What Makes Travelers Sick

 American water.

Travelers worry that our fierce advocacy of the free market includes opposition to government meddling in the water supply. I regularly assure them that all American tap water is drinkable.

American food.

No one believes that Taco Bell or McDonald’s sell healthy food, but foreigners worry that these exotic, colorful substances are toxic. We Americans are warned about eating in nations with poor sanitation; about one in three American tourists in these areas get sick. If we’re careful, our sickness rate drops to… Actually, it doesn’t drop. No one knows how to prevent traveler’s diarrhea. The Swiss get sick when they come to the US.

Air conditioning

Americans accept air conditioning with even more enthusiasm than personal firearms, but most of the world has never caught on. They tolerate it as an odd American custom but believe that air from a machine is unhealthy whether it’s automobile exhaust or a box in a window. When someone gets sick, they turn it off. I wear a suit, so caring for foreign tourists during the summer is a painful experience.

Air Travel

Travelers blame the airline for any illness that occurs within a week of flying. This is not so for aches and pains and unlikely for an upset stomach but true for respiratory infections.

Stress

Vacations are stressful, particularly if children are involved. They miss their friends; they hate the food; they prefer watching TV to sight-seeing; they refuse to adjust their sleeping hours.  It turns out that stress makes everything worse, but it doesn’t cause anything, so there’s no reason for the parents to get sick. When they do, it’s a respiratory infection, usually the children’s fault.

A Better Medicine

A 2 year-old was ill with vomiting, diarrhea, fever, and a rash. That sounded bad.

I know a pediatrician who makes housecalls, and I considered sending him. But the news came from the guest’s travel insurer, and their pronouncements are often exaggerated. I decided to go.

The guest greeted me at the door with a cheerful toddler at his side. That, to my relief, was the patient. He still had diarrhea, and a spotty rash was present but fading.

Suffering a respiratory infection, the child had seen the family doctor and received the traditional antibiotic. Instead of amoxicillin (the world’s most popular antibiotic for people who don’t need an antibiotic), he had prescribed Augmentin, excellent when necessary but a legendary stomach upsetter.

The parents took for granted that the solution was a better medicine and something for his rash and diarrhea. But this was one of those situations where stopping everything works best. 

Green Is Not a Big Deal

One mystery I’ve never solved is why patients worry about green bodily fluids.

Guests with a cough tell me that they wouldn’t have called if their mucus hadn’t turned green. In fact, in an otherwise healthy person, green mucus is rarely a serious sign. Ditto for yellow. Everyone’s respiratory tract produces a quart of mucus a day. When it’s irritated, it produces more, and it can change color.

If you vomit on an empty stomach you might see bile which is green. This has no great significance. Many patients believe that they shouldn’t vomit if their stomach is empty, so something ominous is happening. This is not so. The signal to vomit comes from your brain, not your stomach.

Patients with diarrhea often save it in the toilet for my examination. I consider it bad manners to refuse to look, but normal stool can turn green.

There are exceptions. Blood from these orifices is never normal, so it’s OK to show me. If your stool or vomitus is black – pitch black, never dark brown – that’s usually bleeding.

A good rule (although my lawyer insists that I add that plenty of exceptions exist) is that you should see a doctor if you feel bad. If you don’t feel bad, it’s probably not necessary. Don’t pay too much attention to green stuff.

Converting Two Visits Into No Visits

A man at the Bonaventure was suffering an earache. The pain was not severe and had been present several days, but he wanted it checked. This seemed like an easy visit.

But it was 5:00 on Friday. My traffic app showed a solid red line for the ten mile freeway drive downtown, converting a half-hour trip into… I hated to contemplate it. I explained that I could be at his room between 8 and 9. That was fine with him.

I had barely hung up when the phone rang again. A guest at the Warner Center Hilton had diarrhea. The Hilton is fifteen miles in the opposite direction from the Bonaventure with an equally red freeway. I could have scheduled it for later, but if a third call arrived….

