Sunday, September 29, 2013

Major and Minor Tranquilizers

Guests often ask for something to calm them, and I try to comply by stocking Valium.

Tranquilizers relieve generalized anxiety but not the pain of a terrible event such as a family death. Unhappy victims regularly ask for something to “put me to sleep,” but only general anesthesia does that. Even sleeping pills merely produce drowsiness; if you’re miserable, sleep comes hard.

I give a Valium injection if asked, but I have a low opinion of its tranquilizing properties. Valium pills work better because the more you take, the drowsier you get. The effect of the maximum Valium injection does not impress me. I prefer Thorazine.

Valium and its relatives are minor tranquilizers; the Thorazine family belongs to the major tranquilizers. “Major” and “minor” have nothing to do with strength; they refer to the seriousness of disease. Thorazine helps schizophrenia, a major mental illness. The first of a numerous class of drugs called phenothiazines, its discovery in 1952 marked a huge advance because it calmed schizophrenics enough so many could leave mental hospitals and live on the street, thus saving tax money.

People who deny schizophrenia is a brain disease claim Thorazine works because it makes patients somnolent. In fact, many newer phenothiazines aren’t sedating, but they work as well. Thorazine and its family turn off the positive symptoms of schizophrenia:  hallucinations, delusions, bizarre behavior. Movie schizophrenics seem to enjoy themselves, but hearing a voice inside your head frightens most people even if it’s God.

Despite their dramatic effects, phenothiazines don’t cure schizophrenia because they don’t eliminate the negative symptoms such as apathy, social withdrawal, and self-neglect. Being around a well-behaved schizophrenic remains an uncomfortable experience. Something is missing.

Wednesday, September 25, 2013

A Week's Vacation

Returning from a week’s vacation, I took my phone off call-forwarding. Knowing that I keep detailed records, the colleague who covered E-mailed me the information I needed.

Seven hotels phoned; he made four housecalls and took care of three over the phone.

Universal Assistance, a travel insurer, called once. He asked for their credit card number which they gave, and he made the visit.

World Aid, another travel insurer, called twice but refused to give a credit card, so he refused the calls. I fax my invoices to World Aid which usually pays in a month or two. When they don’t, I phone to remind them. Many hotel doctors hate pestering agencies for payment, so they insist on a credit card.

International Assistance called three times, and he declined as soon as they identified themselves. IA still owes him for visits in years past. International Assistance has a poisonous reputation among hotel doctors because it often took six months to pay when it paid at all. Institutions such as clinics and hospitals can deal with this (state-run Medicaid programs are not much better), but individuals soon give up.

Ironically, my patience with IA has been rewarded. After the latest change of ownership a year ago, it got its act together. It now pays reliably every month and provides a great deal of business, but a long time will pass before it lives down its reputation among my colleagues.

Inn-House Doctors called five times, and he made two visits: one to Hollywood and one to the airport area. A national housecall service, Inn-House serves a few hotels and travel insurers but many airline flight crew. In their eternal search for better hotel rates, airlines have been boarding crew further and further from Los Angeles airport which is twenty miles from my colleague’s home. He declined two visits to Long Beach (45 miles) and one to Anaheim (60 miles).

Thursday, September 19, 2013

It's Just a Stomach Virus

“I’m worried about sunstroke,” said a guest at Maison 140 last week. Her husband was vomiting, and they had returned from a walking tour of Beverly Hills. The temperature was in the 90s.

Sunstroke is life-threatening, and it takes much more than a hot afternoon walk in Los Angeles to bring it on. I’ve never made the diagnosis, but hotel guests worry about it.

“Someone put something into my drink.”

You might think no one outside of a bad movie would say this, but I hear it perhaps once a year. It’s alarming to fall violently ill after a night on the town, and Los Angeles is an exotic locale to many patients, so anything can happen.

“The sushi tasted funny…”

It’s common sense that food your stomach rejects must be noxious, but if you’ve been paying attention you know that using common sense to explain an illness is proof that you don’t know what’s going on.

Food poisoning is not rare, but the responsible toxins are tasteless. Also, infections such as Salmonella are not the result of spoilage but contamination of ordinary food with feces.

It’s impossible to diagnose food poisoning unless more than one person is sick. Almost everyone blames an upset stomach on the previous meal, but it’s most likely a virus. Google “viral gastroenteritis.”

