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 The Rape of Emergency Medicine Page 1 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- The Rape of Emergency Medicine Page 2 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. The Rape of Emergency Medicine Page 3 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 The Rape of Emergency Medicine Page 4 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 The Rape of Emergency Medicine Page 5 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.