Tricky Problems

 It upsets me to collect a fee and then send a patient to a clinic or emergency room for care I can’t provide in a housecall. I try to anticipate these.

Many guests phone after a painful accident, hoping I can do an exam and tell them whether or not they have a fracture. Sadly, unless it’s visible to the naked eye, I can’t. It turns out that medical science does little for broken toes, ribs, or noses, and most common fractures (arms, wrist, hand, finger, foot, ankle) are not emergencies. If a guest is willing to wait till office hours, I can make them an appointment with an orthopedist.

Upset stomachs make up the second most common ailment that I hear about. These usually don’t last long, and I carry medicines that help. Stoics often prefer to wait. This is not unreasonable, but the longer symptoms – usually vomiting – last, the less likely that medicine will help. After about a day of vomiting this becomes so unlikely that I send the guest to where they can receive IV fluids.

Abdominal pain is usually benign in a young person but less so as the years pass, and it’s tricky. Entire books have been written on it. I recommend the shortest:  Early Diagnosis of the Acute Abdomen by Zachary Cope, a British surgeon. He wrote it in 1921, and revised it every few years till he died in 1971. 

You can download it free. He’s a droll and witty writer, easy for laymen to understand.

Should I Make a Housecall?

Only half my callers require one.

As I repeat, I’m happy to phone a pharmacy when guests forget legitimate medication: blood pressure pills, heart pills, contraceptives, etc. I don’t do this for guests who tell me “I had the same thing last year, and my doctor prescribed……” 

Exceptions exist. If a caller has had gout I believe him. It’s acceptable to treat a young woman with a typical bladder infection over the phone. If you’re wondering about symptoms of a “typical” bladder infection, I’m not telling. You have to tell me. Most “my doctor prescribes...” calls concern upper respiratory infections where the guest has received the traditional placebo antibiotic and believes he needs another.

Guests with stuffy ears don’t object if told they need a housecall, but I resist the temptation because ordinary congestion causes bilateral ear discomfort without pain. Over the phone, I advise aggressive use of nasal spray before takeoff and before the plane descends.

Injuries can be tricky. A doctor’s exam rarely diagnoses a fracture, but most common injuries are not urgent, even when a fracture is present. If guests are willing to wait until business hours, I can send them to an orthopedist’s office, more civilized than an emergency room. For back pain, a housecall is better. If you go where there’s an x-ray, you’ll get one, and experts agree that back x-rays are almost never helpful.

Much of my decision on making a housecall depends on the law of averages. Chest pain in a fifty year-old is usually not serious, but it’s unwise to assume this. It’s less unwise in a twenty year-old. A sore throat in a child or adolescent might be strep which medical science can cure. After age fifty it’s almost unheard of. I’ve never seen a case.

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. 

Always Pack a Flashlight

A guest searching for the bathroom at night stubbed his toe. Pain was excruciating.

Vomiting at 2 a.m. is good housecall. Chest pain at 2 a.m. is usually not a housecall. But some decisions when the phone rings at 2 a.m. are tricky.

Nothing about an injured toe is urgent except for the pain. Even if it’s fractured, the only treatment is to splint the toe by taping it to its neighbor.

Having told this to the guest, I hoped that he wouldn’t insist on a housecall. Once in the room, there is no problem, but I often never get there. After half an hour, while I’m still on the freeway, the guest may realize that the pain is tolerable and that he is on the hook for substantial cash (hotel doctors charge more during wee hours).

As often as not, the guest goes back to bed after asking the hotel operator to phone me and cancel. If I’m lucky, the operator makes the call.

I Know It's Not Broken...

“I can walk on it, so it’s not broken…” “I can move it, so it’s not broken….”  Never forget that popular health beliefs are generally wrong. I walked on a painful foot for a week before an X-ray that revealed the fracture.

My greatest service to injured hotel guests is not in diagnosing fractures which is usually impossible but saving them the misery of spending hours in an emergency room. Doctors do little for cracked ribs and broken toes except to relieve pain, so X-rays aren’t necessary. 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 for minor injuries.

