The Rape of Emergency Medicine

310 Pages·1992·0.729 MB·English

by  James Keaney

The Rape
of Emergency Medicine

James Keaney, M.D.

© 2004 by the American Academy of Emergency Medicine
Table of Contents

Prologue..............................................................................1
Chapter One: Steinerman.................................................8
Chapter Two: The Contracts and Their Holders.......13
Chapter Three: Suits and Scrubs....................................25
Chapter Four: Origin of a Species..................................45
Chapter Five: Crips and Bloods......................................54
Chapter Six: The Anderson Syndrome..........................62
Chapter Seven: Caveat Emptor.......................................82
Chapter Eight: Cro-Magnon.........................................99
Chapter Nine: The Quiet Room....................................108
Chapter Ten: The Other Side of Midnight................126
Chapter Eleven: A One Way Ticket to Palookaville.142
Chapter Twelve: Utah...................................................154
Chapter Thirteen: Pinnacle, Inc..................................167
Chapter Fourteen: The Missing Chapter....................187
Chapter Fifteen: Chart Wars.......................................188
Chapter Sixteen: Physicians of a Lesser God.............200
Chapter Seventeen: Mea Culpa.....................................214
Chapter Eighteen: California Dreamin’......................220
Chapter Nineteen: The Empire Strikes Back...............237
Chapter Twenty: The One Hundred and Eighty
Thousand Dollar Pair of Sunglasses...........................246
Chapter Twenty-One: Uncle Hershel’s Visit.............256
Chapter Twenty-Two: The Thousand Year Pyramid..277
Chapter Twenty-Three: Nighttime..............................286
Chapter Twenty-Four: A Modest Proposal.................300
Mahoney’s Commandments of Emergency Medicine..306
To James and Ruth, Jackie and Jeremiah, Robert, Maureen,
Christopher and Peter
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Prologue

“…and the Lord hath taken away” Book of Job

Jenny’s body lay on the pathologist’s slab. Her tall slender frame
belied her mere seven years. It was hard to believe she was so full of
life twenty-four hours ago. It was even harder to believe she was such
a beautiful girl, now that her body was covered with petechiae (pa-
teek-ee-ii), a hideous, red-blue rash.

Petechiae are small, 1 to 3 millimeter, oval-round red spots resem-
bling M & M candies. They represent collections of oxygen-carrying
red blood cells that have escaped their vessel walls and leaked into
the skin. Unlike more benign red rashes, petechiae don’t blanch
when pressed upon.

Jenny’s petechiae were so numerous they coalesced into ecchymotic
(ek-ee-motic) blemishes. Ecchymosis is the medical term for black
and blue marks. Jenny’s body was covered from head to toe with
little purplish lakes surrounded by innumerable satellites of red
spots, sparing only her long blond hair still in a pony tail.

Her mother called the funeral home, but the owner recognized the
infectious disease, and told her there was nothing he could possibly
do for Jenny now. It would have to be a closed casket with her favor-
ite toys on top. Her mother looked at Jenny for the last time, think-
ing how much her daughter looked like she’d been beaten, and in
fact, Jenny had been beaten-not physically, but by organized emer-
gency medicine.

Paul Adkins was the pathologist on call. He was a brilliant, heavy-
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set, midwestern farm boy with huge blue eyes and thinning, sandy-
blond hair, a muscular former fullback at the University of Illinois at
Champaign-Urbana. His loves were biology and the study of disease.
He would have stayed in Boston after medical school and residency
training had it not been for his other loves, the land and what grew
on it.

Not just any land, but Indiana farm land, mid-central Indiana top-
soil, eighteen inches deep and so black one always thought it had
just rained. It was eighteen inches of fertility where the elongated
soybean root, eighteen inches deep itself, enjoyed its finest nurturing
home anywhere in the world. Even the Japanese had no trade barri-
ers against these plump little beans, making the world’s finesse tofu
and bean curd. Adkins was harvesting an early crop of soybeans on
his father’s farm when the call came in. They wanted Jenny autop-
sied as soon as possible.

