To the Bone Read Free

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.
    â€œGive 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.
    â€œHow are we doing?” he asked Jackie.
    â€œBlood 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.
    â€œVery 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.
    â€œThat’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.
    â€œAny ID on her?” he asked.
    â€œThe paramedics found her purse,” Leah said, in