The guest was not terribly ill, so I pointed out that most diarrhea is self-limited. I gave dietary advice and recommended an over-the-counter remedy that was a good as the one I hand out (actually the same), and suggested we talk again in a day. Happy to get free medical advice, he agreed.

At 6:30 the Bonaventure operator called to inform me that the guest wanted to cancel the visit. When I phoned both guests the next day, they were doing fine.

My Favorite Infections

Number one is urine infections in women, because I quickly make them go away. Handing over a packet of antibiotics, I assure someone who has been running to the bathroom every half hour that she’ll feel better by the next morning. In men, urine infections are usually prostate infections; these resolve slowly.

Eye infections (“pinkeye,” conjunctivitis) go away quickly after we prescribe antibiotic drops because most conjunctivitis goes away quickly whether or not antibiotics help (mostly they don’t). Everyone with a pink eye assumes they need eye drops, and doctors are happy to oblige, so we find these satisfying to treat.

Some intestinal infections respond to antibiotics but almost all occur in poor parts of the world. They’re rare in the US where vomiting and diarrhea is usually a “stomach virus” and short-lived.   

Amazingly, experts debate whether antibiotics help ear infections. Doctors in many nations don’t prescribe them, but Americans do. Patients give us credit when they get better. We like that.

Good News, Usually

A flight attendant with diarrhea is usually good news. Airline crew are young, so they suffer uncomplicated medical problems, and diarrhea qualifies. Her hotel in Costa Mesa was 46 miles away, but it was Saturday morning, so traffic was light, and I’m paid extra for the distance.

To my annoyance, this was one of those inexplicable weekend days when the freeway was jammed although it wasn’t a holiday, and I never saw an accident.

After caring for the guest, always the easiest part, I got back on the freeway and its creeping traffic. Five minutes later my phone rang. This was bad news because freeway driving is more tiring than practicing medicine, and I had had enough. The caller was a national housecall service, and, to my surprise, the patient was in Costa Mesa, a half mile from where I’d been.

Unaware that I was nearby, the service quoted its usual fee for a long drive, so I retraced my route, cared for the guest, and returned to the crowded freeway. I was weary when I finally arrived home, hours past lunch time, but it had been a lucrative day in the fascinating life of a Los Angeles hotel doctor.  

Don't Get On the Plane!

“My flight leaves tonight” is a phrase I like to hear because it means the guest will return to the care of the family doctor. Until then he or she is my responsibility. Now and then, I don’t like to hear it. 

A guest awoke feeling well but soon noticed some abdominal pain.

When I hear “abdominal pain” I ask about vomiting and/or diarrhea and hope it’s present. That points to a stomach virus, usually a short-lived and not very serious problem.

Abdominal pain alone can mean a stomach virus, but I also consider serious conditions (gallstones, diverticulitis) and potentially fatal ones (ectopic pregnancy, blood clots). I prefer to send these guests directly to an emergency room, but sometimes I end up at the hotel.

This guest considered my question before deciding that he had diarrhea. Maybe… My abdominal examination turned up nothing requiring urgent attention. He was young, so several life-threatening problems were unlikely. The pain itself was unpleasant but not quite excruciating.

It was a difficult decision, but doctors are paid generously to make difficult decisions.

I told him that he probably had a stomach virus, but I couldn’t rule out something serious. I would give him something for the diarrhea and check back. I added that he might need some tests and that he must not get on the plane if the pain persisted.

When I phoned after three hours, he had checked out.

Making the Doctor Feel Bad

If a prescription gave you diarrhea or made you vomit, you would complain. But until well into the twentieth century, people looked on a good “purge” as an excellent way to expel toxins. Physicians took pride in their cathartics, and when patients discussed a doctor’s skill, they gave high marks for the violence of his purges.

People who consult a doctor expect him to behave in certain ways. 21^st century Americans frown upon purges, but this is not a mark of superiority because we seem to expect medicine. It should be one only a doctor can prescribe; over-the-counter drugs don’t count. Pills are good; an injection works better.

