To The Bone

Chapter 14

Monks arrived back at Mercy Hospital before eight o'clock the next morning. He had slept poorly – had lain awake beside Martine for a long time after making love, finally dozing a little. But the memory tapes had kept playing in his head, and he was wide awake by six. He had gotten up, showered and shaved, and driven to the city.

He stopped first at the Emergency Room to check for messages. There were two. One, a hand-scrawled note from Roman Kasmarek, just said, "Stop by."

The second was an official hospital message, typed by a clerk and computer-printed: "Dr. D' Anton wishes to extend the courtesy of examining the records of Eden Hale. Please call at your convenience."

Monks rolled the paper up and tapped it against his thigh as he walked down to the morgue. There were such things as changes of heart, but by and large they made him suspicious.

The hospital's cafeteria food was good and usually tempted Monks, but this morning he settled for a scoop of scrambled eggs and toast. He and Roman found a table in a corner. The place was busy, filled with staff in different colored uniforms and a few visitors who were early, or who had spent an anxious night waiting with an ill friend or relative and were not done with their vigils yet.

'The initial tox screen is in," Roman said. "And I had a chance to look at the body before the city took her. This isn't all official, but here's what I'm sure of." He held up his forefinger, ticking off points. "She had a relatively high level of Valium in her system, but nowhere near lethal. There's no direct connection to the death." A second finger appeared. "You were right about the DIC. She bled out. That's what killed her."

Monks felt a measure of relief. His diagnosis had been correct.

But there remained the question of his treatment. "What caused the DIC?"

Roman's ring finger rose to join the other two. "I saw no evidence of surgical infection. No pregnancy, no obvious signs of trauma, carcinoma, any of the other usual causes. It's possible they'll turn up on autopsy, but I doubt it. But there was an infection. We found salmonella in her bloodstream."

"Salmonella," Monks said, laying down his fork. "Salmonella doesn't cause blood clotting. Just the opposite."

Heads at nearby tables turned toward them. Monks lowered his voice.

"She might have had salmonella, but I can't believe that's what did it," he said.

Roman's hand opened, palm out, for patience. "Take it easy, Carroll. I'm just telling you what the tests show."

"Have you ever known salmonella to act like that?"

"Not the common stuff, enteritidis" Roman said. "Which is what this is, or at least what it looked like. There are other kinds."

"You're sure it's not typhoid?" Monks said. "I thought about that." Typhoid fever was caused by a type of salmonella, and he feared that he might have missed it after all.

"Almost positive. I'm doing cultures, so we can verify it. But there are no other indications of typhoid, and it doesn't fit with the DIC."

Monks waited.

"But we've got to keep in mind, there are new strains of everything cropping up all the time," Roman said. "It's possible that this is some form of salmonella that looks like the regular thing, but has a much more severe effect."

"Do you really buy that?"

Roman shook his head. "I'm stumped," he admitted. "Maybe some other factor. Maybe a preexisting condition that's not obvious."

"I'm going to look at her records today," Monks said. But he doubted that D'Anton would have missed something like that.

"There's only one other thing I can think of that might have had that general effect," Roman said. "Some kind of toxic substance."

Monks focused a click. Toxins had been listed as a possible cause of DIC, but he hadn't given it much thought. So soon after the surgery, Eden would have eaten little or nothing.

"Such as?" Monks said.

"I thought about a contaminated drug."

So had Monks. "Everything the paramedics brought in was prescription, or looked that way," he said. "Pharmaceutically stamped pills." A bad batch was possible but highly unlikely. She might have taken something homemade. But both men were very familiar with the effects of street drugs, including those cut with dangerous fillers, like strychnine in heroin. And anything common would have shown up on the tox screen.

"What else?" Monks said.

"Not something you'd find around the house. I'd recognize anything from cleaning fluids to rat poison. Maybe in agriculture, or industry. She wasn't involved in anything like that, was she?"

Monks felt the insane urge to laugh. "Industry, but not that kind."

"What do you mean?"

"She was an adult film actress. Look, she was recovering from surgery. She'd have gone straight home from the clinic. She wouldn't have been out wandering around."

"Any indications that she was suicidal?"

Monks had never spoken with Eden Hale, never seen her really alive. There might have been a dark, despairing side to her. But it didn't jibe with what he knew, and it didn't seem to follow that a woman who had just gone through an expensive, painful treatment to become more beautiful would want to kill herself immediately afterward. Particularly in a protracted, agonizing way.

