"Mercy ER, this is Medic Twelve with Code Three traffic."
The voice, choppy with static and backed by a wailing siren, came over Mercy Hospital's paramedic radio, from an ambulance out on the San Francisco streets. Code Three meant that it was racing toward the hospital as fast as the night allowed.
The Mobile Intensive Care nurse monitoring the radio leaned closer and pressed the talk button on the handset.
"Medic Twelve, this is Mercy ER," she said. "Go ahead."
Carroll Monks walked across the Emergency Room and stood beside her, listening.
"Mercy ER, we're bringing you a young white female, age approximately twenty-five. She's unconscious, with almost no blood pressure. She does have a very weak femoral pulse, but no radial pulses. Ah, hold on a second, Mercy."
Monks heard the driver yell something to his partner in the ambulance's rear. His words and the reply were lost in noise.
The driver's voice came back on. "We haven't been able to start an IV. We can't find any veins. Repeat, she does not have an IV running. She has respiratory depression and we are oxygenating her."
The nurse said, "Medic Twelve, do you have any history on her?"
"Negative, Mercy, not much. She was in an apartment, alone. Looks like she's had a recent surgery, probably her breasts. We found some Valium, but we don't think it's an overdose."
"Who called her in?"
"She managed to call 911. We got sent by City Triage."
Monks took the microphone from the nurse, and said, "Any signs of massive bleeding?"
"There's some vomit with blood in it," the driver rasped through the static. "But not massive."
"Nothing from the surgery? Other external wounds? Blood around the apartment, or in the bathroom?"
"Negative, Mercy," the driver said again.
Monks's mind started tracking a flow chart of probabilities, for a young woman who was bleeding badly, with the blood staying inside her. None of them were good.
The nurse watched him questioningly, a look asking if he wanted any more information. He shook his head, giving her instructions as he handed her the microphone.
'Take her directly to the trauma room, Medic Twelve," she said.
"Roger, Mercy. ETA is six minutes."
Monks turned back to the ER and the next pressing task-organizing who was going to need to be where, during the next half hour. Screws had been tightening in his head all night, and this had the feel of being the most severe one yet.
It was 3:51, an early Friday morning in July. San Francisco was going through a heat wave, with temperatures that had hovered in the nineties for the past several days. The usual cooling sea breezes and evening fog were gone, driven off the coast by hot winds that swept through the Central Valley like blasts from a furnace. Inland, the thermometer had been topping 110.
But inland, they were used to it. Here, the leaden air and damp armpits and gummy asphalt underfoot were like a sudden sneaky enemy, one that worked just below the level of consciousness. Monks could sense it in faces – tension, friction, as if a layer of social lubrication had been eroded by the heat. People were rubbing too close together, and the ER had been simmering hotter as the hours passed. It was amazing how many human beings were up, about, and in need of medical help, all through the night.
He had just left the bedside of a seventeen-year-old girl who was giving birth to her third baby, a process she had started some twenty minutes earlier in her boyfriend's car. Staff were trying to get her sent to OB, but OB was busy, and the on-call obstetrician was not yet available. It looked like the youngster was going to appear in the ER any minute now.
In the next bed, a fat middle-aged man was doing his best to die of a heart attack. They had shot him full of clot-busting drugs and shocked him back to life three times, but the monitor kept quavering in the danger zone. This was tying up two nurses and the other ER physician on duty. A cardiologist was supposed to be on the way to take him to the Cath Lab, but cardiology was busy, too.
The knife wound in Bed Five was coming around without complications, but during the past minutes, his voice had risen from querulous to strident and he was becoming combative. The SFPD cops who had brought him were gone, back on the streets to deal with their own hot night. Hospital Security would probably have to be called to put him in restraints, but Security had their hands full right now in the lobby. One uniformed officer was moving uneasily among the crowd of at least twenty, while another flanked the desk where the triage nurse worked to separate out the most gravely ill and injured. Many were in pain, most had been waiting a long time, and there was a volatile racial mix of young black and Hispanic males, with girlfriends or wives who looked at least as tough as the men. Monks had been peripherally aware of a lot of restless movement on the other side of the lobby's glass doors – bobbing heads and strutting bodies, a dizzying collage that made him think of a huge, many-limbed beast about to fall into a frenzy and tear itself apart.
And now an ambulance was on its way, bringing a woman in critical condition. At least, Monks thought, this would bring more uniforms. It might help stabilize the tense crowd.
