"Give me an immediate tox screen, plus a trauma panel," he said. "And give me four units of type-specific or O-negative red cells." The tech scurried away. Giving blood that had not been checked against the patient's own type was risky, but there was no time for a complete cross-match. This woman needed blood, now.
"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?"