Most of you will deny expecting medicine whenever you see a doctor. You want help. If you’ll get well without medicine, you won’t be upset… I often encounter such patients, but the other sort turns up regularly. I’m slower to prescribe than most, so I have many opportunities to see disappointment in patients’ eyes when they realize I don’t plan to “give them something.” This makes me feel bad.

Doctors genuinely want to help you, and it depresses us when we can’t. We also feel bad when we’ve done our best, and you don’t feel “helped.” So we often add a prescription or order a test to convince you that we’re doing what a proper doctor should do.

I Just Got Back From Mexico...

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 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 swimming 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.

An Untypical Case of Stomach Flu

I once cared for a Fiji Airline flight attendant suffering stomach flu. These are miserable episodes of cramps, vomiting, and diarrhea that rarely last long. She was better the following day, but on that day I returned to the hotel to see another flight attendant with similar symptoms.

In the hotel room, I repeated my stomach flu exam, delivered the usual advice, and handing over medication. She asked if the medication was safe if she were pregnant.

Doctors are human. Having made a diagnosis, my inclination was to stick to it, but I asked a few questions. Her period was overdue. She admitted that her nausea, although worse today, had begun a week ago. Her cramps, also worse today, had also been present.

One of many rules medical students learn is that when a young woman has abdominal pain, one always considers an ectopic pregnancy. That’s usually a pregnancy in the fallopian tube which, unlike the womb, had no room for the growing fetus.

I told the flight attendant that she needed a test to see if she had an ectopic pregnancy which is an emergency. She did not disagree. I phoned the agency that handles airline crew. Their medical department agreed that this was appropriate, and it turned out positive.

We Yearn to Help

If a prescription gave you diarrhea or made you vomit, you might complain. But until well into the twentieth century, the average American looked on a good “purge” as a way to expel disease. Physicians took pride in their cathartics, and when patients discussed a doctor’s skill, they gave high marks for the violence of his purges.

Nowadays Americans frown upon purging, but we seem to expect a medicine. It should be one only a doctor can prescribe; over-the-counter drugs don’t count. Pills are good, but an injection is better. Of course, modern drugs often work, but this is a minor matter compared to the deep human desire that a doctor do something.

I apologize if this sounds mildly insulting; I suspect most of you will deny expecting a drug. You want whatever will help. If nothing will help, you want to know.

Such sensible patients do appear, but no day passes when I don’t see disappointment in a patient’s eyes when he or she realizes I don’t plan to “give them something.” 

Doctors genuinely want to help you, and we feel bad when we can’t. We also feel bad when we do our best, and it’s obvious a patient doesn’t feel “helped.” So many of us add a prescription to convince you that we’re doing what a proper doctor should do.

I Prefer Vomiting and Diarrhea

Two women at the Holiday Inn were ill. The mother suffered low abdominal pain with vomiting and diarrhea. It seemed like the usual stomach flu. I assured her it wouldn’t last long and gave medication.

Her adult daughter also complained of low abdominal pain but without other symptoms. Viral gastroenteritis can occur without vomiting or diarrhea, but I feel reassured when they’re present. It’s a good rule that when two members of a family are ill at the same time, it’s the same illness, but no rule is absolute.

The problem is that isolated low abdominal pain in a young woman can indicate an urgent problem such as ectopic pregnancy or twisted ovary. This seemed unlikely, but I couldn’t rule it out. If she weren’t better in a few hours, I explained, she must go to the local emergency room. She did not object.

When I phoned a few hours later, the mother’s symptoms had vanished, and the daughter told me she felt a little better. Patient tend to tell doctors what they believe we want to hear, so “…a little better,” does not reassure me. Pressed, she admitted that she wasn’t feeling better. When urged to go to the emergency room, she worried about her lack of insurance and the late hour but promised to give it serious consideration.

I passed a restless night. When I phoned the next morning, she had recovered.

A Difficult Night

People blame an upset stomach on their last meal, but mostly these are viral infections. Although miserable, they rarely last long. Doctors enjoy short-lived illnesses because we get the credit when they go away.

