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 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. An hour of exercise is as exciting as an hour brushing your teeth, and I’m deeply suspicious of anyone who claims to enjoy it.

Even better, the second patient 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, causing frequent infections. This was another, so I gave him antibiotics in good conscience.

These were satisfying encounters, but there was a downside. Because both were at the same hotel, I finished before 11 o’clock, too early to skip my workout.

 

 

Dodging a Bullet

The army does not hand out generous transportation allowances, so it housed this officer’s family in a single room of a Days Inn. Arriving, I squeezed past stacks of luggage and between three rollaway beds where the children slept.

I suspected the officer’s wife had pneumonia. Although rarely serious in a young patient, she looked sicker than usual: feverish and short of breath. 

Doctors make most decisions based on evidence or gut feeling, but sometimes a third factor intervenes: inconvenience. For example, as a patient it’s risky to be the final appointment before lunch or at the end of the day. There’s a small chance the desire to get out of the office will influence the doctor. Rarely, this leads to a decision that comes back to haunt him. I’ve been around long enough to think twice before making a decision that saves aggravation.

Leaving after giving an antibiotic for pneumonia was a reasonable option, but, reluctantly, I announced that the wife needed to go to an emergency room.

Aggravation followed. The father did not normally care for the children, so I sat patiently for half an hour as he woke them, struggled with their clothes, made several phone calls to reschedule his flight, and then shifted a dozen boxes between his wife’s bed and the door. After this was well under way, I left to fetch my car, parked two blocks away. Fitting six people into a tiny Honda took additional effort.

It was a relief to usher them into the waiting room, explain matters to the clerk, and say my goodbyes. It was a greater relief to learn, when I called the hospital later, that the wife lay in the intensive care unit and on a respirator, fighting a catastrophic pulmonary infection.

The Old Man's Friend

A guest was coughing and feverish, and I heard crackling noises when I listened to his lungs, a sign of fluid. I suspected pneumonia.

I prefer diagnosing pneumonia to an upper respiratory infection because I can prescribe an antibiotic and skip the stressful explanation of why I’m not prescribing an antibiotic.

Unfortunately, this guest was 85. Most victims of pneumonia don’t need hospitalization. Even without treatment, most recover. This is not the case with the elderly where, long ago, pneumonia was known as “the old man’s friend.” Dying of pneumonia when you’re already feeble is apparently not a bad way to go.

The son did not like hearing that his father must go to an emergency room, but they went. When I phoned the following morning, I learned that the diagnosis was pneumonia. The doctor had prescribed an antibiotic and sent them out.

I was shocked. Hospitals always admitted elderly patients with pneumonia. What incompetent was on duty?...  The son assured me that his father was resting comfortably and promised to return to the hospital if symptoms worsened. When I called that evening, they had checked out.

If something bad happens, they will sue the hospital, but they will also sue me. It takes a long time for a malpractice lawyer to organize a suit, so his letter wouldn’t arrive for about a year.

I Save a Life

The phone rang at 5 a.m. but I am an early riser. April Travel Insurance told me of a lady with a cough at the Residence Inn in Manhattan Beach. Vacationers hate to get sick, so even a bad cold produces wee-hour calls.

This sounded easy. It was a fifteen mile drive, but the freeways were clear, and I would return before the rush hour.

Guest often feel obligated to demonstrate how miserable they feel, and this lady coughed loudly from the time I walked in. Listening to her lungs was difficult because she wouldn’t stop, but what I heard was not reassuring. A bad cough doesn’t necessarily mean a bad disease, but this patient had one ominous sign: she was my age.

I phoned April Insurance to explain that the lady needed a chest x-ray and possible hospitalization. This is bad news for an insurer. An ordinary emergency room visit costs over a thousand dollars, a hospital admission for pneumonia twenty times that. Some insurance services work hard over their fine print to avoid paying for expensive incidents, and I occasionally urge guests to go to the hospital after they’ve learned that their insurance won’t cover it.

April doesn’t do that. The dispatcher explained that he would arrange matters. Later that day, the husband informed me that his wife had been admitted for pneumonia.

An Unwelcome Visitor from the Past

A young man at the Chateau Marmont had been coughing for two weeks. He had a fever, and my stethoscope revealed lung noises typical of pneumonia.

I enjoy diagnosing pneumonia because, in an otherwise healthy person, it’s the only common illness with a cough that doctors can cure. Everything else is a virus. 

I didn’t like this particular diagnosis. It takes a tough germ to cause pneumonia in most people, so unpleasant symptoms begin quickly. This man’s cough had persisted for some time. Furthermore, he was gay and admitted to having unprotected sex. I suspected that he had a pneumocystis infection. Pneumocystis is a fungus so benign that it lives in the lungs of most of us, causing no trouble.

Until forty years ago, it was rare, affecting patients already sick with cancer or serious diseases requiring drugs that suppressed immunity. Doctors were mystified when Pneumocystis began attacking previously healthy young men during the 1980s. It turned out to be the most common sign of AIDS.

It’s rare again today because we track immune cells of HIV patients and prescribe preventive drugs when the numbers drop. This young man had not been tested, but he was no fool. He cut short his visit and returned home.