour.

Lin Ye looked away and turned to look at the intranet terminal at the nurses' station.

"Have the results of the urgent blood tests and biochemistry reports been released yet?"

"I'll go refresh it!" Fang Rui rushed to the front, pressed F5 to refresh the page, and gasped as he stared at the pop-up report. "Professor Lin, the blood test results are in... the values ​​are wrong!"

Lin Ye walked a few steps to the screen.

The hemoglobin level did not rise after the four bags of red blood cells were transfused into the operating room; instead, it dropped from 85 g/L before entering the operating room to 51 g/L.

The percentage of reticulocytes was as high as 16.8%, far exceeding the upper limit.

In the urgent biochemical test, the total bilirubin level surged to 142 μmol/L, with unconjugated bilirubin making up the majority.

The attending physician, pulling his wheelchair over, glanced at the patient and his expression changed.

"How could you have fallen so violently? You just received a blood transfusion of 800 milliliters! Are you still bleeding heavily in your abdominal cavity? Is there a hidden hematoma in your pelvis?"

"Major bleeding will not cause bilirubin to double in three hours, let alone force out 16% reticulum."

Lin Ye snatched the bright red urine sample from the foot of the bed, stepped into the treatment room, inserted it into the turntable of the benchtop high-speed centrifuge, closed the protective cover, and pressed the knob.

Two minutes later, the rotor slowed down and came to a stop.

In hematuria caused by common trauma, the red blood cells will compact and settle at the bottom of the tube under gravity after centrifugation, and the supernatant will return to a pale yellow and clear state; even in myoglobinuria caused by crush injuries, the sediment will separate into layers after settling.

Lin Ye held the test tube between his fingers and held it up to the light.

There were no clumps of red blood cells at the bottom of the tube.

The liquid in the tube was a deep red from top to bottom, as evenly as if a tube of dark red wine had been poured.

"This is free hemoglobin..." The attending physician stared at the test tube, the pores on his back tightening. "Did the red blood cells explode inside the blood vessels?"

"Acute intravascular hemolysis." Lin Ye put the test tube back on the shelf. "Red blood cells break down in batches in the circulation. The broken cell membranes release hemoglobin, which blocks the renal tubules. Indirectly, the overflow of bilirubin induces jaundice."

Fang Rui looked bewildered: "How could hemolysis suddenly occur out of nowhere? I checked the blood matching report, the blood type is definitely correct!"

Lin Ye didn't reply, but reached out and tore off the pre-hospital emergency transfer form from the medical record board.

At the very bottom of the accident scene emergency response section, there is a red stamp of the Special Operations Detachment, and next to it is a line of direct dial numbers for the on-site investigation team.

Lin Ye grabbed the landline phone from the wall and dialed directly.

After two beeps, the receiver was connected, and the background was filled with the noise of walkie-talkies and mechanical cutting.

"The EICU at the First Municipal Hospital is currently treating the driver of the bus you dismantled and handed over." Lin Ye spoke rapidly. "Is the on-site technical team present? Immediately retrieve the original configuration sheet for the bus. What kind of refrigerant was used in the roof-mounted air conditioning unit?"

There was a pause of half a second on the other end, followed by a frantic rustling of papers being sifted through.

"Ten years ago, the long-distance bus had a roof-mounted high-pressure unit containing a refrigerant formula containing chlorofluorocarbons and high concentrations of industrial anti-knock additives. When the crash occurred, the front piping completely collapsed, and high-pressure gas poured directly into the driver's area. What happened?"

"understood."

Lin Ye hung up the phone and turned around.

"The air conditioning pipe burst, and the high-pressure refrigerant, carrying the explosion suppressant, poured directly into the respiratory tract. Those organic chemicals are lipid-soluble, and once they enter the bloodstream, they damage the cell membranes of red blood cells."

"No wonder there were constant crackling sounds in the airway," the attending physician realized. "This is hemolytic pulmonary edema induced by microvascular embolism!"

"We can't continue transfusing regular red blood cells; they'll just continue to be dissolved." Lin Ye made a decisive decision. "Stop routine CRRT and immediately switch to large-volume plasma exchange. Use a filter to discard all the contaminated plasma and replace it with healthy plasma!"

Nurse Zhao had just put down the internal phone, her brows furrowed deeply.

"Plasma exchange cannot be performed."

Everyone in the room turned to look at her.

"The blood transfusion department just replied that the patients with ruptured livers and spleens and massive bleeding who were brought in through the tunnel this morning have used up all the fresh frozen plasma in the blood bank's reserves," Nurse Zhao said in a low voice. "The city blood bank's emergency blood delivery vehicle is stuck on the cross-river bridge, and the morning rush hour traffic is so bad that it will take at least two hours to get to the hospital."

Two hours.

The countdown hanging in Lin Ye's eyes showed only one hour and forty minutes left.

The monitor's alarm suddenly became shrill.

The driver on the hospital bed coughed as if he were choking. Then, a clump of bloody sputum mixed with pink foam gushed out from the transparent corrugated tube of the ventilator connected to the tracheostomy tube.