Neil McMahon - To The Bone

Monks started working his way free. He was losing blood – could feel the wetness down the side of his face and neck, seeping from his back, and below his waist into his pants. He was already weak and getting weaker fast. The canvas had him wrapped tight as a cocoon, with no end or opening. It was like fighting some giant soft thing that patiently absorbed his struggles, flexing but never giving ground.

Finally, his groping hands found an edge. He wormed his head and shoulders under it, forearms pushing the weight away, feet scrabbling wearily on the floor as if he were climbing a hill of loose sand.

When he got his head free, he could see that the attacker was lying on his side facing Monks, motionless, curled into himself. There were more expanding patches of blood on his shirt. His face was contorted with pain and rage, but Monks recognized him instantly:

Todd Peploe, the clinic's maintenance man.

His hair and forehead were smeared with blood, too, but that, Monks knew already, was not Todd's. It had come from Julia D'Anton, when Todd had worn her bloody scalp like a wig, to lure Monks in.

The following Monday morning at seven, Mercy Hospital Emergency Room's monthly Quality Assurance committee meeting was starting. The conference room was unusually crowded. In fact, it was packed. All the thirty-some seats were taken, and there were more people in the hall. The air was filled with a low buzz of talk.

Monks had gotten there early and found a chair near the back. He was moving very carefully and stiffly because of his wounds. None of the scalpel slashes had been deep, thanks, in part, to the canvas tarp that had enwrapped him. But they had required a total of 173 stitches. He felt like Frankenstein's monster, his torso a tight sack stuffed full of flesh that the wrong twitch could pop open, ripping a seam like a zipper. The cuts hurt like hell, too, and he was almost salivating with anticipation of an afternoon feast of Percocet and vodka.

But not yet. He was staying clearheaded for this meeting. This was where judgment of his treatment of Eden Hale was going to be rendered by his peers.

He did not know which way it was going to go.

Most of the faces were familiar. Vernon Dickhaut was sitting beside him, and all the other ER docs who were not on duty were also present, along with Jackie Lukas and Mary Helfert, the nurses who had worked with him on Eden. Roman Kasmarek, the pathologist, was sitting on his other side. Baird Necker, the chief administrator, and Paul Winner, the internist who had criticized him, were there, too, along with several nurses and physicians from other departments. Apparently, the word had spread. This case was not just interesting – it was now tinged with notoriety.

Dick Speidel, the committee chairman, stood up at the head of the long conference table. He was a commanding figure, big and bearlike. The room got quiet.

"I'm sure I don't have to remind anybody that these proceedings are protected from discovery," Speidel said. "I've approved some non-ER personnel who have asked to sit in. But what happens here, stays here.

"We're going to start right off with Dr. Monks's case, because I don't think we have three times the usual number of people just for the coffee and doughnuts." A sprinkling of laughter arose. Monks did not join in. "Committee members have had a chance to look over the material, including my own review. I'll recap it.

"In brief, it's been established beyond doubt that the patient, Eden Hale, died of florid DIC. We're quite sure now that it was caused by ricin – a poison that was deliberately administered to her – but there was no hint of that at the time.

"Dr. Monks's diagnosis was correct, and, by my lights, very astute. He also acted correctly in addressing the DIC with utmost urgency. It was far and away the most serious presenting problem.

"The pathway he chose is a thornier issue. Blood products are the major treatment for DIC. But heparin's clinical boundaries aren't established. There's no definite evidence it would have helped with someone that far gone. It might have helped, and in the circumstances it certainly wasn't unreasonable. He was fully aware that it was a desperate measure, and it probably wouldn't succeed – but it was either that or stand there and watch her die.

"However, there's a case to be made that administering the heparin was an unnecessary procedure, and even inappropriate."

Speidel paused, with a certain amount of dramatic flair, like a jury foreman about to take the poll.

"My own opinion is that the outcome was predictable – the patient was beyond saving when she came in – and that Dr. Monks acted well within the reasonable standard of care," he said. "I'll open this up by asking the other ER physicians if they agree. Gentlemen and ladies, this is not a feel-good encounter session. If you think Dr. Monks performed unacceptably, let him have it."

Monks waited, his sore gut tensed like a prizefighter's, waiting for a punch.

There was a nervous rustling, people rearranging themselves in their seats, recrossing legs, shuffling through their notes.

No one spoke.

"Birds of a feather, sticking together, huh?" Paul Winner said sarcastically.

"And now," Speidel said, without looking at him, "I'll invite comment from other departments."

Winner stood up, too. "Dr. Monks, I know you just went through a traumatic experience. But this happened before that, and we can't just let it slide out of sympathy for you, or because the ER wants to protect its own. Matters like this reflect on the overall reputation of this hospital, and everybody associated with it. I'm sure a lot of people in this room feel the same way."

He surveyed the crowd with stern eyes, waiting for support. Mary Helfert, the nurse who had questioned Monks's use of the blood thinner, raised a tentative hand, and a few of the non-ER physicians nodded uncertainly. But still, no one spoke.

Speidel gave the silence plenty of time before he said, "What's your specific objection, Dr. Winner?"

"My specific objection is pumping a potent drug into somebody when you aren't sure of the consequences. You can't go treating patients like guinea pigs!"

"How would you have handled it?"

"I'm not an ER physician, but-"

"But you feel free to correct those of us who are?" Speidel interrupted.

Winner slammed his hand down on the table. "He's not the kind of doctor we need at this hospital – him and all the muck he finds to roll around in." His forefinger stabbed the air toward Monks. "I don't want you seeing my patients anymore."

"Done," Monks said.

"I'm taking this up with the chief of staff," Winner said. He left the room, pushing his way roughly through the crowded chairs.

"You want to take my next shift for me, Paul?" Vernon Dickhaut called after him. "I'd like to see you take on the Saturday Night Knife and Gun Club."

There was laughter again, longer and louder.

This time, Monks smiled, too.

Baird Necker was waiting for Monks outside in the hall.

"All right, I should have backed you up," Baird said. "I feel like shit. That's my apology. I don't expect you to accept it."

"I think Paul Winner's right, Baird. I'm not the kind of doc you need around here."

'Tuck him. He's adequate, and he'll be retiring soon. Those are the two best things I can say about him." He clapped Monks on the shoulder and started walking toward the elevator. "Except for all the publicity you can't seem to help attracting, we've come out of it fine. Come on upstairs, I need a smoke."

"I don't think you heard me," Monks said, not moving. "I'm tendering my resignation. I haven't had time to write the letter yet, but I'll get to it in the next couple of days."