To the Bone

“M
ercy ER, this is Medic Twelve with Code Three traffic.”

The voice, choppy with static and backed by a wailing siren, came over Mercy Hospital's paramedic radio, from an ambulance out on the San Francisco streets. Code Three meant that it was racing toward the hospital as fast as the night allowed.

The Mobile Intensive Care nurse monitoring the radio leaned closer and pressed the talk button on the handset.

“Medic Twelve, this is Mercy ER,” she said. “Go ahead.”

Carroll Monks walked across the Emergency Room and stood beside her, listening.

“Mercy ER, we're bringing you a young white female, age approximately twenty-five. She's unconscious, with almost no blood pressure. She does have a very weak femoral pulse, but no radial pulses. Ah, hold on a second, Mercy.”

Monks heard the driver yell something to his partner in the ambulance's rear. His words and the reply were lost in noise.

The driver's voice came back on. “We haven't been able to start an IV. We can't find any veins. Repeat, she does
not
have an IV running. She has respiratory depression and we are oxygenating her.”

The nurse said, “Medic Twelve, do you have any history on her?”

“Negative, Mercy, not much. She was in an apartment, alone. Looks like she's had a recent surgery, probably her breasts. We found some Valium, but we don't think it's an overdose.”

“Who called her in?”

“She managed to call 911. We got sent by City Triage.”

Monks took the microphone from the nurse, and said, “Any signs of massive bleeding?”

“There's some vomit with blood in it,” the driver rasped through the static. “But not massive.”

“Nothing from the surgery? Other external wounds? Blood around the apartment, or in the bathroom?”

“Negative, Mercy,” the driver said again.

Monks's mind started tracking a flow chart of probabilities, for a young woman who was bleeding badly, with the blood staying inside her. None of them were good.

The nurse watched him questioningly, a look asking if he wanted any more information. He shook his head, giving her instructions as he handed her the microphone.

“Take her directly to the trauma room, Medic Twelve,” she said.

“Roger, Mercy. ETA is six minutes.”

Monks turned back to the ER and the next pressing task—organizing who was going to need to be where, during the next half hour. Screws had been tightening in his head all night, and this had the feel of being the most severe one yet.

It was 3:51, an early Friday morning in July. San Francisco was going through a heat wave, with temperatures that had hovered in the nineties for the past several days. The usual cooling sea breezes and evening fog were gone, driven off the coast by hot winds that swept through the Central Valley like blasts from a furnace. Inland, the thermometer had been topping 110.

But inland, they were used to it. Here, the leaden air and damp armpits and gummy asphalt underfoot were like a sudden sneaky enemy, one that worked just below the level of consciousness. Monks could sense it in faces—tension, friction, as if a layer of social lubrication had been eroded by the heat. People were rubbing too close together, and the ER had been simmering hotter as the hours passed. It was amazing how many human beings were up, about, and in need of medical help, all through the night.

He had just left the bedside of a seventeen-year-old girl who was giving birth to her third baby, a process she had started some twenty minutes earlier in her boyfriend's car. Staff were trying to get her sent to OB, but OB was busy, and the on-call obstetrician was not yet available. It looked like the youngster was going to appear in the ER any minute now.

In the next bed, a fat middle-aged man was doing his best to die of a heart attack. They had shot him full of clot-busting drugs and shocked him back to life three times, but the monitor kept quavering in the danger zone. This was tying up two nurses and the other ER physician on duty. A cardiologist was supposed to be on the way to take him to the Cath Lab, but cardiology was busy, too.

The knife wound in Bed Five was coming around without complications, but during the past minutes, his voice had risen from querulous to strident and he was becoming combative. The SFPD cops who had brought him were gone, back on the streets to deal with their own hot night. Hospital Security would probably have to be called to put him in restraints, but Security had their hands full right now in the lobby. One uniformed officer was moving uneasily among the crowd of at least twenty, while another flanked the desk where the triage nurse worked to separate out the most gravely ill and injured. Many were in pain, most had been waiting a long time, and there was a volatile racial mix of young black and Hispanic males, with girlfriends or wives who looked at least as tough as the men. Monks had been peripherally aware of a lot of restless movement on the other side of the lobby's glass doors—bobbing heads and strutting bodies, a dizzying collage that made him think of a huge, many-limbed beast about to fall into a frenzy and tear itself apart.

And now an ambulance was on its way, bringing a woman in critical condition. At least, Monks thought, this would bring more uniforms. It might help stabilize the tense crowd.

He stepped to the main desk. “Call City Dispatch Center,” he said. “Tell them we're going on diversion.”

Leah Horvitz, the charge nurse, nodded and reached for the phone. Leah was a fiercely competent veteran, uncowed by any situation Monks had ever seen. But even she looked relieved. The ER would now be temporarily closed to any more ambulances bearing the victims of shootings and stabbings, wrecks and rapes, overdoses and organ failure and madness. The staff were already overwhelmed—they could barely handle what they had, and to take on anything more could be dangerous to patients. But it was something Monks had only done rarely, and it left an unpleasant taste. There was the unavoidable sense of letting down the team.

He caught the eye of a magenta-uniformed nurse named Jackie Lukas and motioned her to meet him at the Trauma Room. She was slim, ponytailed, athletically attractive. He knew from experience that he could count on her to stay cool.

“We've got an ambulance coming in five minutes,” he said. “A woman with no blood pressure, and they can't get an IV in her arm. I'm going to put a big tube in her ankle vein.”

