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

The small meeting at 10 a.m. was held on the third floor of the administration building.

Lin Ye stood at the meeting room door, holding the revised list, his eyelids heavy with sleep.

Nurse Zhao handed him a cup of coffee from behind.

"Take this. Don't let it cause you to fall asleep on the spot when the dean questions you."

Lin Ye took it: "You're going too?"

"Director Qin said that I wrote the triage rules, so if I don't go, who will?" Nurse Zhao straightened her uniform. "Besides, I have to keep an eye on the medical affairs department to make sure they don't change the wording completely."

Liu Zhenhua had just walked over when he heard the second half of the sentence.

"I'm still here."

Nurse Zhao nodded: "That's why I said it to your face."

Qin Hai stepped out of the elevator: "Alright, let's go in."

There weren't many people in the conference room.

Dean Chen Shouyi, Vice Dean in charge of medical affairs, Liu Zhenhua from the Medical Affairs Department, Qin Hai from the Emergency Department, Luo Jianping from the Neurosurgery Department, Shen Ruomei from the Obstetrics and Gynecology Department, Han Qing from the Endocrinology Department, He Jianye from the Nephrology Department, and several nursing and quality control personnel.

When Lin Ye sat down, his knees almost touched the bottom edge of the conference table, and the notebook in his hand was pressed down on his lap.

Chen Shouyi looked to be in his fifties, with gray hair. On the table was the handwritten list that had been photographed by a mobile phone.

He didn't read the edited version first.

Instead, he picked up the printed photos.

"Was this on the wall at the nurses' station last night?"

Nurse Zhao said, "Yes, Dean. The handwriting is ugly, but it's usable."

Chen Shouyi glanced at her and smiled: "Being usable in the emergency room is more important than looking good."

The tension in the meeting room eased a little.

Liu Zhenhua projected the edited version onto the screen.

The title is:

[Trial Version of the Nighttime High-Risk Warning List for the Emergency Department of the First Municipal Hospital]

The following categories are divided into several types.

The chest and abdominal pain was atypical, but the vital signs were abnormal.

Altered consciousness after drinking alcohol or falling and injuring oneself.

The elderly patient had a history of head trauma combined with antithrombotic medication.

Unusual quietness and seatbelt signs in children after trauma.

Pregnant women may experience abdominal pain, uterine contractions, or abnormal fetal heart rate due to trauma.

Risks of low-grade fever and neutropenia following chemotherapy.

Dialysis patients experience fatigue, nausea, slow heart rate, and missed dialysis sessions.

Anxiety-like dyspnea is preceded by metabolic disorders, hypoxia, and arrhythmias.

Each entry is followed by four columns: "Key Evidence," "Pre-examination Tests," "Trigger Consultation," and "Record Key Points."

Chen Shouyi looked very slowly.

When he reached the third page, he looked up and asked, "Are these all cases encountered during the recent emergency room night shifts?"

Qin Hai pushed the revised list forward by half an inch: "Yes."

"Were they all discovered by Lin Ye first?"

Qin Hai did not rush to answer.

Lin Ye tightened his grip on the list.

If the answer is "Lin Ye discovered it alone", then half of this list is useless.

Qin Hai's finger pressed on the corner of the list: "He was the first to raise many of the initial risk warnings. But the treatment wasn't done by him alone. Emergency triage, review by the attending physician, specialist consultation, nurse execution, and record-keeping by the medical affairs department—not a single step could be missing."

Chen Shouyi nodded: "That's exactly what I want to hear."

He looked at Lin Ye: "You tell me yourself."

Lin Ye stood up.

His voice was a little hoarse from staying up all night, so he took a sip of coffee before speaking.

"Dean, I am a resident physician. There are many treatments that I cannot, and should not, decide independently. This list is not for young doctors to give orders beyond their level, but to let everyone know which abnormalities cannot be ignored when encountering atypical patients at night."

He turned the page to the section on childhood trauma.

"For example, Lele has no external bleeding and doesn't cry. If we only judge her based on 'quiet,' she might be placed in the yellow zone. But the seatbelt injury, rapid heart rate, low blood pressure, cold extremities, and tenderness in the upper left abdomen combined are enough to warrant a red rating."

Then I came across the topic of fever after chemotherapy.

"When chemotherapy patients have a low-grade fever, their families often think that IV fluids are sufficient. However, a low-grade fever can also be a sign of severe infection when there is a lack of neutrophils. The checklist reminds us to have a culture done first, treat the infection as soon as possible, and call the ICU for evaluation in advance, rather than waiting until the patient goes into shock."