Monday, September 16, 2013

Isn't Science Wonderful: continued

As I wrote last time, doctors treat strep throat with an antibiotic. Does it work?

That seems a no-brainer. After all, antibiotics definitely kill strep. But the answer turns out to be….maybe. In scientific studies, giving antibiotics to patients with strep throat is not dramatically effective. Some doctors suspect they don’t work. This contrasts vividly with treating strep infections in other areas such as the skin where it’s often lifesaving.

“Wait a minute!!” assert experts including my professors in medical school. It’s true that strep throat goes away in three to five days even if not treated, they point out, but doctors must treat in order to prevent rheumatic fever, a disease that can produce devastating heart disease. Scientists don’t understand why, but a small percentage of strep victims go on to develop rheumatic fever. Antibiotics lower the risk.

Are they right? Again science delivers the answer: maybe. Evidence for preventing rheumatic fever in America comes from a study conducted sixty years ago when rheumatic fever was common in the US. It’s rare now. I’ve never seen a case. Everyone agrees it wasn’t a terrific study.

Some doctors believe that rheumatic fever is so rare in the US that giving an antibiotic is more likely to cause harm (yes, antibiotics can cause harm) than benefit.

While it’s fun to make controversial statements in this blog, with patients I stick to the standard of practice. Inevitably, this means I sometimes give treatments whose scientific basis is weak. If you prefer therapy that’s guaranteed, you must stop seeing scientific practitioners like me and seek out alternative or complementary healers. Google “alternative medicine.”  You’ll notice that their treatments always work.

Thursday, September 12, 2013

Isn't Science Wonderful?

“He has pus on his tonsils, so it’s probably strep,” said a guest, calling about her teenage son. I hear this phrase regularly. It causes me some stress because I know that later I might find myself delivering a why-antibiotics-won’t-help explanation to a disappointed audience.  

One popular (i.e. wrong) medical belief is that pus on tonsils is a sign of strep throat. In fact, this is true only ten to twenty percent of the time. Viral infections produce identical exudates.

Arriving in the room, I discovered that the boy had pus on his tonsils but also a fever, swollen, painful glands on his neck, and no cough. Good scientific studies show that the presence of these four signs: pus on tonsils, fever, swollen neck glands, and NO cough raise the odds of strep to over fifty percent, so prescribing an antibiotic is appropriate. I prescribed an antibiotic. The family made it clear they were in the presence of an astute physician who knew what to do. Everyone was happy.

Isn’t science wonderful? The answer is yes. But it’s wonderful in ways that are often not satisfying. More in my next post.

Saturday, September 7, 2013

Today's Visits

My phone rang as I walked into the gym. A guest at the Sunset Plaza wanted a doctor to “check out” her 9 year-old daughter who’d awoken with a fever and vomited once. This was a good call. Multiple vomits can be worrisome, but one is OK. I jumped at the chance to skip my morning exercise.

Sunset Plaza parking is indoors and free, a bonus on a hot day and on the Sunset Strip where street parking is impossible. The daughter was recovering, so I reassured the parents, a pleasure for everyone.

As I returned to my car, the phone rang again. This was a perfect time for a second call. Lunch was two hours away. Late morning traffic is the day’s thinnest. I could thrill the guest by announcing a speedy arrival.

The caller was a national housecall service. The patient was a Quantas flight attendant at the Hilton. While there is a Hilton at Los Angeles airport, this one was in Costa Mesa, 45 miles away. This was not so good, but there were compensations.

As I’ve written, in the old days airlines called me directly, and I billed them directly. No airline does that now. They call a national housecall service which, of course, calls me. I’m happy to work for the service because, being a better marketer, it’s acquired far more airlines, so I receive more calls. It also pays much more. This is possible because it charges airlines triple my former fee. You may wonder why airlines are willing to pay so much more, but I don’t. As someone who follows the news, I’ve long since stopped believing that stupid decisions by people who seem intelligent have a good explanation.  

Tuesday, September 3, 2013

Another Perk of Hotel Doctoring

A travel insurer sent me to a woman complaining of asthma. When I arrived, she admitted that she had a little wheezing. She didn’t seem ill, and my exam was negative. She added casually that she had left home without her asthma inhaler, so I wrote a prescription for another.

When guests phone me directly because they’ve forgotten a medicine, I call a pharmacy to replace it at no charge. Guests who phone their travel insurance are often reluctant to admit their mistake, so they claim they’re ill. I like these visits.