He stepped to the main desk. "Call City Dispatch Center," he said. "Tell them we're going on diversion."
Leah Horvitz, the charge nurse, nodded and reached for the phone. Leah was a fiercely competent veteran, uncowed by any situation Monks had ever seen. But even she looked relieved. The ER would now be temporarily closed to any more ambulances bearing the victims of shootings and stabbings, wrecks and rapes, overdoses and organ failure and madness. The staff were already overwhelmed – they could barely handle what they had, and to take on anything more could be dangerous to patients. But it was something Monks had only done rarely, and it left an unpleasant taste. There was the unavoidable sense of letting down the team.
He caught the eye of a magenta-uniformed nurse named Jackie Lukas and motioned her to meet him at the Trauma Room. She was slim, ponytailed, athletically attractive. He knew from experience that he could count on her to stay cool.
"We've got an ambulance coming in five minutes," he said. "A woman with no blood pressure, and they can't get an IV in her arm. I'm going to put a big tube in her ankle vein."
"Fourteen-gauge catheter?"
"Make it IV tubing. Sterile unopened package. And a cutdown tray."
Jackie immediately turned to her work. Monks stepped into the cubicle that housed Bed Seven and the heart attack victim. Vernon Dickhaut, the other ER physician, was at the bedside, looking impatient at being stuck there.
"How is he?" Monks said.
"About the same. The cardiologist's on his way."
"That's good, Vernon, because I'm going to be out of it for a while. There's a critical coming by ambulance. The ER's all yours." Vernon was a North Dakota farmboy with lank straw-colored hair, cornflower blue eyes, and an IQ off the charts. He had been bound for a career in surgery, until a residency rotation with Monks had given him a taste for the ER's adrenaline and action. Monks took a certain pride in having corrupted him, and it had paid. A couple of years ago, Vernon would have come close to panicking at taking full charge, but now it was a challenge he savored.
"Don't let anybody die, huh?" Monks said.
Vernon saluted with mock trepidation.
Later, many times, Monks would remember his own words.
Monks heard Medic Twelve's siren coming from blocks away. After more than two decades in the ER, that sound still touched him with anticipation tinged with fear, like what a journeyman fighter must feel on hearing the first-round bell. Then it was gone, leaving him heightened and ready.
The siren died, giving way to the rumbling vibration of a large motor, and red lights flashing outside the ER's ambulance entrance. Monks dropped his white coat onto a chair at the nurses' station and walked quickly into Trauma One, a cubicle with operating-room surgical lights overhead and glass-fronted cabinets on both side walls. Jackie Lukas and two other nurses were present. One pulled back the curtain that separated the cubicle from Trauma Two, converting the area to one large space with two empty beds. The other nurse had hung two IV bottles on floor stands and was connecting them to plastic tubing.
Jackie pulled a tray from a cabinet and stripped off the sealed plastic covering. She placed it on a Mayo stand, careful not to touch anything sterile, and gave Monks a packet of rubber gloves, size 7½. Monks tore it open and gloved his hands with automatic precision. Then he started selecting and arranging equipment from the cutdown tray. He scissored the end off a three-foot plastic IV tube, angling the cut, then snipping off its sharp point. Jackie took the other end and attached it to an IV bottle.
"Get lab down here right away," he told the other nurses. "I want a full trauma panel on this woman. I need the hematocrit stat, and we'll want blood. Tell X Ray to bring their portable machine."
The paramedics were coming in fast, wheeling their stretcher.
"We kept trying to get fluid into her, Doc," one said. "We couldn't get a vein."
The woman was still unconscious, covered by a blanket and strapped down, eyes closed and head lolling to one side. Her hair was tawny and disheveled. What Monks could see of her face around the oxygen mask might have been pretty, except that it was ghostly white and drawn with pain. She was slim and shapely, wearing a filmy black bed wrap and panties, an expensive matching outfit. But she also had on a heavy surgical bra, the kind worn by women after breast surgery.
They lifted her quickly onto the trauma bed. Monks pulled open the blanket, fingers going to her throat to try for a pulse. It was near zero, and her breathing was shallow and rapid.
The nurses were already stripping off the wrap and bra. Both of her armpits had bandages taped into place, and there were purple bruises down to the waist on both sides. Her surgery had been very recent – probably a breast enhancement via saline bag, with the bandages covering incisions where an endoscope had been inserted. Everything else Monks saw at first glance was in line with what the paramedics had reported. There were no signs of bleeding from the bandages, or anyplace else external.
