Good Luck

 A national housecall service connected me with a guest at the Montage in Beverly Hills. She was suffering the flu; I told her I’d arrive in half an hour.

As soon as I hung up, I realized, to my dismay, that I had quoted my usual fee, forgetting that the housecall service takes a 40 percent cut. The Montage is a super-luxury hotel, and the guest was probably rich, but I couldn’t change the fee.

I was in luck. Not one but three guests in the room had the flu, so it worked out.

Japanese Never Travel Alone

The room contained four young Asian men and extra beds, on one of which lay my patient looking miserable with a wet washrag on his forehead.

At my first question, several pulled out Japanese-American phrase books, a bad sign. It’s a fact that all Japanese study English in school, but all Americans study American history, and how much do they learn?...

Answers to my questions were on the order of “please perform a diagnostic evaluation” or “the reading of the thermometer seems excessive.” I had reluctantly decided to call their travel insurer’s 800 number (phone interpreting is tedious) when the tour leader entered. His English was rudimentary, and, being Asian, he was too polite to tell me when he didn’t understand, but I managed to confirm my suspicion that the young man had influenza, not life-threatening but a terrible illness for young people who take for granted they’ll never be ill.

Helping a Lady

A guest at Checkers, an upscale downtown hotel, had the flu with a 103 fever. I washed my hands before examining her; afterwards I washed again and included my stethoscope. I’ve had the flu shot, but I still worry about catching it. I suffered the flu in 1977, and I remember it as the worst illness of my life until I became elderly.

I finished around midnight. Returning to my car, I passed two young women arguing bitterly on the sidewalk. One insisted on walking to their hotel, the other objected because she was wearing high heels. 

At my age, no one considers me threatening. As I started the engine, one of the women tapped on my window and asked for a lift. I drove her to the Bonaventure, six blocks away. She had been drinking but was coherent and grateful for the favor.

Disappointment

Loews guest was suffering flu symptoms, but mostly he worried about his temperature. I explained that the fever was not an ominous sign. If he wanted to check, he could buy a thermometer. Or I could come to the hotel. He opted for the visit. I told him how much it would cost.

“Oh… I thought it was free,” he said.

I’d heard that before. Your doctor doesn’t answer when you dial, but I do. Naïve guests think I’m downstairs awaiting their call.

He was from Chile. Did he buy travel insurance before coming to the US, I asked. He did. I explained that travel insurance pays for housecalls, and most insurance agencies call me. However, he must phone the insurance first to obtain approval. He promised to do so. 

Half an hour later my phone rang. It wasn’t Loews but the Doubletree. An elderly man had undergone electrical cardioversion for atrial fibrillation – an irregular heartbeat – a month earlier, and he was worried. His heart didn’t feel right. I asked him to count his beats; he counted 80 per minute. That is not particularly fast. I assured him that he wasn’t describing anything dangerous. He wanted me to check him.

These are the best visits. A guest is worried, and I’m already convinced that there’s nothing to worry about. Sure enough, the exam was normal. He was delighted at the news, and I was delighted to deliver it. Everyone was happy.

I was even more delighted to drive to the Doubletree because it’s only a few blocks from Loews. At any minute, I expected a call from the Loews guest’s insurance agency for another easy visit. But it never came.

Lost in Translation Again

“Bom dia” said the woman who opened the door.

“Bomn dia,” I responded. That’s the limit of my conversational Portuguese. My heart sank as I looked around the room which contained a toddler but no adult male. When I see a couple from a foreign country, the husband is likely to speak some English.

The mother pointed at her child, made coughing noises, tapped his chest, and produced a thermometer which she waved significantly. Once she understood that I needed more information, she took up her cell phone. 

After some effort because her husband was in a meeting she delivered a long recitation before handing me the phone.

I heard “He have cough. He have flu. He need medicine.”

