Monday, November 30, 2015

Discovering a Normal Part of your Body

A young woman at the Georgian Hotel felt a cold coming on, so she inspected her throat and discovered a dozen bumps on the far end of her tongue. I reassured her, but she wanted a doctor to see them.

I love housecalls where I know the diagnosis as soon as I hang up the phone. This qualified because the guest had discovered a normal part of her body. When you examine your tongue in the mirror, it seems smooth. People rarely stick it out far enough to reveal a clump of wart-like taste buds deep inside.

I also love telling a fearful patient that he or she has nothing to worry about, so this was a satisfying encounter for both of us.

It may save you some anxiety to memorize the following normal parts of your body.

- Put a finger inside your mouth and feel the gums behind your lower teeth. Moving just to the left and right reveals two hard lumps which may not be the same size. These are part of your mandible, the jawbone.

- With thumb and forefinger, pinch your neck just below the jaw to feel two lumps that mark either end of the hyoid bone that circles the front of your windpipe. You can wiggle them from side to side.

- Run your finger down the middle of your breastbone to an inch beyond the lower end, then push. You’ll feel a hard mass. That’s another bone, the xyphoid process. One guest was certain had a stomach tumor.

- Feel your major lymph node areas (neck, armpit, groin), and remember what you find. Part of the immune system, lymph nodes swell in response to an infection then shrink after it passes - except sometimes a node or two won’t shrink but remains forever as a pea-sized, moveable granule beneath the skin.

Thursday, November 26, 2015

Ultimatums are Risky

Could I see a gentleman at the Omni with an upset stomach?

The dispatcher for International Assistance was delighted to learn that I could. In most cities, dispatchers work hard to find a doctor willing to make a housecall but not in Los Angeles.

I copied the guest’s name, age, room, and insurance I.D. I quoted a fee. That was acceptable. I said I would arrive within an hour. He was pleased to hear that. Then I dropped the bomb. I needed a credit card number.

I could hear the air go out of his balloon.

“We always send a guarantee of payment.”

“And I always receive one. But you don’t pay.”

Some travel insurers pay promptly. Others require repeated phone calls. Pestering the billing department relentlessly usually works, but sometimes I run out of patience, and many visits for International Assistance remained unpaid after six month.

“I’m not sure we have a credit card.”

“Yes, you do. Ask your supervisor.”

All travel insurers have company credit cards but they vary greatly in their willingness to give them out. Some do it routinely. Others require an ultimatum. I hated dealing with Universal Assistance until they coughed up a credit card number. Now I love it when they phone.

But ultimatums are risky. The dispatcher agreed to consult his supervisor and call me back, but I never heard from him.

Sunday, November 22, 2015

A Rash During the Rush Hour

A guest in Long Beach had red spots.

This looked like a terrific visit; skin problems are usually easy. A sudden rash is frightening but almost never indicates something serious. I have no objection to making a diagnosis over the phone, but guests are terrible at describing a rash’s appearance. In any case, they want the doctor to look at it.

My only problem was that the call arrived at 5 p.m. on a Friday, and Long Beach is thirty miles away. I avoid long freeway drives during the rush hour, so I told him I could come around 9.

That wouldn’t work, he replied. He had a business engagement that evening. But he’d be happy to see me the following morning.

Saturday morning drives are easy, but a rash that arrives quickly may depart quickly. I wanted this visit, so I told him I would leave immediately and be there in an hour. Or two. 

Wednesday, November 18, 2015

Hitting the Jackpot

A call arrived during breakfast. Half an hour later the phone rang again. I was pleased because it was an ideal time for multiple housecalls.

I exercise regularly, always before noon because later the gym becomes crowded. Two morning housecalls makes arriving before noon impossible. This doesn’t happen often, so I reward myself by skipping the gym without feeling the usual guilt. Keeping fit is healthy, but an hour of exercise is as exciting as an hour brushing your teeth, and I’m suspicious of anyone who claims to enjoy it.

Where was the second patient? I routinely drive twenty miles between visits so I awaited the location with anticipation. He was at the same hotel, a rare treat!

A downside was that both seemed to be suffering my least favorite illness: a viral respiratory infection. You’ve heard plenty about my reluctance to give antibiotics when they won’t help.