"Prep her ankle," he said, putting on a new pair of sterile gloves.
Jackie poured an iodine solution on the patient's lower leg, from the ankle upward several inches, and scrubbed it with gauze pads. She lifted it while Monks slipped a sterile towel underneath. Then an eye sheet, a drape with a hole in it, went on top of the area. He chose a number-ten scalpel and felt for landmarks – one inch above the ankle bone, and a little toward the front – and cut a one-inch slit completely through the skin. He traded the scalpel for a clamp and inserted its closed end into the fatty tissue, opening the clamp's tip to spread the tissue apart.
The saphenous vein, the size of a thin pencil, was white against white-like her skin, the cut, and the tissue around the vein, bloodless.
A lab tech had come in and was trying to draw blood from a vein in her arm. Monks glanced up at him and said, "You're not going to get anything there, Lab. I'll do a femoral puncture as soon as I'm done with this."
He quickly isolated the vein, lifting it gently on the clamp to separate it from the surrounding tissue. With a new number-eleven blade, he opened the vein and eased in another clamp two inches toward the knee, stretching the vein enough to accept the beveled end of the IV tube.
"We're in," he said. "Open it wide." Just over three minutes had passed since her arrival.
Monks tied the tube in place, took two quick skin stitches to close the incision, and stepped out of the way for Jackie to dress the wound and tape the exposed tube to the leg.
"Pour the fluids to her, ladies, warm saline," he said to the nurses. "Start her on Narcan, one milliliter, IV. And get a Foley catheter into her bladder. Let's see if she's making urine."
He moved to her groin and placed his fingers by her pubic bone, feeling for the femoral artery. There was a faint pulse. He wiped the area with an alcohol swab, accepted a syringe, and slid the needle into the artery's pulse. Blood filled the syringe slowly. He gave it to the lab tech.
"Give me an immediate tox screen, plus a trauma panel," he said. "And give me four units of type-specific or O-negative red cells." The tech scurried away. Giving blood that had not been checked against the patient's own type was risky, but there was no time for a complete cross-match. This woman needed blood, now.
"How are we doing?" he asked Jackie.
"Blood pressure's sixty over zip. It's not coming up yet. She's gotten almost a full liter of saline. We'll start the red cells as soon as we get them."
With the urgent business of the IV and fluids under way, Monks started concentrating on a diagnosis. He put his stethoscope to her chest. Hemorrhaging from the surgery, into the chest cavity, was one of the first possibilities he had considered. But while her breathing was slow, it did not sound like chest cavity or lungs were filled with the missing blood.
Her GI tract was a more likely possibility. Her bed wrap was stained with vomit, dark and granular, the classic "coffee-grounds" vomit of stomach bleeding. There was no obvious link to her breast surgery, but that was something to worry about later. Monks moved his stethoscope to her abdomen.
"Very active bowel sounds," he said. His guess was getting stronger that the blood was in her abdomen, causing irritation. "I need to do a rectal." A nurse gave him an exam glove, while Jackie pulled the woman's knees up and her panties down. Monks noted a tattoo of a bright red apple, with a slyly winking green snake coiled around it, on the left side of her rump. He accepted a dab of lubricant on his fingertip and gently pushed into her. It came out covered with black bloody matter.
"That's it," he said. "She's bleeding into her gut. Get a nasogastric tube into her stomach. Let's see if it's there or lower down. X Ray, film her abdomen, please."
The X-ray tech was a trim energetic Filipino man, poised with his machine. "Right now, sir," he said. He positioned machine and film cassette, then called "X ray!" Monks and the nurses stepped back. The machine buzzed and clunked. The tech pulled the machine back out of the way and left with the cassette.
Monks put his hand on the patient again. The presenting scenario had pretty well arranged itself in his mind by now. She had probably taken Valium for pain from the surgery. Sedated, she had not realized how sick she was getting. At some point, she had started hemorrhaging. She had regained consciousness long enough to call 911.
But by then she was in serious trouble, and she was not getting better. Her blood pressure wasn't rising and her oxygen saturation level was very low, 89 percent out of 100, even though she was on pure oxygen. That was largely because there wasn't enough blood circulating to carry the oxygen to cells. But it was still damned low.
And she had too many bruises – in her armpits, down to her waist, around her breasts, even on her arms and buttocks. Much more than a plastic surgery like that should leave.
