Friday, June 15, 2012

Fatal Diarrhea

Coris USA, a travel insurer, sent me to see a 35 year-old Argentinean lady with diarrhea at the Beverly Hills Hotel.

When a hotel calls, I always speak to the guest. This allows me to take care of trivia without a visit and intercept problems which a housecall can’t help.

When a travel insurer calls, I never speak to the guest. This has the advantage of earning me money for tasks like replacing forgotten prescriptions, but there’s a downside. I insist on more information if the insurance dispatcher mentions symptoms such as chest pain or paralysis, but diarrhea seemed a no-brainer.

Arriving, I learned that her illness was entering its sixth day: too long to be the ordinary stomach virus. The diarrhea was profuse, and she felt weak and feverish. She had recently taken antibiotics, so I wondered this was Clostridium difficile colitis, a rare consequence of the avalanche of unnecessary antibiotics consumed by humans everywhere including readers of this blog.

Every antibiotic you swallow kills trillions of germs living in your bowel, most of whom are doing no harm. They are immediately replaced by other germs that can grow in the presence of that antibiotic (why would you want that?....). Most bowels don’t harbor C. difficile, but if yours does, antibiotics may convert a small population into a large one, and it produces an irritating toxin that causes diarrhea that can be fatal in debilitated hospital patients. 

Diagnosing Clostridium requires more than suspicion, and there were other obscure possibilities. She needed a thorough evaluation.

Fortunately, Coris USA is a good travel insurer: meaning that it (a) pays me promptly and (b) takes my advice. These sound like unrelated qualities, but I’ve found that good travel insurers do both, bad ones do neither.

I phoned Coris’s Miami office with the news and the name of the doctor I recommended. The dispatcher contacted the main office in Buenos Aires for authorization; it appeared within the hour, and the patient went off. If I were dealing with a bad insurer, authorization would be denied or simply vanish into the void. I might phone back several times to hear that authorization was still pending, and I often sent patients off, warning that they would have to pay up front and try for reimbursement later.

Tests turned up Clostridium difficile, and she began improving after a few days of treatment.

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