To The Bone

by Neil Mcmahon

  "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.

  Chapter 2

  Just after seven a.m., Dr. D. Welles D'Anton looked over notes for his first consultation of the day. The patient's name was Lucia Canter. She was new to the clinic. She was forty-three and recently divorced from a husband who had left her for a young trophy wife. Lucia had been born rich and had come out of her marriage richer still. Her children were almost grown. Now she wanted a new life. D' Anton stepped briskly into the procedure room where Lucia was waiting. She was standing in a corner, wearing only a loose, open-backed examination gown. Stripped of clothes and makeup, she was nervous, even a little frightened. But her eyes were trusting. D'Anton had long since realized that the more naked and vulnerable women felt beneath his hands, the more they adored him. It was strange but exhilarating, and he used that power confidently.

  "Good morning, my dear," he said, and gestured at the padded table in the center of the room. "Please sit."

  She did, fingers fidgeting at the hem of her short robe, but then leaving it alone. She wanted to please him.

  "Look straight ahead, Lucia," D' Anton said. She obeyed like a schoolgirl, folding her hands in her lap. He pulled up a chair and leaned close to her, studying her face, his manicured fingers tracing its contours. She was attractive, her skin and figure good. She had had the time and money to take care of herself through the years. But her face was on the gaunt side – a little horsey, in fact, and lined by stress.

  D'Anton's words were more tactful. "You're lucky; you have good bones," he murmured. "Yes, we can do you a world of help. The Miriam Elena look, do you think?"

  Her nervous smile widened, almost into a giggle, at the mention of the supermodel's name.

  "I'm afraid nothing could make me look like her," she said.

  "Don't be so sure, Lucia," D'Anton said archly. "After all, I gave her her face." He pulled the skin gently tighter at the corners of her eyes. "A browlift. A bit of AlloDerm here and there. And cheek implants. They'll soften these grooves beside your nose."

  He sat back. "I'll take some facial measurements, then computer-image projections. You'll have several options. Now, you wanted to consider a breast augmentation?"

  She lowered her eyes and nodded. "When I had the children – you know."

  "Of course," he said soothingly. "Let's have a look."

  She reached behind to untie the gown, then lowered it shyly, her eyes still downcast, like a woman unveiling herself for a first-time lover.

  D'Anton studied the pendulous breasts for a moment, quickly deciding on implant type and size. He lifted the nearer one, gauging the condition of the tissue, and felt her shiver slightly. Her lips were parted; her breath quickened, her eyes half closed. He almost smiled. It was a moment he always savored.

  "Very good, Lucia," he said, clasping her hands in both of his. "I'm betting we can make your daughter jealous. Why don't you go ahead and get dressed, and I'll have my staff set you up a schedule."

  D'Anton stepped out into the hall. Then his body jerked slightly, at the abrupt realization that one of his nurses, Phyllis Quires, was waiting for him. She was a squarely built, stolid woman, but she moved with amazing stealth; often he would turn around and find her simply there. He demanded deference, but sometimes she set his teeth on edge.

  "Yes?" he said, in the clipped, brusque tone he used with employees.

  Phyllis did not usually show emotion, but now her face looked pale.r />
  "Doctor, Mercy Hospital just called," she said. "A woman who had breast surgery yesterday, Eden Hale? She died early this morning in their Emergency Room."

  D'Anton's mouth opened as comprehension took hold. His right knee buckled a few inches suddenly, as if he had taken a hard punch to the jaw. His hand fluttered from his side, groping for a wall to brace himself against.

  Phyllis stepped to him quickly and took his other arm.

  "I'm so sorry, Doctor," she said. "It's not fair that something like this should come along and bother you."

  Chapter 3

  You know this as soon as you wake, hours before dawn: that tonight you will find the one who calls you. Stride through the city like a lion, your coat radiant, your teeth swords, your lungs filling with the scent of her sweet perfume, and blood.

  In the closet where you keep your secret things are souvenirs from earlier times, pieces of jewelry that glow in the darkness with the light of the women who wore them. You can feel it in your fingers as you rub them – a little trace left over from that warmth they gave to you. Each piece has a voice, replaying her last words and sounds, music to accompany the film in your head. You like to listen to them one at a time, but sometimes you hold them all together and close your eyes and crouch there in the dark, until they blend into one murmuring song, like wavelets into surf.

  You knew long ago, when you first began, that all women want beauty – but it comes at a cost. Changing their flesh is a start. But getting to the real, deep perfection they secretly crave is something only you can do.

  The first hint of daylight starts to enter the room.

  It's important to make this day look like any other, so you get ready for work. But first, you check to make sure of the other things you're going to need. Scrubs and gown. Latex gloves. Plastic bedding. Plenty of towels.

  A sterile surgical tray, with a selection of scalpels.