Saturday, May 31, 2014

When Doctors Wish They'd Chosen a Different Profession

Up to age one, infants look on everyone as a friend, so they’re a delight to care for. Afterward, they become aware that some people are strangers, and it’s not a happy discovery. Frightened girls tend to keep quiet, but boys often protest the moment a doctor enters and don’t stop until he leaves.

During one occasion, I removed stitches from the chin of an energetic three year-old. His family doctor had tried, then decided to wait a few days during which time the parents traveled to Los Angeles. Now the skin around the sutures was inflamed, so they had to come out. Normally suture removal is painless, but the child began shrieking at my approach. Both parents struggled to immobilize him, but you can’t prevent someone from moving his chin if that is his intention. Everyone on that hotel floor knew something terrible was happening. It took five minutes to snip four sutures, leaving everyone exhausted.

Tuesday, May 27, 2014

Memorial Day

Everyone left town for the holiday including the local concierge doctors and at least one colleague, but an equal number of travelers arrived, so I was busy.

A Virgin-Australia flight attendant was vomiting at the Warner Center Marriott twenty miles to the northwest. At midnight an Emirate Airline crewlady suffered the same symptom at the Hilton in Costa Mesa fifty miles southeast. My heart sank when I remembered that the freeway to Orange County closes from 11 p.m. to 5 a.m. for major construction, and the long detour is always jammed despite the wee hour. My heart leaped when, checking traffic, I learned that the shutdown was suspended for the holiday.   

The parade of upset stomachs continued at a home near the beach in Venice. This is a delightful, funky area that brings back memories because my wife lived there when I met her during the Ford administration. It’s packed with small houses and shops built before World War I, so no one has a garage. Everyone parks on the street, and on Saturday afternoon the beaches and shops are crowded. The rule on parking (like the rule on difficult spinal taps) is: keep trying. After fifteen minutes I found a spot less than half a mile away. 

Thursday, May 22, 2014

I Just Got Back From Mexico...

I enjoy hearing this because it means an easy visit and a grateful guest.

One third of visitors to poor countries from rich countries get sick. Experts warn tourists to avoid uncooked food, street vendors, ice, and tap water. By obeying, they lower the risk of getting sick to… one third. The truth is that no one knows how to prevent traveler’s diarrhea. Poor sanitation seems essential, but travel itself must play a role. The Swiss get sick when they visit the US.

Tourists visiting the tropics worry unnecessarily about parasites. Germs and protozoa like malaria remain a problem, but larger, exotic creatures reproduce slowly. Victims must stay long enough and undergo repeated exposure before they accumulate enough to realize something is wrong. If you harbor a few dozen schistosomes, flukes, or hookworms, you won’t notice.

Having said this, I visited one horrified guest who had seen what looked like an earthworm in the toilet after a bowel movement. Unfortunately for my education, he had flushed it down. This was undoubtedly an ascarid, a parasite that affects a billion people worldwide and an unknown number in the US. Unlike parasites such as hookworms which bite into the intestine and eat your blood, ascarids swim freely and eat what you eat. You can support a dozen without difficulty. Victims get into trouble when huge numbers cause an obstruction or when a single worm crawls into a duct and gets stuck. 

If you return from vacation with a small infestation, you have little to worry about. The females will mate, but their eggs only hatch outside the body in warm earth, so they disappear down the sewer, and the average ascarid dies after a year or two. Despite this, it’s a good idea to wash fresh vegetables before eating.

Sunday, May 18, 2014

Amazing Medical Maxims

What many laymen believe are serious signs are not – and vice versa.  Here are examples.

1. Local pain is worrisome; widespread pain is reassuring.

When a guest suffers abdominal pain, I ask to see exactly where it hurts. When he or she indicates the entire abdomen, I relax a little. The common stomach virus produces widespread pain. When the patient’s finger rests on a small area, I worry about conditions like gallstones, appendicitis, or diverticulitis whose pain is usually localized.

2. One allergy can be serious; many allergies: not so much.

An allergy is a specific immunological reaction that can be fatal, but most drug reactions are not allergies. If a medicine upsets your stomach or gives you a headache that’s usually what we call “drug intolerance.” If you’re willing, it’s OK to continue it, something we never do with an allergy. However, doctors use “allergy” indiscriminately, and laymen add their own diagnoses, so many patients confront us with a long list of forbidden drugs. The major consequence is not illness but expense. If you say you’re allergic to penicillin, for example, an alternative costs fifty times more.

3. Things don’t turn into other things.

Mostly this comes up with viral upper respiratory infection (cough, congestion, sore throat, fever).  Everyone knows that antibiotics are useless for viruses, but if a doctor diagnoses a virus, many patients believe they’ve wasted the trip. This is where the maxim comes into play.

“If I don’t get something it turns into… “bronchitis…strep…pneumonia…a bacterial infection….”  It doesn’t. In otherwise healthy people, illnesses don’t change into other illnesses, and experts persistently warn doctors that giving antibiotics to prevent complications is positively harmful. They wouldn’t keep warning us if we didn’t keep doing it.

“Why don’t you give me a Z-pac. I promise not to take it unless I don’t get better.”

“If you’re sick after three or four or five days, it’s still a virus.”

“What if my mucus turns green?”

“Still a virus.”

“But my doctor always gives me….”

Bull’s eye!  They best way to get a useless drug is to ask for it. Doctors love helping you. If you make it clear that he’s missed the boat, he may give you something to make you feel “helped.”

