More Guests I Didn't Help

A travel insurer asked me to see nine sick hotel guests. My first thought was food poisoning, but their symptoms turned out to be coughing and sore throat.

I love multiple visits at the same hotel, but I wouldn’t love these. I visualized the scenario: a large group arrives for an expensive vacation where many fall ill, and in America you need a prescription for an antibiotic. Luckily, they tell themselves, we have travel insurance. The doctor will come and give us our Amoxicillin, and we’ll be fine.

My philosophy on antibiotics is that I prescribe them if they’ll help, and I don’t prescribe them if they won’t. This puts me at odds with doctors around the world not excluding the US.

When I see victims of a respiratory infections (fifteen percent of a family doctor’s business) I do my best. Almost all seem satisfied, but a few make it clear that I have failed them.

Luckily, there was a nearby walk-in clinic where these guests would get their antibiotics.

Something to Knock It Out, Part 3

Her vacation had been a disaster so far. Worse, when she tried to buy amoxicillin to knock out her bronchitis, the pharmacist told her she needed a prescription. This was obviously a scam to line the pockets of American doctors, the guest added. She didn’t need my services except to provide the amoxicillin, so I should not take up her time.

This monologue occurred in Spanish. I don’t speak Spanish, but I’ve seen thousands of Latin American travelers, so I got the drift.

This lady appeared upset as soon as she opened the door. Apparently accustomed to this behavior, her husband and a child sat in a corner, trying to look inconspicuous. Following my rule (see the post from March 16) I had no plans to refuse the amoxicillin, but first I had to deliver good medical care. I phoned the travel insurance office, and the dispatcher agreed to interpret.

I asked the usual questions; she answered at great length.

The dispatcher translated but summarized her interruptions with: “she’s mad about something.”

The guest rolled her eyes when I put a thermometer into her mouth and seemed impatient during my exam.

When I concluded that she would recover in a few days with or without an antibiotic but that I would give her amoxicillin, she slammed down the phone and waved off my prescription.

“If you don’t think I need an antibiotic then I don’t want an antibiotic. According to you I should continue to suffer. Thank you very much!….”  I’m not certain those were her exact words, but they were close.

I laid the prescription on the bed. The door closed behind me with a deafening slam.

Something to Knock It Out, Part 2

Influenza had afflicted a guest for five days with fever, body aches, and general misery. He had meetings, he said, and needed something to knock it out.

While antibiotics don’t affect influenza, antiviral drugs such as Tamiflu shorten the illness by a day or two. Sadly, they only work if taken within the first 48 hours; afterwards they are useless although doctors continue to prescribe them.  I gave him some useful medicine and told him that flu rarely lasts longer than five or six days, so he would feel better soon.

After I left, the patient went to a local clinic and received the traditional antibiotic which solidified his conviction that I did not know my business. A day after beginning the antibiotic he felt better which proved it. Confronting the hotel manager, he demanded his money back. Guests often believe that the hotel doctor works for the hotel.

The general manager phoned to pass on the request.

Something to Knock It Out, Part 1

An FBI agent was suffering a bad cough. He informed me that this happened every year, and his doctor knocked it out with an antibiotic.

My philosophy on prescribing a useless antibiotic is that I don’t unless the patient threatens to make a scene.

This FBI man seemed out of an old movie: dressed in suit and tie, composed and unemotional. He made eye contact, listened intently, answered succinctly, submitted to my exam, and did not interrupt as I spoke.

I explained that he had a virus that was incurable but would go away in a few days. As I delivered advice and handed over cough medicine and tablets for his fever, I could see him absorbing the news that I wasn’t prescribing the antibiotic.

He was not a person to quarrel with a figure of authority. He said nothing, but I could sense his inner turmoil….

Deciding the ice was getting very thin, I added: “You said your doctor gives you an antibiotic. This illness doesn’t require one, but I’ll write a prescription in case you want to call him and discuss it.”

He accepted it without comment. He also handed back the medical form that I had asked him to sign. In the hall, glancing at the paper, I saw that he had covered it with obscenities.

No Income Today

A lady at the Westin wanted a housecall for her cough and fever. This seemed reasonable until I learned that she was under treatment for multiple myeloma, a serious blood disease. It affects the immune system, so any sign of infection is a red flag.

I explained that she needed more than I could provide in a hotel room and gave directions to the nearest emergency room.

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Two hours later I spoke to a guest at the Airport Holiday Inn who was experiencing stabbing chest pains. Chest pain is worrisome, but significant chest pain lingers. Fleeting pain in an otherwise healthy person is almost never a serious sign. I looked forward to the visit when, after my exam, I would deliver reassuring news. That anticipation disappeared when the guest mentioned that he had suffered several blood clots in his lung and was taking blood thinners. He added that these chest pains were different.

Different or not, it was a bad idea to assume that these were trivial. I sent him to a facility that could perform tests.

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A travel insurance agency asked me to see a hotel guest in Encinitas.

“That’s near San Diego,” I pointed out. “It’s a hundred miles.”

I’ve traveled that far in the past and charged accordingly, but I didn’t want to quote a fee and risk having it accepted because I wasn’t in a mood for the grueling drive. A local clinic would be cheaper, I informed the dispatcher. 

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“I’m a physician in the U.K., and my wife has conjunctivitis in both eyes. I went to the chemist for antibiotic drops, but apparently I have to see an American doctor.”

