To The Bone

Chapter 4

Immediately after his shift ended at seven a.m., Monks walked downstairs to the hospital's basement and through the long corridor to the morgue. This was a different world than the floors above, which had their elements of grimness, to be sure – they were filled with sickness and pain – but were devoted to healing.

This world below belonged to the dead: here, hope had been abandoned. The hall was deserted and sepulchral, like a subway tunnel, with none of the bustle of upstairs. Footsteps gave off faintly sinister echoes. The faded paint on the walls and the chipped floor tiles, intended to be complementary shades of off-white, had merged over the years into a monotone the color of yellowed teeth that no amount of cleansing or repainting could freshen for long.

But research on the dead provided much of the knowledge that healed the living.

Monks pushed open one of the morgue's double doors, gray steel except for small squares of glass at eye level, and stepped inside. The room was barren concrete, with drains in the floor and, along one wall, what looked like a row of giant filing cabinets. Eden Hale was inside one of them.

The pathologist's glassed-in office occupied one corner. Other furnishings included several racks of surgical equipment, sinks, and two stainless-steel tables. On one of these, a pair of bare feet, toes up, faced Monks. A slender man wearing wire-rimmed glasses and surgical barrier gear was bent over the body. He was wielding the implement known as the bread knife, a sixteen-inch blade sharp as any samurai sword, which could literally cut a cadaver in half. This was Dr. Roman Kasmarek, Mercy Hospital's chief pathologist. Roman was usually in the lab before six a.m., examining tissue samples from the day's first surgeries, then starting autopsies as time allowed.

Monks did a quick inventory. The procedure was nearing its end. A scale was weighted with a hanging organ, and a brain was trussed with string and suspended inside a jar of formalin until it was "fixed" – the soft tissue hardened, to keep it from being damaged by handling. There was a slick of blood and fluids around. Roman was neater than most pathologists Monks had known, but it was still messy business.

His longtime assistant, an ageless gray-haired black man, was rinsing the intestines in a sink, preparatory to opening them. His name was Clifford, but he was known in the hospital as Igor, a reference to his hunched shuffle. He was crafty and wise, and for some reason seemed to like Monks. He flashed a sidelong grin that suggested some illicit secret between the two of them.

Roman, absorbed in his dissection, had not yet looked up. Igor moved to tap him on the shoulder but prudently waited until Roman set down the bread knife before getting that close. Monks recalled a legendary nineteenth-century British surgeon who had made his reputation via lightning-quick amputations, with the limb typically hitting the floor in as little as ninety seconds. Since these were performed without anesthesia, the shortening of the patients' agony was a blessing. The downside was, they usually died of sepsis or shock, and the doctor's scalpel tactics were so aggressive that he was prone to severing testicles along with legs. On one stellar occasion, his flashing blade gutted his assistant, and an observer was so horrified that he keeled over with a heart attack. When the patient succumbed, shortly afterward, the mortality rate reached a whopping 300 percent.

Back at the sink, Igor was wielding his own knife. The first smell of sliced intestines, an experience never to be forgotten, reached Monks's nostrils. He stepped into the hall. Roman joined him a minute later. Dabs of Vicks glistened under his nose. It was probably not easy to look sympathetic while dissecting a cadaver, but he managed.

"Is this about the young woman who died?" Roman said.

Monks nodded.

"I'm sorry, Carroll. I know it's tough on you to lose somebody."

"Somebody young and healthy. What happened doesn't make any sense."

"I only know that she was brought in. Not the details."

"She had DIC, Roman."

Roman's eyebrows rose. "Really." DIC was unusual in itself; the designation "young and healthy" made it extremely so.

"I'm sure of it. But I don't have a clue what caused it. Goddammit, the circulatory system of a vital twenty-five-year-old does not just shut down."

"I'm not disagreeing, Carroll," Roman said soothingly. "Any history on her?"

"It's not available yet. She was in good enough condition to have a breast augmentation yesterday."

"Could it have been an infection from that?"

"That was my first thought, and it's possible," Monks said. "But there was nothing apparent."

"Maybe pregnant? Retained dead fetus?"

"Also possible. I ordered up a test. But-" Monks shook his head. "It just didn't have that feel."

"Carcinoma," Roman said. "Bad transfusion reaction. Trauma. Those are the major DIC causes that come to mind. Doesn't seem likely that she'd have had a surgery if there was anything like that going on. Who performed it?"

"D'Anton," Monks said.

"Well, he has a reputation, but not for being sloppy."

"Anything else come to mind?"

"There are fifty or a hundred idiopathic causes for DIC."

Monks grimaced. Idiopathic was medical jargon for unknown/could be anything.

"She's a city ME's case," Monks said. "Would you have time to look her over before they come get her? Check tox screen and lab?"

"I'll do it as soon as we get this one cleaned up."

Monks thanked him and left. Roman would not be able to open the body or take tissue samples – a big hindrance to a thorough investigation. But he had performed thousands of autopsies over twenty years, in San Francisco and adjacent counties. There was not much he had not encountered, and he was very clear-eyed. It was just possible he would spot something that pointed to the DIC's cause.

