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Thursday, March 22, 2012

Worry

A guest had stumbled in the shower and thrown out her back. Could I make a visit to determine if she needed hospitalization?

Going to the hospital with back pain is a bad idea; even if the patient is in agony, no doctor will admit her without evidence of nerve damage such as paralysis or inability to urinate. He will order x-rays (worthless for acute back pain, experts agree, but an ER tradition), explain that she will recover in a few days, and prescribe pain medication.

My examination showed no nerve damage, so I explained that she would probably improve in a few days. I handed over pain pills, adding that, while it wasn’t essential, I could give an injection that would help for several hours. She agreed, so I gave it.

From there I drove to the Magic hotel in Hollywood where a Danish couple’s 18 month-old was vomiting. He looked fine, and looking is the most important part of a doctor’s exam: sick children look sick. Nothing abnormal turned up on an exam, so my diagnosis was a common stomach virus. I told the parents it might last a day or two and gave the usual dietary advice.

I check on the day’s patients before going to bed, but the Danish parents beat me to it. The child had vomited once again, they reported. He was still in no distress, so I told them it was OK to wait.

“Not so good,” the lady with the back pain replied when I asked how she was doing. She had been vomiting since the injection, and each vomit hurt her back. That’s an occasional side-effect. I assured her it would pass, but I worried. My assurance to the Danish parents was correct, but patients occasionally deliver unpleasant surprises, so I could not suppress more worry as I went to bed.

The lady’s back pain was no better the following morning, but she wanted to fly home. Could I provide medical clearance? Visits for “medical clearance” are a lucrative perk of hotel doctoring because they involve little more than writing the note. I resisted the temptation, explaining that there’s no medical reason why someone with back pain can’t travel. If she could hobble onto the plane, she should go.

Could I give a “mild” injection so she could move more easily. No such injection exists. I suggested she try the pain medicine. I phoned the Danes to learn that the child hadn’t vomited but was now feverish. This was to be expected, I explained, and I approved their decision to give Tylenol.

Later, the lady reported that the medicine made her nauseated. What should she do? I told her it would pass in a few hours. Should she try to make her plane, she asked. I repeated that rest is not helpful for treating back pain.

The Danish child was still feverish, his parents reported, and now he had diarrhea. I gave dietary advice.

Neither guest answered my call that evening. Both had checked out, I learned from the front desk. I had just returned from seeing a young man with low abdominal pain at the USA Youth Hostel. He was worried about appendicitis; my exam made that unlikely but not impossible. Since he had no health insurance, I did not want to make my life easier by sending him to an emergency room where a workup including CT scans would run to about $5,000. His symptoms hadn’t improved when I called, but it still didn’t seem like appendicitis. He promised to phone if there was any change. I worried as I went to bed but only a little.

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