Warning!  I and my legal adviser inform you that these are not rules but impressions. Doctors keep them in mind along with their vast knowledge, wisdom, and judgment. I’m writing this for your amusement, not to help you decide if you need to see a doctor.  

Wednesday, May 14, 2014

I Don't Do Adderall

“A guest at the Century Plaza wants his Adderall refilled. Can you go?” asked someone from the office of a local concierge doctor.

“I can go, but I don’t do Adderall,” I said.

“No problem.” She would find another doctor. Prescription refills are easy house calls.

You’ve heard of childhood attention-deficit disorder. Recently psychiatrists have discovered that it also affects adults. Treatment is the same. That includes drugs related to amphetamines; the most popular for adults is Adderall. As a hotel doctor my only experience with attention-deficit disorder comes from guests who need more Adderall.

None sounded like drug-seekers. All were happy to pay my fee for a visit during which I would check them out. Since there is no way that I can examine a guest and determine if he or she suffers adult attention-deficit disorder, I told them I’d have to speak to his or her doctor. None ever called.

It’s been decades since I made a similar decision on narcotics. Guests occasionally forget their heart pills, but soon after becoming a hotel doctor, I grew puzzled at how many needed more Vicodin or Oxycontin. Some sounded suspicious from the start, but many were clearly in great pain. Their distress tore at my heart, and they often produced a sheaf of X-rays and letters from a doctor. With no reliable way to tell the fakes from the genuine, I gave up on narcotics.

Thursday, May 8, 2014

A Dog-Eat-Dog Business, Part 6

People often ask what sort of contract I have with hotels. The answer is none. Staff call because I’m easy to reach and quick to respond. Once they’ve called a few times, they’re not inclined to change.

I and three colleagues have been in this business for decades. We’re well known and popular, but hotel doctoring is a glamorous occupation, so plenty of doctors yearn to break in.

How can they do this? Guests who want help ask a concierge, desk clerk, operator or bellman. You might think that they learn the name of the official house doctor, but there is often no such person. Except in luxury hotels, selecting a doctor is not a high priority, so the choice may be up to the employee.

This is no secret, so entrepreneurial doctors know who to approach. But how can he phrase a sales pitch? Pointing out that he is a caring, compassionate physician who provides superior care sounds creepy. Doctor web sites and housecall agencies always proclaim this, but you should be skeptical. I’ve worked for dozens; they check my license and malpractice history but never my competence.

The new doctor might offer to charge less, but he never does. The free market doesn’t apply to medical fees.

So what’s left? Services selling to a hotel (florists, tours, masseurs, limousines) often pay a kickback, and there is a long tradition of hotel doctors doing the same. It’s illegal for a doctor to pay for a referral, and I hasten to admit that I have no evidence that any individual on the Los Angeles scene is doing that, but when I start hearing “have you forgotten something?....” hints from bellmen et al, I wonder if a new competitor is making the rounds.

Being entrepreneurs, these doctors have many irons in the fire. They are often too busy to drop everything and hurry off for a housecall, but they know me, so I sometimes visit my own hotels at their request. I collect my usual fee, but these entrepreneurs want their share, so the guest pays extra.

Saturday, May 3, 2014

A Big Tipper

Le Meredien on La Cienega had a firm policy against recommending a doctor. This does not mean it never called, only that a call from Le Meredien means a guest making trouble, and the harassed employee had chosen Doctor Oppenheim as the lesser of two evils:  the greater being burdening his boss with the problem. This happened long ago.

 “I’m here for the gentleman in 499,” I informed the concierge.  “Is there anything I should know?” 

She made a show of checking her computer. “That would be Mister Al-Akbar. He’s been asking for a doctor. Repeatedly. The Kuwaiti consulate had your number."

Concealing my pleasure at that news, I thanked her and headed for the elevator. 499 stood at the end of the hall, the largest suite on the floor. Its door stood open. Knocking, then pushing it further, I encountered the smell of alcohol, never a good sign when the patient is Moslem. No one was in sight, but a doorway led to the bedroom and the prince, a small figure in a huge bed, covers drawn up to his chin. Balding and past forty, his disheveled hair was the single unkempt feature, and a goatee the only evidence of his foreignness

“Pain. Terrible pain,” he announced loudly.

“Where is the pain, Mr. Akbar?”

“Kidney. I have kidney stones in my kidney.” He threw the covers to one side and pointed to his right flank. “My doctor prescribes Dihydroco, but I have no more.”

“That’s not a drug I’m familiar with.”

“It is from London. I live in London.”

“Do you just need a prescription?”

“Also a shot. The pain is unbearable.”

I examined the prince and tested his urine for blood. Everything was normal but this can happen with a kidney stone. I thumped his back over his kidneys, and he groaned. I was not convinced. Le Meredien wasn’t a potential client, so I could expect no advantage from pacifying the prince, and no damage from a complaint.

“I don't carry narcotics, but I can give you a Toradol injection.” A legitimate pain remedy, Toradol is similar to Advil but probably not what he expected.

“Many thanks.”

Any doubt about the prince’s drug consumption vanished when my needle jerked to a halt half an inch beneath the skin. Fibrosis from hundreds of injections had given the prince’s buttock muscle the consistency of wood. I forced the syringe down and delivered the injection. Anticipating the pleasures ahead, the prince clutched my hand in gratitude.

Yanking open the drawer of the bedside table which turned out to be stuffed with hundred-dollar bills, he snatched a handful and pushed them into my grasp.

Grateful the guest had forgotten his request for a prescription, I thanked him and hurried out. Later I counted fourteen bills. We bought a Chinese rug for our living room.