"No," he said. "Not yet, anyway."

"Well, I'm afraid that's not much help," Roman said. "I can run more tests or request the city coroner to. But it's tough when I don't know what I'm looking for."

"You think anything will turn up on the autopsy?"

"It'll bear out the DIC, Carroll. But I wouldn't hang too much on anything more." Roman hesitated, then said, "Just on the off chance it did turn out to be some particularly virulent strain of salmonella, was your treatment consistent with that?"

Monks pushed his plate away and leaned his elbows on the table, pressing the heels of his hands into his eyes.

'The initial phase was," he said. "Somebody comes in dehydrated and bleeding in an unknown location, you start by replacing fluid volume, then blood. Next step is to locate the source of the bleeding and treat that – if you can. That's where I diverged."

"Diverged how?"

"There was no way to treat it, except to try to break up the clotting. I gave her heparin."

"Seems reasonable to me," Roman said.

"If you look at it that way, yes. But going by the book – about the last thing you want to do with something like salmonella is thin the blood."

Monks took the elevator up to Baird Necker's office. This time he was uninvited.

His mind was stepping up its analysis, reviewing what he knew, eliminating some possibilities and considering others further. It was a little more satisfying with the new information, although still frustrating as hell.

Salmonella was a bacteria, a prime cause of what was generically called food poisoning. There were several exotic strains and modes of infection, but by far the most common cases seen in the States came from ingesting tainted food. Poultry was a major carrier.

Salmonella didn't cause clotting, but the opposite – if it was advanced enough, there was copious intestinal bleeding, discharged via characteristic bouts of bloody diarrhea. Usually there wasn't much that could be done, beyond replacing fluids and blood, and keeping the patient stable until the attack ran its course. With proper treatment, the disease was rarely fatal.

In short, if he had not given Eden Hale the heparin, he would be safely off the hook now. She would have died anyway, and the cause of the DIC might remain forever a mystery. But no one would be able to point a finger at Monks and accuse him of doing the wrong thing.

It was futile to think about whether he could have stood there and let her go, without trying something. That way lay madness.

But he had seen plenty of salmonella, and whether this was some new super mutant or the plain old garden variety, he still couldn't believe it was responsible. Something else, some terrible unseen pump inside her, had driven all her bloodstream's clotting factors into the smaller vessels, leaving the larger ones to bleed unchecked.

He thought about what Roman had said. His mind turned the word toxin over and over. But how the hell would she have gotten into something that virulent, and rare enough that it wouldn't show up on the tox screen, or be recognized by a highly experienced pathologist?

He had to admit: if he was looking at himself objectively, he would have seen a man clutching at straws.

"There's a new wrinkle," Monks said to Baird, and told him about the conversation with Roman.

"Salmonella, huh?" Baird said. "I wouldn't think she'd have been hungry, that soon after surgery."

"It only takes a taste. She probably wasn't thinking too clearly, with the Valium. Maybe she nibbled at something, chicken salad from a deli that she'd kept too long. Maybe her boyfriend will know. Did you know he was supposed to stay with her at least twenty-four hours, but he left her alone?"

"He seems like a putz, no argument there. But that doesn't have anything to do with us. This is escalating, Carroll. The young lady's mother and father were here yesterday. They're stunned. They didn't even know she was having the breast surgery."

Monks felt another heavy brick settle onto the load. He had a troubled son of his own, last heard of living on the streets of Seattle. But so far, no one had called on Monks to tell him that his child had died in a hospital far from home and family.

"I got the pretty clear sense that they're not going to make things easy," Baird said. "I told them there were complications that haven't been identified yet. Her father got seriously pissed off. They more or less walked out."

"I could explain it to them more clearly."

"I don't think that would do any good. By the way, one of your nurses has also commented that she didn't think the heparin was appropriate. She says she questioned it at the time."

"With all due respect to Mary Helfert," Monks said, "she's not a physician, and she's certainly not qualified to provide an emergency diagnosis. She didn't know what DIC was."

"It's another thing that doesn't help," Baird said. "I'm starting to look at damage control. If it comes to that, I hope you'll cooperate."

"Meaning, stand still and take the blame?"

"Nobody said anything about blame. But if we had to settle out."

"Before we start convicting, Baird, let's wait till the jury's in. Autopsy, final lab, and tox screen. Her history, any preexisting conditions. And there's still a possibility that this is related to the surgery."