The guest hadn’t vomited for several hours and was already feeling better. As I was congratulating myself on an easy visit, I heard the unmistakable sound of retching from the bathroom. This was her husband, the woman explained, adding that her mother and two year-old were also ill.

When the husband appeared, I took care of him. Unlike his wife, he welcomed an injection in addition to antivomiting pills which I also gave the mother as well as medication for her cramps and diarrhea. The child had diarrhea and little interest in eating but did not look ill. I limited myself to dietary advice and left my phone number.

When I phoned the following day, the husband informed me that the family was fine although everyone had been vomiting all night.

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.

You Can't Make a Diagnosis Over the Phone

I talk to guests before making a housecall, so I have a good idea of what’s happening before I drive off or decide that a visit isn’t necessary. 

“Of course, you can’t make a diagnosis over the phone,” guests tell me.

But I can. Doctors do it all the time. I’d estimate my accuracy at ninety percent. It may be one hundred for some problems: respiratory infections, urine infections, backaches, most rashes, injuries, anxiety attacks. Driving to the hotel, it’s relaxing to know in advance that the guest has chicken pox, gout, herpes, a bladder infection, or the flu. I can deliver my diagnosis, advice, and medication, collect my money and thanks, and drive home. What an easy job!

Jumping to conclusions is a major reason doctors get into trouble, so I pay attention. If a fifty year-old describes chest pain that doesn’t sound like a heart attack, it’s unlikely I’ll tell him that it’s OK to wait. It’s also unlikely that I’ll make a housecall because an examination rarely helps. On the other hand, chest pain in a twenty year-old is hardly ever a serious matter.

Abdominal pain is tricky at any age. Guests suggest gas, indigestion, and constipation, none of which cause severe pain. I worry about a dozen conditions that require a surgeon. Oddly, it’s reassuring when vomiting or diarrhea accompanies the pain. Provided the guest is in good health, it’s usually a short-lived stomach virus, my second most common reason for a housecall. Without vomiting or diarrhea, I’m likely to suggest a clinic visit where a doctor can get more information than a housecall provides.

“I can walk on it, so it’s not broken…” “I can move it, so it’s not broken….”  These are as accurate as most popular health beliefs. I walked on a painful foot for a week before an X-ray that revealed a fracture. Hotel guests yearn to hear that their injury is not serious, and I sometimes comply. Doctors do little for cracked ribs and broken toes except to relieve pain, so X-rays aren’t essential. All bets are off with the elderly, but it requires a good deal of violence to break a young bone. Lifting a heavy suitcase won’t do it; experts urge doctors (in vain) not to order spinal x-rays unless pain persists for weeks.

My greatest service is not in diagnosing fractures which is usually impossible but saving guests the misery of spending hours in an emergency room. Most injuries are not emergencies, even if a bone is fractured. If the guest is willing to wait, I can send him to the more civilized atmosphere of an orthopedist’s office. 

Worry, Part 2

I drove to the Magic hotel in Hollywood where a Danish couple’s 18 month-old was vomiting. He looked fine, and looking is essential:  sick children look sick. Nothing abnormal turned up on an exam, so my diagnosis was a common stomach virus. I told the parents it might last a few days and gave the usual dietary advice.

I check on patients before going to bed, but the Danish parents beat me to it. The child had vomited once again, they reported. He was still in no distress, so I told them it was OK to wait.

My assurance was proper, but patients occasionally deliver unpleasant surprises, so I worried a little as I went to bed.

I phoned the Danes the following day to learn that the child hadn’t vomited but was now feverish. This was to be expected, I explained, and I approved their decision to give Tylenol.

The Danish child was still feverish, his parents reported the next day, and now he had diarrhea. I gave dietary advice.

There was no answer the following morning. From the front desk I learned that they had checked out. I had just returned from seeing a young man with abdominal pain at a youth hostel. He was worried about appendicitis; my exam made that unlikely. Since he had no health insurance, I did not want to make my life easier by sending him to an emergency room where a workup including CT scans would run to about $5,000. His symptoms hadn’t improved when I called, but they still didn’t seem like appendicitis. He promised to phone if there was any change. I worried a little as I went to bed.

