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Snakes in Memphis

Snakes in Memphis

In the past twenty years, several fields of medicine have emerged to the forefront as research has catapulted them to the top. Others have remained stagnant, still others have fallen. Within the week, I had an encounter with a local emergency room physician which opened my eyes to the ineptitude of the healthcare system, especially the emergency departments in the Memphis area.

D.D. is a forty-four-year-old male who complained of abdominal pain for two weeks; Classic right upper quadrant pain associated with gallbladder disease. He was in some extremis, but not to the point of being toxic by any measure. D.D. has a high pain threshold which makes diagnosing the severity of illness based on clinical signs difficult.

One of our nursing staff evaluated him and sent him for an ultrasound of his gallbladder. As anticipated, his gallbladder was filled with stones and retracted, essentially scarred down and non-functional. But, a scarred-down, non-functional gallbladder does not cause pain, only an inflamed, scarred-down, non-functional gallbladder does. When my nurse revealed D.D.’s ultrasound findings, I ordered blood testing to discern the presence or absence of pancreatitis, a complication of gallstones. His test results were positive for pancreatitis (high amylase and lipase levels).

Over the course of his two-week gallbladder inflammation, the pain had diminished a bit because he took doxycycline (antibiotic) he had in the pantry. His self-directed treatment helped. Nonetheless, he needed to have his gallbladder removed. We tried to get him into two different surgery offices for an acute evaluation, but no one would see him because they were too busy. What is odd about this story is that in Canada, under their socialized health service, he would have had surgery immediately to reduce the chance of complications, reducing the risk of higher cost of care. However, no surgical office would even accept him for an urgent evaluation. Their response was the same in both circumstances: send him to the emergency room for an evaluation.

What people reading this blog may or may not know was I trained for three years in emergency medicine at the University of Cincinnati before I did fellowship training in medical toxicology and clinical pharmacology. I worked for seventeen years in emergency medical departments including the Med’s. I was the founding chairperson of the Department of Emergency Medicine, University of Tennessee, Memphis, College of Medicine. I know an emergency when I see one. D.D.’s condition was an emergency as far as I was concerned. But, our local surgical associates were too busy to handle an emergency. Off to the emergency room he went. I called the attending physician in the emergency department at a local for-profit hospital and presented his case to him. He sounded a bit stressed but realized that D.D. needed to come to his place for definitive care. There is no such thing as a direct admission into the hospital anymore.

After several hours, D.D. contacted me while he was in the emergency department. His evaluation had ended, he was being discharged without being evaluated by a surgeon, and D.D. said the emergency physician was running around the emergency department like a chicken with his head cut off. I was disturbed that a surgeon had not seen him since he had cholecystitis with the complication of pancreatitis. I had never heard of an emergency case being discharged home to get through it on his own. I told D.D. he had to come to our office in the morning to get intravenous antibiotics and re-evaluations. I would care for him until a surgeon could see and evaluate him for urgent removal of his gall bladder. He said, “Thank you.”

After speaking to D.D., I received a call from the emergency physician caring for him. I had spoken to him earlier. The physician was a little timid on the phone. “Doctor, I am sorry. I couldn’t do what you wanted. I am sending your patient home. He has a little pancreatitis and some gallbladder disease. I ran it by the surgeon and he said your patient just needs to follow-up with you. The surgeon-on-call did not feel your patient was sick enough to have his gallbladder removed now.” I was surprised, “Well. That’s strange. How can he have just a little pancreatitis? He has it or he doesn’t. That’s a bad sign.” I paused a moment, “How long have you been practicing?” The physician said, “Twenty-five years.” I asked, “Where did you get your residency in emergency medicine?” He responded, “I didn’t. I did a family practice residency at University of Tennessee.” Then, he said, “Your name is familiar to me.” I responded, “I ran the Med’s emergency room for several years. Left in 1997.” He replied, “I was a medical school student then. I did an emergency medicine rotation at the Med.”

I then asked him, “Is your malpractice insurance paid up?” He laughed and said, “Yes.” I replied, “You’re gonna need it. You really don’t know what you’re doing. He’s sick. Did you ask the surgeon to see him in the emergency department?” The physician replied, “Nope.” I replied, “Double your malpractice insurance. This is your lucky day. I’m gonna take care of D.D., and make sure his condition does not deteriorate. I’ll see him every day and give him IV antibiotics to keep him from getting septic. I’ll make sure he does as well as possible since you dropped the ball. How’s that sound?” The physician on the other end of the phone was silent. Then, he spoke, “I’m sorry I didn’t do what you wanted this time. Maybe next time.” I laughed, “This isn’t about me. It’s about D.D. We’re physicians. It’s about our patients. If I were you, I’d find something else to do. You’re not fit to be in the emergency room. Good luck.” He replied, “Thank you.”

I saw D.D. on the day of the ice storm. He was in pain and tender in his right upper quadrant. No surgical office was open. I gave him intravenous fluids and antibiotics. I instructed him about what to do in case his condition suddenly degenerated. He is going to come to my office every day until we get him stable and ready for surgery.

The healthcare system is badly broken. This is not the first time I have encountered incompetent physicians in the emergency departments at local hospitals. It is getting worse. This family practice physician has no business working in an emergency department in an urban setting like Memphis. He would be better suited for Alaska or rural Maine because those regions have no physicians and any physician is better than no physician at all. But in Memphis, we have hospital systems that are massive. They should have the most skilled physicians in the emergency departments, not the least skilled. I believe he thought the patient was not that ill so he blew off his pancreatitis as just “a little.” That is tantamount to telling a woman is “a little pregnant.” You either are or are not. Little is not a descriptor of acute illness.

I am thinking of getting a tee shirt made that says, “Don’t Get Sick in Memphis.” Do not get me wrong, there are some excellent physicians in Memphis. I refer to them all the time. But remember, only the mongoose can smell the breath of the snake. And there are a bunch of snakes in the Memphis area. You know what I mean.

Doc

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