Baird looked away, drumming his fingers on his desk. "D'Anton called me again – told me you went by his clinic. I wish you hadn't done that."

"Why the hell not? Physicians consult with each other when they're treating the same patient. Besides which, the surgery's going to be examined in the postmortem. It's not like there's any secret involved."

"I don't want to bring him into this."

A sour taste rose in Monks's mouth. "An ER doc is expendable," he said. "But not your golden boy – cash cow plastic surgeon?"

"I've got to think of the hospital, Carroll. He's world famous."

'There doesn't seem to be any doubt in anybody's mind about that. Especially his."

"He's bringing in millions of dollars' worth of business to this place. Which helps cover what the ER loses."

Monks's eyes widened in outrage. "The ER's in the business of healing the sick. Not scheduled elective surgery."

"Knock off the self-righteous bullshit. Are you telling me reconstructive surgery's not important?"

"I have all the respect in the world for reconstructive surgeons," Monks said. "But D'Anton caters to rich women's vanity. Period."

"People are entitled to any kind of health care that makes them feel good."

"As long as they can pay for it?"

"This hospital cannot operate as a charity," Baird said, speaking the words one angry syllable at a time. It was a line Monks had heard him say many times.

"Not to mention the fact that the ER provides sixty percent of all admissions, plus lab and other spin-offs," Monks said. "Which makes it possible for this hospital to survive, no matter what your bean-counter computer programs say."

"If they come in electively, they pay for what they get." Baird's forefinger jabbed at Monks's chest, an imaginary skewer. "But in the ER, we've got to take them whether they pay or not. So a lot of the time, they don't."

"We should start letting them die in the streets? Have the feds and the state close us down?"

There was a pause. Monks realized that they had both almost been shouting.

Baird pushed his chair back and stood up. "Let's cool off. This isn't doing either of us any good."

Several responses flashed through Monks's mind, but they all rang of adolescent bluster. Baird was right – this was not doing any good.

He left without speaking, went outside, and leaned against the building in the shade. It occurred to him that a red beer would taste just fine. He heaved himself off the wall and started walking to a bar called Charley's, just two short blocks away.

Charley's was an old-fashioned tavern, a long narrow room with a scarred bar, a burger grill, and worn vinyl booths. It was quiet, dark, inviting, the kind of place where you could easily spend a day or three.

But by the time he was inside, Monks had calmed down. There was too much going on. He could not afford a dull mind. He got a club soda and took it to a booth at the back.

He tried to decide which was justified – his anger at being sold down the river, the queasy feeling that he might, in fact, have mishandled the incident – or the even queasier one that a slick attorney could make it look like he had. He started assessing potential targets of liability.

First, chronologically, came D'Anton. But Roman had ruled out a surgical infection. The possibility of some other condition that D' Anton had not checked for, or had ignored, was not likely.

D' Anton had given Eden the Valium. It had probably factored in, by keeping her sedated – she might have called for help earlier, otherwise. But there was no direct connection to the death. His prescription was within reasonable limits, and it was not his responsibility to see that the drugs were used properly after she left the clinic.

Unless something damning turned up in the records or the autopsy, D' Anton was in the clear.

Next came Ray Dreyer, the fiancé. He had agreed to care for her for twenty-four hours after the surgery. But he was not a professional, not operating under any license or bonding. He might be liable to some degree, but on a personal level.

Then there was Monks.

For lawyers, the issue was clear. When someone undergoing medical treatment was injured or died, someone else was to blame. The simple rule for malpractice went: there had to be negligence, there had to be injury, and the negligence had to have caused or contributed to the injury.

Assuming that the DIC was, in fact, the cause of death, Monks was also in the clear legally. Nothing he'd done had contributed to that.

But if a procedure was seen as questionable or simply unnecessary – such as administering the heparin – that was still sufficient grounds for an attorney to file a deep-pockets lawsuit, in the hopes that the hospital would settle out, for a hefty sum.

And Monks's name would be entered in a national registry of physicians who had tacitly admitted to negligence – tarred forever by that brush.

He walked back inside to a house phone and put out a page for Dick Speidel, the chairman of the Emergency Room's Quality Assurance committee.

Monks was in luck – Dick Speidel answered the page. Speidel was also an ER doc, so he didn't keep regular hours, and he wasn't on shift today. But he acted as liaison between the emergency group – a self-contained corporation that contracted with Mercy Hospital – and the hospital's administration, so he tended to be around quite a bit on business.