Most injuries are not emergencies, even if a bone is fractured. If guests are willing to wait, I can send them to the more civilized atmosphere of an orthopedist’s office. 

Deception

A tour leader explained that one of his group wanted a doctor to look at her hand. She had fallen.

Minor injuries are easy, but I don’t want to collect money from someone who needs an x-ray and then send them off to pay more money somewhere else. 

I quizzed him. What happened? Where was the pain? Was there much swelling? He assured me that it was not a big deal. The lady just wanted a doctor to check it.

He was lying. When a member of a tour goes to an emergency room, the leader must go along. Anxious to avoid such a tedious job, tour leaders often hope a doctor will make the problem go away.

The lady had a swollen, painful left wrist. If you fall and instinctively catch yourself on your outstretched hand, you’re likely to break a specific spot at the end of your radius. It’s so common it has a name: the Colles fracture.

I was certain she had a Colles fracture, so off they went.

A Medicolegal Visit

A guest was eating lunch in the hotel restaurant when the chair collapsed. Unfortunately, her hand was resting underneath. The desk clerk asked if I could come immediately.

During my early years, I would hurry over, take care of the problem, and present my bill only to have the guest insist that the hotel was responsible. Management sometimes disagreed, so I learned to settle matters over the phone.

“I need to know who’s paying,” I said.

The clerk she put me on hold, returning to announce that the hotel would take care of it. This would be my 146^th  medicolegal visit, my name for a housecall when the hotel offers to pay. Most involve minor injuries that occur on the premises. There were also thirteen upset stomachs, purportedly from hotel food, and nine insect bites, always bedbugs according to the guest.

I arrived to greet a young Englishwoman, her hand in a bowl of ice. Two fingers were exquisitely painful. She needed an x-ray. I found a local orthopedic group on the internet and phoned.

“An initial visit is $500,” said the receptionist. “She needs to pay when she comes in.”

“Wow!” said the guest when I passed this on. This was probably not a comment on the size of the fee (which the hotel would cover) but the traditional European amazement-cum-horror at American doctors’ preoccupation with money.

Both fingers were fractured. Fortunately, her visit was ending, and she flew home the next day.

Bad Credit Cards

A member of an Argentine soccer team fell while roller staking, wrenching his ankle.  A doctor from their travel insurer in Buenos Aires determined that he needed an orthopedist but that this could wait until office hours the following day. However, the doctor wanted someone to examine him that evening, so my phone rang.

The team was staying in Long Beach, 35 miles away, but the rush-hour had passed, and the agency did not object to the extra fee. This was International Assistance. I’ve made 896 of its visits, but after an ownership change, it became extremely slow to pay. Losing patience, I insisted it give me a credit card number, so I could pay myself. This is always a critical request, because some agencies refuse and disappear from my radar. But International Assistance agreed.

As soon as I hung up, I remembered that IA’s current credit card had expired in August. When I called back, the dispatcher put me on hold to consult her superior. After a few minutes, she returned with a new number.

I phoned the credit card company and entered my identification and the credit card number only to hear the computer declare: “Do not honor! Do not honor!” I phoned IA again, awaited the consultation, and received another card. “Do not honor!” intoned the computer a second time.

“Invalid credit card number” I heard on my third attempt. This turned out to be my mistake; in my increasing frustration, I made an error entering her third number. After correcting it, I heard the satisfying: “Approved” following by a confirmation number. Insurance agencies often give me bad credit cards. I suspect their business is as competitive as mine, so many are in perilous financial condition.

My patient was reclining on a couch, an ice pack on his ankle, his teammates gathered around. The ankle was massively swollen, and he was in pain. Waiting would not have caused permanent harm, but people with painful injuries deserve quick attention.

Fortunately, IA is an agency that takes my advice even when it costs money, so his companions took him to an emergency room to deal with fractures of both leg bones.