“It’s unusual to have bacterial conjunctivitis in both eyes,” I said. “If you’re certain, ask the pharmacist to phone, and I’ll approve the prescription.”

Later the pharmacist phoned. When it comes to their own illness or that of their family, doctors are no more accurate than laymen, but they have no interest in my opinion. 

Fatal Diarrhea

Coris USA, a travel insurer, sent me to see an Argentinean lady with diarrhea at the Beverly Hills Hotel. Diarrhea is usually an easy visit.

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

Every antibiotic you swallow kills trillions of germs, mostly harmless, living in your bowel. They are immediately replaced by other germs that can grow in the presence of that antibiotic. 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 a severe, occasionally fatal diarrhea. 

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

Fortunately, Coris USA is a good travel insurer: meaning that it (a) pays promptly and (b) takes my advice. These sound unrelated, but I’ve found that good 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 remain pending indefinitely. I often send patients off, warning that they will have to pay up front and try for reimbursement later.

Tests were positive, and she began improving after a few days of treatment: an antibiotic but one different from the one that caused the problem.

Miracle Cures

As a hotel doctor, I save lives – almost always by calling paramedics or sending guests to an emergency room.

Now and then I cure someone by removing a sliver, ear wax, or a foreign body from an eye. Patients are grateful; it’s a thrill for me, too.

When laymen think of saving lives, they may picture a doctor handing out a prescription, but this is rare. Antibiotics are genuine miracle cures for infections such meningitis, endocarditis, severe cellulitis and other infections that require hospitalization.

When doctors prescribe an antibiotic in the office, it’s mostly as a placebo but even when used properly for infections we encounter (urine, skin, throat) these would usually resolve without treatment.

Cures are a surgeon’s specialty. If a part of your body is diseased, and the surgeon cuts it out, you’re cured.

When an Antibiotic Helps

If you receive an antibiotic for a respiratory infection, it’s probably a placebo because almost all respiratory infections are viruses.

If you receive an antibiotic for a skin infection, there’s a chance you have a bacterial infection that an antibiotic won’t help. A boil or other collection of pus will heal if the pus is drained. If the doctor gives an antibiotic but doesn’t drain the pus, it will also heal. That’s because most infections, boils included, eventually heal.

You’ll get an antibiotic if your doctor diagnoses an ear or sinus infection. It’s a bad idea to ask if this will help because (if he’s honest), he’ll admit that no one knows. In experiment after experiment, when researchers compare patients given and not given antibiotics for ear or sinus infections, the results are never dramatic. Often there’s no difference. Sometimes they help a little. Doctors in some nations don’t treat these with antibiotics.

That’s why urine infections are my favorites. It’s not controversial that antibiotics help. For infections in young women, help comes quickly, usually within a day. These are satisfying encounters for everyone concerned.

Be Careful What You Ask For

He had been coughing for several days, a guest explained, adding that he probably needed a Z-pak. When a patient suggests he needs an antibiotic, a doctor feels one of two emotions.

(1) Pleasure because this guarantees an easy visit. Give the antibiotic, and the patient will make it clear that the doctor has done what a good doctor does. I doubt most of you realize the importance of your gratitude. No matter how you try to conceal it, if you’re disappointed, we feel depressed.

(2) Depression. In an otherwise healthy person, the only common illness with a cough that antibiotics cure is bacterial pneumonia which is not common. All others are viral infections. These affect fifteen percent of everyone who consults a doctor, so they are no trivial matter.

Over the phone, I quizzed him about his symptoms and then explained that he was suffering a self-limited illness requiring only over-the-counter remedies. When he insisted that he needed a doctor, I directed him to a nearby urgent care clinic where he would get his antibiotic.

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.

Sometimes This is a Thankless Job

A one year-old at the Ramada was fussy and congested, but my exam was normal. She had a cold, I explained. It was not serious but might last a few days. Staying in bed wouldn’t make it go away quicker. The parents should encourage the child to drink, but it was OK if she didn’t eat. They were already giving Tylenol for the fever, and that was fine. They should try to enjoy themselves.

“So she doesn’t need anything,” said the father. I assured him she didn’t.

I gave them my phone number and promised to keep in touch. They thanked me effusively as I left, but I was not fooled.

Understand their point of view. They were in a strange city on an expensive vacation, and their child was sick. Naturally, all fun was cancelled and the doctor summoned fix things.

Had I written a prescription, I would be doing what a proper doctor does. They would have given the medicine and waited. Not giving “anything” meant that I considered the illness trivial. That was clearly wrong.

Mind you, obeying long and sad experience, I had carefully explained that the child might feel under the weather for several days. They had listened and nodded, but their yearning took priority.

I intended to call in 24 hours, but the following morning their travel insurer phoned to say the parents were requesting another visit. I explained that that wasn’t necessary. I would call.

“She’s the same. The fever hasn’t gone away,” said the mother.

I repeated that this was to be expected and that she should wait. She agreed and thanked me for calling.

No one answered when I phoned the next day. The insurance agency dispatcher explained that the mother had called earlier to demand another visit, so he had sent her to an urgent care clinic.

The child had barely swallowed the first spoonful of Amoxicillin when she began to improve. By evening she was fine, and the parents were congratulating themselves. Who knows what might have happened if they hadn’t found a competent doctor?