"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."