My good luck held. The first guest had a cough and high fever, probably pneumonia because listening to her lungs revealed abnormal noises. In an otherwise healthy person, pneumonia is the only common chest infection that medical science can cure. So I cured her.

On another floor, I examined a middle-aged man who explained that he had bronchiectasis. This is an uncommon condition in which a small area of the lung becomes obstructed and suffers frequent infections. This was another, so I gave him antibiotics in good conscience.

These were satisfying encounters, but there was a downside. Because both patients were at the same hotel, I finished before 11 o’clock, too early to skip my workout without guilt.

Saturday, November 14, 2015

Broken Glasses

An elderly lady smiled and gestured me to come in. As I followed, she remained silent, a sign that she spoke no English. If someone doesn’t know “hello” comprehension is generally poor. 

“Portuguese.” she said.  “Speak Spanish?”

When I shook my head, she took up her cell phone. The first number didn’t answer. The second, after a short conversation in Portuguese, proved unfruitful. She continued dialing. She was Brazilian, and most South American travelers have travel insurance. If I phone the insurance agency’s 800 number, someone will interpret. Unfortunately, my call hadn’t come from a travel insurer but a national housecall service, Expressdoc. When Expressdoc needs a housecall in Los Angeles, it calls me.

I could phone Expressdoc and ask for the agency’s number, but that makes them uncomfortable. I sympathize; housecalls is a viciously competitive business.

The lady finally found a multilingual friend, and we proceeded with the consultation, passing the phone back and forth. As usual, delivering medical care was the easiest part of the housecall. She had broken her glasses. She complained of a headache, but I suspected she wanted a doctor’s note so insurance would pay for a replacement.

Tuesday, November 10, 2015

A Prominent Scam

A guest at the Luxe explained that he was in town for six weeks and needed a disabled parking pass. He had the Department of Motor Vehicles form. All he needed was a signature.

I offered to come to the hotel, but – even at half my usual fee – he didn’t want to pay. I could have politely withdrawn, but he might then ask the hotel to recommend another doctor, never a good idea. As I do when it’s an easy service, I told him I would sign the form gratis if he came to my house.

After hanging up, I felt uneasy. Eleven percent of Los Angeles drivers have a disabled parking pass; it’s clearly a scam, and I didn’t want to add to it. What if I had to refuse him? When guests complain after I refuse narcotics, hotel management takes this with a grain of salt, but a parking pass….

You can imagine my relief when I answered his knock and saw that he had only one leg.  

Friday, November 6, 2015

What Antibiotics Do To Your Body

When I started out in the 1980s, pharmaceutical companies sold pills labeled “placebo.” They don’t do that today, so a doctor who wants to prescribe one uses a real drug.

Today’s most popular placebos have names like amoxicillin and Z-pak (azithromycin). These help many conditions but not the respiratory infections for which most are prescribed.

Swallowing any antibiotic kills trillions of germs inside your body. If it’s a placebo, those germs are not causing your problem. Other germs immediately move in. Of course, those are germs that can grow in the presence of that antibiotic. If, in the future, they decide to make trouble, another course of that antibiotic might not discourage them. Do you want that?

Experts have been denouncing placebo antibiotics for decades, but their arguments are feeble. They warn about side-effects and allergies, but these are rare. Most antibiotics, useful or not, are safe over the short term.  
The long-term consequences are catastrophic. Soaking the environment with unnecessary antibiotics is giving rise to extraordinarily resistant bacteria. Even today about 40,000 Americans die of infections no antibiotic can treat, and this increases every year.

But who cares? It’s a fact that people with a short-term problem don’t take the long view. That might include your doctor.

Monday, November 2, 2015

Another Free Service

Her child’s nose was bleeding, explained the mother. Could I come?

I was tempted. Once in the hotel room, I would ask questions. I would take out my otoscope and peer up the child’s nose. In the end I would reassure the mother and tell her to pinch the nose and wait. The bleeding would probably stop. Persistent nosebleeds are rare and require expert attention. Then I would collect my fee and leave. 

Over the phone, the mother revealed that the child was in good health and suffering a cold.  Respiratory infections occasionally produce a nosebleed. I reassured the mother and told her to pinch the nose and wait. When I phoned later, the bleeding had stopped.