In response to my question, the father insisted that this was everything she had said, but I knew he was summarizing. I asked more questions and received short versions of her long answers. The child looked happy and not at all sick, and my examination was normal. He had a cold. He’d coughed for four days and might cough for a few more, I explained. She was already giving him Tylenol, and no other medicine is safe for a two year-old. Luckily, he didn’t need medicine or bed rest or a special diet. It wasn’t even necessary to stay in the room.

If I had handed over a bottle of medicine, every mother from Fiji to Mongolia to Nigeria would understand that I was behaving like a doctor. But I wasn’t. What was going on?

I’ve encountered this hundreds of times, so I work very, very hard to communicate that the child has a minor illness (husband’s translation: “Doctor says child is OK…”), that no treatment will help (husband’s translation: “Doctor does not want to give medicine…”) and that being stuck in a hotel room is boring, so she should try to enjoy herself (husband’s translation: “Doctor says go out; child is OK…”).

Tap, tap, tap…. The mother beat a tattoo on he child’s chest in a wordless appeal. Everyone knows that a sick child must be confined and given medicine. Why did the doctor keep saying that he wasn’t sick?

I repeated my reassurance, and the husband translated. When, at the end, I asked if she understood she knew the proper answer: yes. She remembered her manners as I left and thanked me effusively.

I left feeling as discouraged as the woman. She was in a strange country, trapped in a hotel room with a sick child. Despite her best efforts, the foreign doctor didn’t understand that her son needed help.

Why You Get Sick, Part 2

You do get sick because:

        1.  No one is perfect.  The healthiest human is full of clumsy design defects.  Our back muscles are too weak, so even normal activity can injure them.  Human veins are too flabby to resist a normal blood pressure; that’s why we get hemorrhoids and varicose veins.  Roughage may be good for you, but humans can’t digest some carbohydrates.  That’s why a high fiber diet causes gas.

        2.  Your “resistance” is too strong.  Don’t blame a fever on that infection you caught.  Your body itself generates extra heat whenever an invader is present.  Some experts claim fever is good for you, but the evidence is thin.

        The human immune system is too strong for its own good - and trigger happy!  Allergies occur when it tries to defend you against an innocent pollen, drug, or food.  Even worse, it may decide one of your own organs is the enemy.  Thyroiditis, the most common cause of thyroid deficiency, is an “autoimmune” disease.  An overactive immune system may also assault the heart (rheumatic fever), liver (autoimmune hepatitis), kidney (glomerulonephritis), joints (rheumatoid arthritis), or skin (eczema, hives).

        3.  Nature plays no favorites.  It assumes germs and viruses have as much right to exist as you.  Catching the flu, for example, is not a sign of weakness.  Most healthy people exposed to a new flu virus get sick.  Then they recover, but this is not a defeat for the virus.  Multiplying during the illness, many escape into the air to infect others.  The flu virus normally infects a victim for a week or so, then moves on.  That’s the role it plays in nature.  Your role is to get the flu now and then.

        Medical science works to give humans an advantage in this competition, and we’ve done pretty well.  But nature is impartial.

A Death

A guest at the Park Sunset complained of the flu. His temperature was 101; my examination was normal, but patients with influenza have a normal exam.

He looked miserable, but he was forty-one and in good health, and everyone with the flu looks miserable. There was no reason not to give the usual remedies and check back later. This happened long ago, but I still remember the inexplicable feeling that something was not right. I couldn’t bring myself to leave him in the room.

Leaving after extracting a guest’s promise to go to an emergency room is a bad idea. If the guest decides not to go and something dreadful happens, I’m the last doctor he’s seen. Calling paramedics was another option, but they might not share my unease.  

Explaining that he required further attention, I drove him to the nearest hospital. The next day I phoned. He had been admitted and died a few hours later. The doctor who cared for him was as mystified as I. We theorized he was suffering an overwhelming infection from an unknown source. Perhaps he took drugs. This was early in the AIDS epidemic, and victims sometimes died abruptly when their immunity vanished. We never found out.