Adkins liked to view every body before looking at the medical re-
cord. He wanted his own, overall, unbiased impression first. When
Adkins first saw Jenny’s body, he thought the cause of death to be
fulminate Rocky Mountain Spotted Fever. It had been quite some
time since he’d seen a body so completely covered with petechiae
and ecchymosis. Adkins could already see early, black, gangrenous
changes appearing on the tips of Jenny’s nose, fingers, and toes. He
wondered how she’d caught it so late in the season since he himself
hadn’t noticed any ticks on the farm dogs in the past month. Rocky
Mountain Spotted Fever is spread by the bite of a tick, and is ironi-
cally more common in the Midwest than the Rocky Mountains.

Perusing the medical record, he found the diagnosis to be meningi-
tis. This wasn’t surprising since meningitis causes a similar derma-
tologic picture, but with a more rapid demise than Spotted Fever if
not recognized and treated early.
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At the bottom of the medical record, Adkins noticed something
unusual-there were two emergency department charts. Jenny was
seen twice yesterday, within a six hour period, in the emergency
room.

The name on the first chart was all too familiar to Adkins. It was
Doctor Monk. Monk, as everyone called him, had seen Jenny
twenty-four hours earlier. Jenny’s mother had brought her in be-
cause of cold symptoms, fever, vomiting, and because her daughter
“wasn’t acting right.”

Adkins saw where Monk had noted a rigidity to Jenny’s body, a stiff
neck being one of the classic signs of meningitis. He saw where
Monk had even noted a few peculiar red spots on Jenny’s chest.
Petechiae are ominous physical findings in any febrile child, de-
manding an immediate spinal tap and the rapid administration of
intravenous antibiotics.

Surely even Monk knew what petechiae were, and most assuredly,
Monk could not have seen them, noted them on the medical chart,
and not known their significance? Petechiae are red flags waving at
even the most unobservant physician shouting meningitis, and
spreading petechiae in the presence of a fever grab at the physician
demanding intervention.

Meningitis means bacteria growing in the spinal fluid, that rich,
nutritious fluid medium that allows intrusive, unwelcomed bacteria
to proliferate exponentially. In a matter of hours, the crystal-clear,
low-pressure fluid cushioning the brain turns into a turbid, yellow,
pus-filled covering that now circumferentially crushes the brain and
cranial nerves within the prison of the bony skull. If untreated, the
mortality is one hundred per cent, but if recognized and promptly
treated, astute clinical physicians can reduce the mortality to less
than fifteen per cent. Monk, of course, had not picked up on Jenny’s
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stiff neck, sending her home with a cortisone cream for her rash.

Monk would never see the autopsy report. Earlier that day, Pyramid,
Inc., a large emergency medicine physician contract group, called
Monk, telling him of their desperate “manpower need” in LaCrosse.
One of their emergency physicians had suddenly “taken ill,” and the
emergency room wasn’t “covered” tonight. They told Monk to pick
up his tickets at the airport, and they would book the hotel.

Steve Waterbury, the assistant hospital administrator, had tipped off
Pyramid, Inc. that Monk had missed another crucial diagnosis, and
this one might not blow over so easily.
Adkins, who hated both Waterbury and Pyramid, would surely
launch an investigation, and so Norman Lyle, who’d founded Pyra-
mid, Inc. six years ago, took the message himself. He’d become a pro
at this, not trusting his junior staff with this type of delicate situa-
tion, and actually, this philosophy made Lyle a pretty busy man.
Many of the physicians who worked for him had severe problems,
but by contracting with many hospitals in various states, he could
move bad emergency physicians from place to place until the heat
died down. He also thought it best not to tell Monk why he was
moved so often. There was no sense discouraging him, and Lyle,
instead, improved Monk’s morale by telling him he was specifically
chosen to go to new client hospitals.

Monk would fly to LaCrosse, and Walsh, his replacement, would fly
in from Indianapolis. Earlier that week, Walsh was found
unarousable while on emergency duty at a Pyramid client hospital.
The nurses found an empty bottle of scotch in Walsh’s “on call
room.”

