"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."