Monks ran through a quick differential diagnosis in his head. GI bleeding in the upper intestinal tract or stomach was usually caused by ulcers. She was young, but it was possible. He dismissed liver failure from alcoholism, at least for now; she didn't have that look. A diverticulum, an outpouching on the colon, was another possibility, especially if the bleeding was lower GI, in the intestines.
Then there was the surgery she had just undergone. It was hard not to speculate that there might be a connection.
Monks stepped to the door and caught Leah Horvitz's eye. She hurried over.
"Any ID on her?" he asked.
'The paramedics found her purse," Leah said, in staccato, no-nonsense syllables that matched the rest of her. "Her name's Eden Hale. A Los Angeles address on her driver's license. Home phone's here in San Francisco, but nobody answers."
"See if you can get hold of a family member. Find out if there's any history of ulcers or other GI bleeding."
"She had a discharge form from a plastic surgeon's office," Leah said. "Dr. D'Anton. The Valium's from him, too."
"D'Anton, huh?" Monks said, surprised. Dr. D. Welles D'Anton was San Francisco's premier plastic surgeon, with a clientele of the rich and beautiful. Monks knew him only by reputation. D'Anton was considered to be arrogant, but extremely competent – not the kind of surgeon who might have botched a relatively simple procedure.
"I already called his office," Leah said. 'The nurse is looking up Eden's records, and she'll call back if there's anything that might be related. She didn't want to wake Dr. D'Anton."
Monks nodded. He did not expect that D'Anton would be taking phone calls at four a.m.
Monks went back to help the nurses keep working at replacing the body's fluids, the first and by far most critical step to stabilization for any of the blood-loss scenarios. Her veins were filling and her blood pressure rising a little, but she was still unconscious – still not responding in any way he could sense.
His concern was turning to worry.
A small eternity later, eight minutes by the clock, the second unit of blood was going in through the IV. Monks was more and more unhappy. The nasogastric tube showed bleeding, but not that much, and it looked like it was upper and lower. That did not make sense. And there was all that goddamned bruising.
Something was swimming under the surface of his consciousness, but refusing to come to light.
He considered wild shots, like typhoid fever. He had seen a few cases in Asia, and recalled that there might be rose-colored spotting on the skin, along with the severe abdominal distress. But the resemblance of those spots to these was superficial, and typhoid was virtually unknown in this environment.
He kept touching her, probing, looking, listening. Then he realized that some of the bruises were new – they had appeared since she had entered the ER. There were several on her arms and legs, about the size of a nickel, where his own and the nurses' fingers had touched. She was bruising as they watched, on the spot.
Then the nagging thought in his unconscious broke through.
"DIC," he said, in astonishment.
The recording nurse at his elbow, Mary Helfert, was writing down times and procedures. "Say that again, please?"
"DIC. Disseminated intravascular coagulation."
She looked uncertain – she had probably never encountered the term, except maybe for mention in a nursing school textbook, years ago – but this was no time to explain. Monks flipped the sheet away from the rest of Eden's body. Fresh blood trickled steadily from the needle punctures in her groin and from the cutdown incision at her ankle. Her nose oozed blood from where the NG tube had been inserted. There were new bruises on her hip.
DIC was what it looked like, all right. Her small blood vessels were clotting off, using up the clotting factors in her blood. Without those, she was bleeding everywhere else.
"What the hell is going on?" he said. His rising voice made the nurses glance nervously at each other. "Ulcers don't cause DIC. Diverticulitis doesn't cause DIC. Is she septic?"
Monks turned away from the bed and forced himself to another place in his mind, a place he hated and feared. It was a court of last resort, where he had to make an instantaneous decision with too little time and information, and a life at stake. He stood stock-still, eyes closed, weighing the facts he was sure of against his deductions and intuitions, the known against the inferred, the risks of what he was considering against the near-certain consequences of playing it safe.
He turned back and said, "Tell the lab to run blood cultures and a pregnancy test. Get me six platelet packs, two units of fresh frozen plasma, and ten bags of cryoprecipitate. We're going to treat her for severe DIC. Get an IV in her arm. Jackie-"
He could see that she was surprised, but ready.
"Give her ten thousand units of heparin IV, and hang a drip at a thousand units per hour."
Mary, the recording nurse, lowered her clipboard and stared at him. "You're going to give her a blood thinner? When she's already bleeding?"
