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

"Get out of the way! Get out of the way!"

The triage nurse pushed a stretcher and ran wildly, crashing open the emergency room door.

A young man in his early twenties was huddled in the car, his face ashen, his hands pressed tightly against his upper abdomen, his black hoodie completely soaked with cold sweat.

"Transfer to another bed! Install multi-parameter monitoring, measure pulse oximetry and blood pressure!"

Lin Ye quickly stepped forward and, together with Fang Rui, carried the person to the emergency room bed.

As soon as Lin Ye made contact, he felt that the patient's forearm skin was cold and wet, like an ice cube just pulled out of deep water.

The monitor lead patch was quickly fastened to his chest.

Drip, drip, drip...

Heart rate 138, respiration 32. After the cuff was inflated and deflated, a striking low blood pressure reading appeared on the screen: 76/48 mmHg.

"Microcirculatory failure, shock!"

Fang Rui's expression changed drastically, and he immediately grabbed the IV tubing.

"Sister Zhao, insert two 16-gauge large-diameter indwelling needles and administer compound sodium chloride via pressurized rapid infusion!"

The young man who came in with him was so frightened that he lost his composure and stammered as he held onto the bed railing.

"Doctor, we spent the whole night at an internet cafe, ate two boxes of fried chicken cutlets and spicy hot pot, and drank three cans of iced cola. Around 10:30, he suddenly started dry heaving violently in the bathroom, vomited two mouthfuls of bile, then screamed and collapsed to the ground... clutching his stomach and crying out in pain, unable to even stand up!"

Fang Rui reached out and ran his hand around the patient's abdominal wall; the abdominal muscles were taut and tough.

"The upper abdomen is flat and extremely tender."

Fang Rui turned to look at Lin Ye and quickly gave his assessment.

"Sudden onset of severe upper abdominal pain accompanied by acute shock after overeating is highly consistent with acute peptic ulcer perforation. Gastric acid leakage has corroded the peritoneum, causing peritonitis. An abdominal X-ray in an upright position must be performed immediately to check for free air under the diaphragm. The general surgery department should be notified to prepare for emergency laparotomy repair!"

"Don't rush to flatten the sheet."

Lin Ye stopped Fang Rui's hand, which was about to open the examination form.

He bent down, bringing his nose close to the patient's faint breaths.

The air carried a slightly acidic odor of vomit residue, but not the fishy, ​​foul smell characteristic of severe gastrointestinal bleeding.

More importantly, although the patient was pressing on his abdomen, his breathing was extremely shallow and rapid, and with each rise and fall of his chest, the expansion of the left side of his chest cavity was significantly slower than that of the right side.

Lin Ye pulled out the stethoscope and pressed it directly onto the lower field of the patient's left lung.

The vesicular breath sounds were extremely weak, almost completely absent, and only faint tubular breath sounds could be faintly heard from the distance.

A countdown pops up:

【02:45:10】

【02:45:09】

The critical window for emergency treatment was less than three hours.

Lin Ye removed his stethoscope, his gaze shifting from the abdomen upwards until it landed on the triangular area of ​​the neck above the patient's collarbone.

The patient's left neck was slightly swollen. There was no redness or bruising on the skin surface, but under the cold light of the shadowless lamp, there was an unnatural fullness under the skin.

Lin Ye extended his right index and middle fingers and gently pressed the pads of his fingers on the patient's left supraclavicular fossa.

Shake, shake, shake...

An extremely subtle, supple, and peculiar friction sensation traveled from my fingertips.

It's like gently squeezing dry, fresh snow with your fingers during the coldest part of winter.

Subcutaneous crepitus.

A typical "snow-holding sensation under the skin".

The gas has traveled along the interstitial spaces all the way to the superficial fascia under the skin.

Lin Ye's expression suddenly turned cold. He quickly pressed the stethoscope probe back onto the third and fourth intercostal spaces on the left sternal border and held his breath.

Along with the patient's weak and rapid heartbeat, a very strange friction and clicking sound came from the stethoscope.

The pericardium and mediastinum are compressed, and air bubbles repeatedly rupture under the pressure of the heartbeat—Harman's sign, a specific murmur of mediastinal emphysema.

Stop the abdominal X-ray.

Lin Ye put away his stethoscope.

"The lesion is not in the stomach, but in the chest cavity. It's a spontaneous esophageal rupture, Boerhaave syndrome."

Nurse Zhao and Fang Rui, who were preparing to draw blood in the emergency room, were both stunned.

"Esophagus rupture?"

Fang Rui was somewhat bewildered.

"He was clearly saying his stomach hurt!"

"The lower esophagus is anatomically located close to the cardia and diaphragm. The pain caused by a rupture is highly concentrated below the xiphoid process and in the upper abdomen, and is often misdiagnosed as gastric perforation and severe pancreatitis."

Lin Ye directly tore open the patient's shirt and pointed to the left side of his chest wall.

"The combination of a large amount of greasy food and iced carbonated drinks produced a lot of gas, and the violent dry heaving caused the internal pressure at the gastroesophageal junction to spike to a critical level instantly. The left posterior wall of the esophagus lacked the protection of the outer membrane and muscle, and the entire layer burst open with a tear."

The hairs on the backs of all the medical staff on site stood up at the same time.

Highly acidic stomach acid, undigested food residue, and potent pepsin, along with the negative pressure in the chest cavity, are flowing liter by liter through the ruptured wound into the fragile mediastinum and left pleural cavity.

It corrodes mediastinal blood vessels, dissolves mediastinal fat, and crushes the left lung.

This is one of the most terrifying acute conditions in clinical practice in terms of mortality.

If emergency surgical repair is not received within twelve hours, acute chemical mediastinitis and erosive empyema will completely destroy all organs, with a mortality rate exceeding 50%.

"An abdominal X-ray cannot detect a rupture in the esophagus, and it will only delay treatment."

Lin Ye decisively gave the order.

"Fang Rui, insert a large-volume nasogastric tube for low-pressure continuous suction to remove all residual acid from the stomach and reduce leakage into the pleural cavity! Sister Zhao, establish two central venous access lines and administer Ringer's solution and hydroxyethyl starch at full speed. Administer vasoactive drugs as needed to bring the mean arterial pressure back above 65!"

"good!"

Nurse Zhao immediately opened the pressurized IV bag.

Lin Ye picked up the green emergency phone next to the ambulance and, bypassing the regular outpatient department, dialed the dedicated hotline for the cardiothoracic surgery department:

"Emergency red zone calling the thoracic surgery on-call team. Bed 1, 24-year-old male, suffered a sudden spontaneous esophageal rupture complicated by tension pneumothorax and chemical mediastinitis after severe vomiting, and is currently in shock. We are currently performing preoperative anti-shock resuscitation. Please prepare for emergency thoracotomy and exploration of the operating room immediately, and notify the cardiopulmonary bypass and anesthesiology departments to prepare for the operation!"

The chief thoracic surgeon on the other end of the phone visibly gasped.

"A confirmed diagnosis of esophageal rupture? This is a rare case, maybe two or three per year. Is the evidence strong enough?"

"There is a noticeable sensation of snow under the skin of the neck, a positive Harman sign, and absent breath sounds in the left lung."

Lin Ye answered without hesitation.

"We're now using the emergency equipment and the green channel to get an enhanced chest CT scan, plus oral meglumine diatrizoate for contrast imaging. Meet us in ten minutes at the CT room entrance to review the images!"

Lin Ye hung up the phone and turned to push up the flatbed railing.

"Fang Rui, take the defibrillator and emergency transport kit, and come with me to the CT room on this trolley!"