After he finished speaking, only the sound of the projector whirring filled the conference room.

He Jianye pulled the list a little closer to himself: "I suggest you bold the dialysis item. Make the words 'missing dialysis,' 'low sodium,' and 'fruit' bigger. We can explain it a hundred times in public education, but it's not as scary as one emergency defibrillation."

Han Qing drew a line next to "anxiety-like dyspnea": "The wording for the diabetic ketoacidosis section should also be carefully considered. Don't let the triage nurse diagnose acidosis, but trigger blood glucose and blood gas analysis."

Shen Ruomei turned to the page about maternal trauma: "Regarding maternal trauma, fetal heart rate monitoring should be moved up. Less external bleeding doesn't mean everything is fine."

Luo Jianping tapped the table: "For the elderly with head injuries, clearly state the antithrombotic medications. Ask about aspirin, clopidogrel, warfarin, and newer oral anticoagulants. Don't just ask 'Did you take anticoagulants?'"

Nurse Zhao whispered to Lin Ye, "See? The directors are starting to take over space on your cheat sheet."

Lin Ye couldn't help but laugh.

After listening to the opinions from each subject, Chen Shouyi closed the compiled version in his hand.

"I agree to try it out."

Liu Zhenhua sat up straight.

Chen Shouyi continued: "We'll first pilot this on the emergency room night shifts for two weeks. Instead of handing out documents for everyone to memorize, we'll post them at the triage desk and in the resuscitation room, and mention one point during shift handover. After two weeks, we'll review the data to see if the risk of missed diagnoses has decreased and if consultations have increased excessively."

Qin Hai didn't remove his hand from the list: "I have one more request."

Chen Shouyi looked at him and said, "You've always had a lot of demands."

"The checklist shouldn't become a tool for assigning blame," Qin Hai said firmly. "It's a reminder, not an excuse for nitpicking after the fact. Doctors make judgments based on evidence, and their records are complete. Even if the outcome is unfavorable, it can't be used to simply reverse the process."

Liu Zhenhua spoke first: "It's already written in the trial implementation guidelines. It's used for risk mitigation and process triggering, not as a basis for separate accountability."

Qin Hai glanced at him.

"Don't go back and delete what you said."

Liu Zhenhua: "I won't delete it."

Chen Shouyi tapped the table: "Then it's settled."

When Lin Ye sat down, he realized that his back was covered in sweat.

The system notification light will light up gently.

Team process development: Initial completion.

[Emergency Room Nighttime High-Risk Warning List: Under Trial Implementation.]

[Zero-fatal ER weekly progress: 3/7]

He rearranged the pages of the list, his fingertip pausing on the corner of the paper.

Every piece of "suggestion" you give in the future may be used by others.

After the meeting, Chen Shouyi called Lin Ye aside for a private talk.

"I heard that all the department heads are afraid of you working the night shift now?"

Lin Ye didn't know how to answer for a moment.

Nurse Zhao answered for him, "Dean, it's mainly because the department heads don't get enough sleep, it's not his fault."

Chen Shouyi smiled.

"This is probably a good thing. What hospitals fear most is not insomnia, but that no one is awake when they should be."

Qin Hai did not refute.

When I returned to the emergency room, the handwritten list on the wall had been taken down and replaced with a revised trial version.

Nurse Zhao looked at the neatly arranged paper and suddenly felt a little disgusted.

"It's too clean."

Lin Ye said, "It'll be dirty tonight."

Sun Zhiqiang poked his head out of the office: "Shut up."

At 9 PM, the fourth night begins.

The emergency room was not crowded. The list was posted behind the triage desk, black and white, like a new face that had just started working.

At 9:47, a middle-aged woman helped her husband into the house.

The man was in his forties, his right calf was wrapped in gauze, his face was flushed, and he was sweating on his forehead.

"Doctor, he pricked his foot with a nail yesterday, and today his leg hurts and he has a fever. The community hospital told him to come in for a tetanus shot."

Just as the triage nurse was about to ask about the wound, the man suddenly frowned.

Why can't I open my mouth completely?

Nurse Zhao suddenly looked up.

This item is not yet on the newly posted list on the wall.

The system notification lights up at the edge of the forest field of vision.

[Fourth high-risk alert activated.]

[Risk: Early stage of tetanus, risk of airway congestion and spasms.]

Key abnormalities: contaminated wound, difficulty opening mouth, fever, muscle tension.

Lin Ye looked at the calf that was wrapped in gauze.

The trial version of the list has just been posted on the wall.

On the fourth night, it brought a question it had never written before.