"She's bleeding because she's clotting" Monks said. "If we don't break that cycle, she's dead."
"Are you sure it's DIC, Doctor?"
Monks's temper jumped another notch toward the snapping point. "I'm not sure of anything, except that we've got minutes. Everybody get moving, please"
Jackie, stable, competent, and obedient, was already taking out a vial of the clear heparin and drawing it up. But she looked worried, too.
She had a right to be. It was a very long shot. If Monks was correct about the DIC, Eden Hale was probably going to die anyway.
If he was wrong, the heparin might kill her.
Monks pushed down hard with the heels of his hands on Eden Hale's sternum, five times, at one-second intervals. Then he leaned close to her face, his head turned to the side and his ear to her lips, listening for a sound of life. He straightened up and stared at the monitors, willing a miracle. He had been doing this for fifteen minutes. CPR was like running a race, a desperate physical effort to stay ahead of the enemy, death.
Finally, he admitted that he had lost. He stepped back, shoulders sagging with fatigue.
"All right," he said. "We'll stop now."
In fact, it had been all over for at least the last five minutes. The nurses knew it, and were quietly tidying up. Their body language said it all.
"What time are you pronouncing her, Doctor?" Mary Helfert said. She was stiff, all business, holding her clipboard like a shield. Her body language was unmistakable, too. She did not approve of his decision to use heparin.
Monks looked at his watch. 'Tour forty-three a.m.," he said. "I can't sign a death certificate. The DIC killed her, but I don't know what caused that."
"Will this be a medical examiner's case?"
He nodded. The death fit several criteria that automatically put it in the city's jurisdiction for autopsy. It was unexpected, and she was young and healthy.
"Keep trying to find the family, and have them notified," Monks said. This was usually done by contacting local police or sheriffs and having them send an officer to the house. It was considered more humane than a phone call from a hospital. "And call Dr. D'Anton's clinic as soon as it opens." Any history that D' Anton might have been able to give them was academic now, and probably would not have helped anyway. But he might know how to contact the family, and he should be informed.
The recent surgery was one more criterion that made Eden Hale a city ME's case. The possibility remained that the DIC had been caused by surgical infection.
Monks walked out of the cubicle, washed, and went to the ER physicians' room.
They had come close to saving her. The heparin had started to dissolve the clotting, and her circulation had started flowing properly again – but by then it was just too late. Weakened by the long lack of blood and God knew what else, her heart had stopped. The coroner's report would help them fill in the blanks.
Monks hated to lose a patient, and hated like hell to lose one who was essentially healthy – hated the helpless anger at not being certain what was wrong. It was like being sniped at by an enemy he could not see.
What had come in from Lab and X Ray so far had confirmed what he already knew or guessed. Her hemoglobin was very, very low, at 3.7 grams per deciliter. Normal ran at about 15. The platelet count was 2,880, with normal upwards of 150,000. The coagulation panel showed prolonged PT and PTT. All of which meant that she had almost no blood, and what she did have wasn't clotting. Her urine was dark orange, 4+ for blood, negative for white cells. That was a reasonably sure indication that she did not have a urinary tract infection as the source of the DIC. The X rays showed nothing unusual except the two whitish circles of the breast implants.
Monks looked again at the material the paramedics had found in her purse, from the clinic of Dr. D. Welles D'Anton – a discharge form from the surgery, and a glossy informational pamphlet. Its cover featured a stunningly beautiful woman, smiling in invitation to the world of glamour. Several pages of text, with drawings, briefly described available procedures. The back flap showed a photo of D'Anton himself. He had a handsome patrician head and a confident stare.
D' Anton – pronounced Dan-ton, and heaven help the fool who said it wrong in his presence – had spent some fifteen years developing a reputation as a miracle worker for models, actresses, and socialites. They came from all over the globe to his luxury San Francisco clinic, to be transformed by him.
And D'Anton had graced Mercy Hospital by making it his venue of choice for more extensive procedures. He contributed generously to the hospital and had helped to fit out a top-flight reconstructive surgery unit that brought in a lot of money and prestige.
Apparently, Eden Hale had been one of his devotees.
Monks lingered in the physicians' room a minute longer, wishing to Christ he could pack it up and go home. But his shift was not over until seven a.m. He walked back out to the triage desk to take the next case in line, acutely aware of the closed curtain of the trauma cubicle where Eden 's body would lie until the morgue attendants came to get her.