If not, Monks would have to wait for the medical examiner's findings – a minimum of six weeks, probably more like months – with the possibility that, even then, nothing new would turn up.

He walked back upstairs to the Records library, poured himself a cup of bad urn-brewed coffee, and sat down to do his charts. He was a firm believer in getting the information on paper while it was still fresh in his head, and in noting extensive details. He had worked as an investigator for a malpractice insurance company for more than a decade, reviewing cases where other physicians were being sued and advising the company as to whether to fight it in court or settle out. Time after time, he had encountered situations where another sentence or two on a chart might have made the difference in justifying what a physician had done and why.

But his concentration kept returning to Eden Hale. He gave up on the other charts, went to the hospital's main library, and started looking for information on DIC and heparin. An hour later, he had tapped several sources, but he was not much wiser.

The major causes of DIC were what Roman had named – sepsis, malignancy, trauma, reaction to transfusion, complications of pregnancy, with many other idiopathic possibilities. DIC had a mortality rate of 85 percent. Some findings indicated that heparin might help in small-scale DIC. It had not been shown to help in large-scale DIC. But then, nothing had.

Eden's onset had been massive and fast. It might have gone differently if he had gotten her a few hours earlier.

He was staring at her chart, pondering, when he realized that the name being called on the hospital paging system was his:

"Dr. Monks, please call 5100 immediately."

5100 was a direct line to the office of Mercy's chief administrator, Baird Necker. A summons like this was rare.

Monks went to a house phone and spoke to Baird's secretary, who told him that Baird would like to see him. The word immediately was used again.

Monks packed his charts into his daypack and took the elevator to the sixth floor. It was just after eight a.m.

Baird Necker's secretary greeted Monks cautiously. Necker and Monks respected and even liked each other, with a common interest in keeping the hospital at top performance. But circumstances sometimes made them adversaries, and when Monks showed up here, it was usually because there was trouble.

The secretary picked up her phone, spoke to Baird briefly, and nodded. Monks walked through to the inner office. It was spare and orderly, decorated only with a photo of Baird's wife and children, and several framed certificates hanging on the walls – diplomas, professional affiliations, and an honorable discharge from the Marine Corps.

Baird, bullnecked and crew-cut, was sitting at the desk, reading the schedule of today's meetings and events. A foot-long Tabacalero cigar was laid out with military precision in the desk's left front corner, square to both edges, with a brass dovetail cigar cutter resting beside it. When Baird finished lining out his day, he would go up onto the hospital's roof and light up, then return there many times to relight for a few minutes, until the cigar ended up a soggy stump that he would abandon, with great regret, at quitting time.

"So I walk into my office, and first thing, I get a call from Welles D'Anton," Baird said. "Hot enough to fuck twice. Yelling that we killed a patient of his."

Monks felt his hands tightening – a sign that he was getting seriously annoyed.

"Not only that, we even had the nerve to try to interrupt his beauty sleep," Monks said. "In case he had information that might have helped keep her alive."

"Calm down, Carroll. D' Anton's touchy."

"My nurses and I were frantic trying to save that girl, and I'm supposed to worry about him being touchy?"

"You want to tell me what happened?"

"She came in comatose," Monks said. "No clear reason. Within a few minutes, I recognized a condition called DIC. Widespread clotting that was blocking her circulation. Breaking that up was the only hope of getting fluids in. I tried, but her heart failed – she was just too weak. What caused the DIC, I still don't know."

Baird picked up the cigar, held it for a few seconds, then put it back down, straightening it carefully.

"I also got a call from Paul Winner," Baird said.

"Winner? What the hell does he have to do with this?" Winner was a sixtyish internist, an old-schooler who did not care for ER docs in general, or for Monks in particular. When Winner was starting out, ER medicine as a specialty did not exist; internists and GPs were on call to handle emergency duties. This did not necessarily make for a high level of competence – certainly not by current standards – but he still considered himself highly qualified.

"He heard about the case – heard you treated the girl with heparin," Baird said. "He wanted me to know he thought it was insane, administering a blood thinner to someone who was bleeding out."

Monks remembered that the recording nurse had objected, too – wondered if she knew Winner and had put this bug in his ear.

"Paul Winner wasn't there," Monks said. "And he doesn't deal with situations where somebody's life's on the line. You're right, he'd have done it by the book – never in a million years would he have taken that chance."

"The bottom line is, the chance didn't work, Carroll. Sorry to put it like that."

"But it might have, Baird. It came close. What would you rather, that she didn't even have that?"

"I'd rather not have the situation I'm facing."

Monks put the heels of his hands against his eyes and pressed hard. It felt good and gave the illusion of helping to clear his head.

"Look," Monks said. "There had to be another factor at work, something that was assaulting her overall system."

"But you don't know what?"

"Not yet."

"Any hard evidence of it?"

"No," Monks admitted.

"Will it turn up in the autopsy?"

"I don't know."

Baird slapped a heavy forearm down on the desk, glaring. "What am I supposed to do with that?"

"Remember that I've been doing this a long time. If I don't go by Paul Winner's book, I've got a reason."

"If you'd recognized that mystery cause and treated it," Baird said, "would it have turned out different?"