“Fourteen-gauge catheter?”

“Make it IV tubing. Sterile unopened package. And a cutdown tray.”

Jackie immediately turned to her work. Monks stepped into the cubicle that housed Bed Seven and the heart attack victim. Vernon Dickhaut, the other ER physician, was at the bedside, looking impatient at being stuck there.

“How is he?” Monks said.

“About the same. The cardiologist's on his way.”

“That's good, Vernon, because I'm going to be out of it for a while. There's a critical coming by ambulance. The ER's all yours.” Vernon was a North Dakota farmboy with lank straw-colored hair, cornflower blue eyes, and an IQ off the charts. He had been bound for a career in surgery, until a residency rotation with Monks had given him a taste for the ER's adrenaline and action. Monks took a certain pride in having corrupted him, and it had paid. A couple of years ago, Vernon would have come close to panicking at taking full charge, but now it was a challenge he savored.

“Don't let anybody die, huh?” Monks said.

Vernon saluted with mock trepidation.

Later, many times, Monks would remember his own words.

 

Monks heard Medic Twelve's siren coming from blocks away. After more than two decades in the ER, that sound still touched him with anticipation tinged with fear, like what a journeyman fighter must feel on hearing the first-round bell. Then it was gone, leaving him heightened and ready.

The siren died, giving way to the rumbling vibration of a large motor, and red lights flashing outside the ER's ambulance entrance. Monks dropped his white coat onto a chair at the nurses' station and walked quickly into Trauma One, a cubicle with operating-room surgical lights overhead and glass-fronted cabinets on both side walls. Jackie Lukas and two other nurses were present. One pulled back the curtain that separated the cubicle from Trauma Two, converting the area to one large space with two empty beds. The other nurse had hung two IV bottles on floor stands and was connecting them to plastic tubing.

Jackie pulled a tray from a cabinet and stripped off the sealed plastic covering. She placed it on a Mayo stand, careful not to touch anything sterile, and gave Monks a packet of rubber gloves, size 7
¹
/2. Monks tore it open and gloved his hands with automatic precision. Then he started selecting and arranging equipment from the cutdown tray. He scissored the end off a three-foot plastic IV tube, angling the cut, then snipping off its sharp point. Jackie took the other end and attached it to an IV bottle.

“Get lab down here right away,” he told the other nurses. “I want a full trauma panel on this woman. I need the hematocrit stat, and we'll want blood. Tell X Ray to bring their portable machine.”

The paramedics were coming in fast, wheeling their stretcher.

“We kept trying to get fluid into her, Doc,” one said. “We couldn't get a vein.”

The woman was still unconscious, covered by a blanket and strapped down, eyes closed and head lolling to one side. Her hair was tawny and disheveled. What Monks could see of her face around the oxygen mask might have been pretty, except that it was ghostly white and drawn with pain. She was slim and shapely, wearing a filmy black bed wrap and panties, an expensive matching outfit. But she also had on a heavy surgical bra, the kind worn by women after breast surgery.

They lifted her quickly onto the trauma bed. Monks pulled open the blanket, fingers going to her throat to try for a pulse. It was near zero, and her breathing was shallow and rapid.

The nurses were already stripping off the wrap and bra. Both of her armpits had bandages taped into place, and there were purple bruises down to the waist on both sides. Her surgery had been very recent—probably a breast enhancement via saline bag, with the bandages covering incisions where an endoscope had been inserted. Everything else Monks saw at first glance was in line with what the paramedics had reported. There were no signs of bleeding from the bandages, or anyplace else external.

“Prep her ankle,” he said, putting on a new pair of sterile gloves.

Jackie poured an iodine solution on the patient's lower leg, from the ankle upward several inches, and scrubbed it with gauze pads. She lifted it while Monks slipped a sterile towel underneath. Then an eye sheet, a drape with a hole in it, went on top of the area. He chose a number-ten scalpel and felt for landmarks—one inch above the ankle bone, and a little toward the front—and cut a one-inch slit completely through the skin. He traded the scalpel for a clamp and inserted its closed end into the fatty tissue, opening the clamp's tip to spread the tissue apart.

The saphenous vein, the size of a thin pencil, was white against white—like her skin, the cut, and the tissue around the vein, bloodless.

A lab tech had come in and was trying to draw blood from a vein in her arm. Monks glanced up at him and said, “You're not going to get anything there, Lab. I'll do a femoral puncture as soon as I'm done with this.”

He quickly isolated the vein, lifting it gently on the clamp to separate it from the surrounding tissue. With a new number-eleven blade, he opened the vein and eased in another clamp two inches toward the knee, stretching the vein enough to accept the beveled end of the IV tube.

“We're in,” he said. “Open it wide.” Just over three minutes had passed since her arrival.

Monks tied the tube in place, took two quick skin stitches to close the incision, and stepped out of the way for Jackie to dress the wound and tape the exposed tube to the leg.

“Pour the fluids to her, ladies, warm saline,” he said to the nurses. “Start her on Narcan, one milliliter, IV. And get a Foley catheter into her bladder. Let's see if she's making urine.”

He moved to her groin and placed his fingers by her pubic bone, feeling for the femoral artery. There was a faint pulse. He wiped the area with an alcohol swab, accepted a syringe, and slid the needle into the artery's pulse. Blood filled the syringe slowly. He gave it to the lab tech.

“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.