Monks met him in front of the ER's main entrance. Speidel was about Monks's age, a big bearlike man with thick dark hair and kind, cynical eyes. Like most longtime emergency personnel, he was under no illusions about textbook situations versus bloody, desperate, real ones.

"I need to make it clear, I'm speaking to you in your capacity as QA chair," Monks said. This made the conversation official business: the information exchanged was not available to any outsider, except by subpoena.

Speidel's eyebrows rose. "Nuclear secrets? Terrorist attacks?"

"I've got a Death Review coming up."

Speidel nodded. Word had already gotten around.

The hospital's Quality Assurance system, QA for short, reviewed all internal mishaps and mistakes, from medical errors to people slipping and falling. Everything that happened under its auspices was undiscoverable by the courts – its privacy was protected, including, especially, from lawyers. All personnel, from the chief of staff on down through janitorial, were under a strict injunction of confidentiality. Bribery and ratting did happen, but not often. This maintained rigorous honesty without vulnerability; it was the hospital's method of self-policing and self-educating. Like all systems, it had its flaws, but in Monks's experience, it worked remarkably well.

Eden Hale's Death Review was going through the QA system's standard channels. It was clearly the Emergency Room's case, and up to the ER committee's chair, Speidel, to assign another, nontreating ER physician – not Monks – to review it. The Medical Records department would provide all pertinent information. That physician would then fill out a form, answering three questions: Given the circumstances, was the outcome predictable? Was the treatment within the standard of care? Does this case need review by the full QA committee?

Monks wanted to know what his peers thought – what they would have done in his place; whether he was justified or damned.

"I'd like you to expedite the review, Dick," Monks said. "If it does go to committee, to do it this month instead of next."

Speidel frowned. "That's next Monday, Carroll."

"I know it's a lot to ask."

"Are you kidding? Most guys would put it off indefinitely and hope it went away. I just meant I'm not sure if I have time. I haven't even assigned it yet."

"If I screwed up, I want to know it," Monks said. "The hospital ought to know it, too. There are rumblings about litigation."

Speidel gazed off at the ocean. Monks knew that as liaison and QA chair, he would be acutely concerned about any situation that might reflect badly on the ER.

"All right," Speidel said. "If you don't have any objections, I'll do the initial review myself."

"That's more than fine with me."

"I'll let you know tomorrow morning."

Speidel went back inside. Monks stayed there for a minute, deciding what to do next. A distant fog bank was forming on the horizon, like a mirage. It offered a teasing promise of cooler air. That would be a blessing.

Ray Dreyer's phone number wasn't listed. But he had logged in at the ER desk yesterday. Monks coaxed the charge nurse into looking up his address and phone.

It was almost nine a.m. now, but he was reasonably sure that Dreyer was not an eight-to-fiver. If anything, the call might wake him up.

After four rings, a digital voice answered. "The person you are calling is not available right now-" It seemed that Dreyer wanted to stay anonymous.

Monks waited for the beep, then said, "Mr. Dreyer, this is Dr. Monks. I attended Eden Hale-"

The phone clicked, and a male voice said, "Yeah, I remember."

So Dreyer was screening calls, too. His tone made it clear that he was not feeling any friendlier. Monks decided to forget about social graces and get right to it.

"It turns out that Eden had salmonella in her bloodstream. Food poisoning. Any ideas how she might have gotten that?"

"Hey, I don't know what she ate," Dreyer said. "She had stuff in the refrigerator."

"You didn't stop anyplace after the clinic? A deli, takeout?"

"Uh-uh. We went straight back to her apartment."

"Did Eden keep anything around, like chemicals?"

Dreyer's tone turned wary, probably from worry about recreational drugs. "What kind of chemicals?"

"Insecticides?" Monks said. "Photography equipment, heavy-duty cleaning fluids?"

Dreyer laughed thinly. "She never cleaned anything in her life, except when she took a bath. There's about five tons of makeup, if that counts."

It was a tender sentiment for a lost love.

"What about drugs?" Monks said. "This is just between us. Did she take anything besides the Valium the doctor gave her?"

"No way, man. All she wanted to do was crash."

And so she had, Monks thought.

"Okay, thanks," he said. "We're still working on this."

"So am I," Dreyer said mysteriously.

Monks hung up, walked back out to his battered Bronco, and drove to D'Anton's clinic.