Westerly, Jenny’s private family doctor, had recently returned from
vacation. He was a good old southern boy who drove a white, nine-
teen seventy-seven Lincoln Continental still sporting Texas license
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plates. Westerly was a softly-tailored, charming country doctor, a
genteel man with a great big forgiveness pocket who’d been in gen-
eral medical practice for thirty-five years. He’d just found out about
Jenny’s death, but Westerly had seen many people die, and he just
couldn’t understand why Adkins was so angry at that little Monk
boy. After all, people with meningitis die and it’s that simple. He did
wonder why Monk hadn’t at least given Jenny some of the latest
antibiotic samples the Eli Lilly salesman left in the emergency room.
They were free, and it was Monk’s trademark to use anything and
everything new. Monk’s medical professors were the drug salesmen
who promoted their new and expensive medicines, telling of the vast
number of diseases for which their product was indicated. Good
marketing also gave Monk the illusion of being up on the latest
medical developments.

“Maybe Monk was slipping?” thought Westerly, who himself, loved
to dispense and prescribe medications of all kinds-antibiotics, diuret-
ics, tranquilizers, creams, lotions, salves, anything he felt closest to
the patient’s needs or potential needs. He loved the look on patients’
faces when they were being “treated.” They always said “Thank you”
when they had a bottle of penicillin in their hands. Westerly was
certainly no medical nihilist, having never believed in viruses any-
way, or for that matter, any condition for which there was no treat-
ment.

Unfortunately, Doctor Westerly wasn’t a very good diagnostician,
many of his patients coming back with side effects to the unneces-
sary medicines. He would then prescribe new medications for their
treatment-induced illnesses, making his patients even happier the
second time. Patients knew he was brilliant because Westerly was a
talkative doctor who always told them in advance of the specific
possible side effects, and when his patients came down with their
adverse reactions, they were astounded at Doctor Westerly’s accu-
racy. They also felt personally responsible for their side effects be-
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cause Doctor Westerly had told them, “It only happens to one out
of a thousand patients, but you’re such a fine person, I’m sure it
won’t be you.” He loved giving his patients their ointments, and
they loved rubbing them into their drug-induced rashes.

Ironically, Doctor Westerly had learned a great deal of pharmacol-
ogy this way. He was a smart man with an impressive memory, and
were it not for his laziness, he would have been an excellent clinician
as well, but without his vast experience with medical toxicology.

Besides, Westerly enjoyed his reputation, and in fact, local internists
occasionally called him, asking his opinion on various medications
and their side effects. Once he even opened the monthly County
Medical Society meeting with the statement, “I’m not much on di-
agnosis, but I’m Hell on therapy.” Even Adkins found himself roar-
ing with laughter. Between Monk’s misprescribing and Westerly’s
over prescribing, the small Indiana farm town of Dupage had be-
come an unknown proving ground for the Food and Drug Admini-
stration.

Westerly had to go down to the emergency room to comfort Jenny’s
family. He also had to give them antibiotics in case they too had
become colonized with the meningitis-causing bacteria. The bacteria
might be living in their throat or nasal passages since many people
carry pathogenic (capable of producing disease) bacteria even though
they are not clinically ill.

Eradicating an organism in a nonsymptomatic carrier is a form of
prophylaxis. Years ago, Westerly tried to incorporate the work pro-
phylaxis into his working medical vocabulary, but he found it diffi-
cult to pronounce and kept getting it confused with immunization.

Westerly gave Jenny’s family members some medications to take for
a few days, explaining all the possible side effects.
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Westerly, an old-time general practitioner who still “delivered” ba-
bies, was suddenly paged to obstetrics. The nurse midwives usually
waited until the babies were partially delivered before calling Doctor
Westerly since everyone knew it was best if he participated as little as
possible in the procedure. He would arrive just as the head and
shoulders were delivered, put his hand on the nurse’s shoulder and
say, “There,…steady,…a little more to the left,…” and “GOOD,”
when the legs came out. He would then say very loudly, “I couldn’t
ah done better myself,” and both doctor and mother would share a
brief belly laugh. He’d point his finger sternly at the mother, tell her
to rest, take plenty of fluids, eat healthy food, and that he would see
his brand new patient in two weeks for her first immunization shot.
He next prescribed a sleeping pill, told the new mom it might make
her dizzy, nauseous, possibly weak, and then left the hospital.

Driving home that afternoon Westerly marveled at how the size of
his practice never changed. The number of patients through the
years had always remained constant. Jenny was gone, but today the
Lord giveth a new life…and a new patient. There was nothing new
under the summer sun, even in Dupage.