Phrases Patients Love to Hear, Part 2

4.  “Staying in bed won’t make this go away any faster.”

Many laymen believe illness requires rest. They skip work or school. Mothers go to great (and futile) length to keep children immobile. Travelers waste days in a boring hotel room. This myth is so universal that when I reassure non-English speaking guests, I ask them to repeat what I’ve just said. Almost always, they miss the negative.

5.  “The fever (or vomiting or diarrhea) won’t harm you.”

Temperature by itself - even to 104 - won’t damage a healthy person.  Patients should pay attention, but they needn’t worry that death is near. When patients ask for a genuinely dangerous temperature, I answer “over 105,” but this is less helpful than it sounds because at this level, patients feel very bad. Similarly, healthy laymen fear that a few episodes of vomiting or diarrhea will produce serious malnutrition.

6.  “You’ll feel under the weather for a few days; then you’ll feel better.”

Patients may suffer for a week, but once they see a doctor, they want things to move quickly, so I warn guests that this might not happen. In my experience, if I neglect this, patients become concerned if they’re not feeling better the next day and take advantage of #3.

7.  “It’s not your fault.”

All our efforts at patient education plus the popularity of alternative medical theories have convinced Americans that they are responsible for getting sick. This is occasionally true but mostly not.

A Risky Housecall

A lady at the Holiday Inn in North Hollywood reported that her husband was suffering diarrhea. She added that he had fainted during the last several episodes. I had never heard that before. Doubting that I could solve the problem, I told her we needed to call the paramedics. Sure enough, they took him to the hospital for a day of rehydration.

Waiting for the Other Shoe

I buy drugs and give them out gratis. Ten years ago generic Lomotil, the leading diarrhea remedy, jumped from about $20 per thousand to over $200. I switched to Imodium which is probably as good. It’s sold over the counter at Walmart. I buy a lot of drugs at Walmart.

In 2014, I wrote that I tried to reorder doxycycline, an old antibiotic that remains the best treatment for several common infections. My supplier’s web site quoted $1,600 for 500. I knew that was a typo because I’d paid $30 the year before. But it wasn’t. Fortunately, there’s another antibiotic that works well at only four times the old cost. 

Some of you are aware of the furor over the skyrocketing price of Epipen, a device that makes it easy to inject adrenalin during a severe allergy attack. Google it if you’re not. Read the justification from the company’s chief executive. Doesn’t it sound smarmy and dishonest? Don’t you hate her? Epipen is sold throughout the world at the old price, and the company does not complain that it’s losing money.

Congressional Republicans have joined Democrats in denouncing the increase. The furor will fade; the price will remain. Unique among western nations, American government agencies are forbidden from influencing drug prices, and no one to the right of Bernie Sanders is suggesting a change.

Several times a year a similar kerfuffle hits the headlines and runs its course, but I deal with it regularly. A year ago a bottle of my antibiotic ear drops went from about $8.00 to $300. So far antibiotic eye drops haven’t done the same, and experts say one can substitute them, but I’m waiting for the other shoe to drop.

A Real-Life Stereotype

A diamond dealer from Israel, a guest at the L.A. Marriott, fell violently ill with a stomach virus. He went to an emergency room, remaining overnight for IVs and tests. Returning to the hotel, he felt better except for some diarrhea. I examined him and reassured him and handed over anti-diarrhea pills.

“Are you Jewish,” he asked.

“I’m a doctor,” I said.

He thought for a while and then asked “Would you give me a discount on the bill?”

I gave him a discount.

After another pause he asked “Would you keep the old fee on the invoice that I give to my insurance?”

I told him I’d already made the change.

“But the insurance charged too much: $90 just for a week in America!” he complained.

“Are you kidding?... You should kiss the feet of whoever sold you the insurance. Wait till you see the bill from the emergency room. It’ll be about $5,000.”

He didn’t believe me.