"I don't think anything could have brought her back from that DIC."

"But it sure would look better, Carroll."

Baird got up, walked to a west-facing window, and stood staring out with hands shoved into his slacks pockets, sport coat hiked up over his wrists. The hospital was located in San Francisco's southwest quadrant, less than a mile from the Pacific shore. Monks could see that there was not a trace of fog; sky and ocean were both pale blue, the horizon indistinguishable. It was going to be another hot day.

"I'm not saying you were wrong," Baird said. "I'm telling you what it could look like to an outsider. Like you followed your hunch, instead of standard procedure."

"She wasn't responding to standard procedure," Monks said. "And it wasn't a hunch. It's what the literature says. And it's what I know in my bones from twenty-five years of practice."

"You know I trust your judgment."

The implication was clear. Not everybody would.

Baird turned back to him with a gaze that was softened, even sympathetic. This disturbed Monks.

"How many shifts did you work this week?" Baird asked.

"Three. Why?"

"Busy as hell, weren't they?"

"They usually are." Monks was puzzled, frustrated by fatigue, unable to grasp where this was going.

Then he got it. Anger rose with a rush of blood to his face.

"You can't be serious, Baird."

"Take it easy. I'm trying to think like a lawyer. If somebody decides to cause trouble about this, we stand to get stomped. Lots of money, bad publicity. On top of everything else, it turns out she was an actress. Not big-time, but the papers are still going to eat it up."

"What happened to that trust in my judgment?"

Baird ignored the question. "Her parents have been notified. They're on their way here from Sacramento."

"I'll be available to talk to them."

"I don't know if that's a good idea or not. But her fiancé's here now, waiting in one of the conference rooms. He wants to talk to you. With a hard-on, in case you're wondering."

"Thanks for the warning."

"Go home and get some sleep."

"I doubt it," Monks said. "I'll have my cell phone. Give me a call if you want to meet." He paused at the doorway. "She did not die because of anything that did or didn't happen in the ER, Baird. She was dying when she came in, and we couldn't reverse it. There's a big difference."

Monks was sure of that, as sure as it was possible for him to be. But he admitted that he would feel a hell of a lot better if he knew what had caused the DIC – knew beyond question that there was no other pathway he could have taken that might have headed off its attack and saved her life.

Passing through the outer office, Monks said to Baird's secretary: "There's someone waiting to see me?"

"Conference room three, Doctor."

He stepped into the hall, trying to brace himself for the encounter. But there was no time. A man was waiting right there, pacing. He was in his early thirties, good-looking, with a deep suntan and dark moussed hair, wearing baggy slacks and a Hawaiian shirt. He seemed ill at ease, carrying himself with a sort of aggressive slouch. His eyes were angry, and it struck Monks that his refusal to wait in the conference room was a statement of defiance. But there was petulance in them, too.

Monks cleared his throat. "Are you here about Eden Hale?"

His gaze snapped swiftly to Monks. "Yeah."

"I'm Dr. Monks."

"Can you tell me – what-the-hell – happened!" The words were spaced apart and emphasized.

Monks's hands tightened again. He made them relax.

"She was in very bad shape when she came in. Mister-"

He hesitated, as if his name was information he was not sure he should release. "Dreyer. Ray."

"I'm very sorry," Monks said. "We did everything we could."

"I leave her home, perfectly fine, then boom, she's dead?"

"You were with her last night?" Monks asked, his interest sharpened.

Dreyer's eyes narrowed warily. It seemed that he did not like answering questions, period. Perhaps with good reason.

"Yeah."

"When did you leave her?"

"I don't know, about seven. I had business."

Eden Hale had been alone when the ambulance got her, at about three-thirty a.m. Dreyer's business had kept him out all night.

"She was all right then?" Monks asked.

"Well, her tits were sore. But yeah. She took some Valium and went to sleep."

"Did you talk to her after that?"

"No. I came back to her apartment this morning. She was gone. The building super told me the ambulance was there. Hey, is this important?"

"It would help if we could pinpoint when the sickness started," Monks said.

"Help how?" Dreyer said, abruptly assertive, as if he was trying to gain back what he had given away. "You done asking questions? Because you still haven't answered mine. What happened to her?"

"The short answer is, I don't know," Monks said wearily. "Maybe the coroner's report will tell us."

"If you'd known what it was, could you have saved her?"

"That's impossible to answer."

"Is it something you should have known?" Dreyer's voice was rising, his chin thrusting forward. "That another doctor would have?"

Monks shook his head. "I'm very sorry," he said again, and turned to go.

"I put years into her career," Dreyer yelled after him. "She was just taking off, and now she's fucking dead."

Monks stopped walking, turned back, and almost gave in to the urge to drop his daypack and punch Dreyer in the face.

Instead, he said, "I hope that business that kept you out all night was important, Ray. Because if she'd gotten to the ER a few hours earlier, she'd have made it."

Dreyer's belligerent stare shifted away – just for a second, but it was enough.

This time, Monks took the stairs, walking the six flights down to ground level with even, unhurried steps – an absurd attempt to regain control of a situation that was rapidly slipping out of hand.