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.

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. 

Lack of Patience

“How quickly can you get here?”

“Pretty quick, but I like to talk to the guest first. Would you connect me?”

I didn’t assume this was an emergency; guests who make urgent requests are more often impatient than sick.

“How quickly can you get here?” asked the guest impatiently.

“Pretty quick. What’s going on?”

“It’s my assistant. He’s got the flu.”

“Could you tell me what’s bothering him?”

“I’m not a doctor. That’s why I called you.”

I suppressed a surge of annoyance. “People mean different things when they say ‘the flu.’ Is he vomiting?”

“No.”

“Is he feverish?”

“Yes. I have a dinner reservation at 6:30. Can you make it?”

It was 5:30. Unless guests feel truly miserable (vomiting, pain) they are usually willing to wait, so I like to delay dinnertime calls until rush hour traffic dwindles. But hotel doctoring is a competitive business, and if I disappointed this demanding caller, he might ask the concierge to suggest someone else.

Creeping 1½ miles to the freeway onramp took fifteen minutes, but then traffic moved steadily, and I arrived on time. In hotel doctoring, delivering medical care is the easiest part. The patient suffered a bad cold and didn’t consider it a serious problem. In person, his boss seemed congenial.

On my drive back, the freeway stopped cold. I took an exit three miles from home.  Despite this, traffic crawled so slowly I was expecting a blocked lane ahead, but it was just the rush hour. It took an hour. On the bright side, I had finished half my dinner when the call arrived, so I wasn’t hungry. And in hotel doctoring, when you finish seeing one patient, you go home.

The Law

A Finnish man with a fever was staying in a Hollywood Hotel. Treating flu symptoms is rarely satisfying, but I was pleased to learn that he was taking nothing for the fever. I handed over some Tylenol, and when I called back that evening he felt better. 

The following day was July 4. Hotel doctors look forward to holidays because freeway traffic is lighter. Sadly, no calls arrived. None arrived the day following or the day after that.

Deep down, no one believes in the law of averages. If you flip a coin heads ten times in a row, that’s not a fluke but as likely as any other combination. And the odds that the next flip will be heads remains fifty/fifty. It’s guaranteed that someone will win the lottery, but the winner always credits God. After several days with a silent phone, I conjure up images of a rival sweeping up my hotels with irresistible charm or fifty-dollar bills. But calls resumed

Yearning for a Rare Disease

When I was an intern, a young man came to our emergency room with fever, body aches, and general miseries.  It seemed routine until we noticed a spotty rash on his hand and feet.  Then everyone perked up.  Rash-on-hands-and-feet is a medical puzzle with plenty of answers.  We racked our brains for diseases that qualified.

“Rocky Mountain Spotted Fever,” said an intern.

“It could be secondary syphilis,” said a resident.

“Maybe typhus,” another suggested.

An old professor arrived, looked over the patient, and then turned to us. “Those are all possibilities, but any virus can produce that rash,” he explained. “It’s probably the flu.” Sadly, from our point of view, he was right.

A Dangerous Occupation

As I entered the room, half a dozen family members stood and bowed. When Japanese bow, it means no one speaks English, so I phoned the Japanese insurance agency that sent me.

Passing my cell phone back and forth to the patient, I asked the usual questions and listened to the dispatcher’s interpretation. After the exam, I phoned the agency again to deliver my conclusions.

The guest had the flu. 

Everyone gathered and bowed as I left. Even as the door closed, I was worrying.

Doctors are casual about washing their hands. If your doctor skips it, his hands carry whatever infection they picked up from previous patients. Remind him.

I usually come directly from home where I don’t handle sick people, but I always wash my hands before seeing a guest; afterwards I do the same. I do this partly though habit but also to protect myself.

As I walked down the hall, I was aware that I couldn’t disinfect my phone which the guest had handled repeatedly. Over the coming week, I’ll learn whether or not I’ll catch her flu.