Jumping to Conclusions

Midafternoon is a slow time, so I take a history class at UCLA, and I’m rarely disturbed. But my phone buzzed.

“This is International Assistance about the patient you saw today. She has begun to vomit and wants another visit.”

That morning I had given ibuprofen to a woman with a headache. She was in Hollywood, a tedious eight mile drive through city streets with the rush hour beginning. After twenty minutes of stop-and-go, a sense of unease grew. Ibuprofen shouldn’t cause such a violent reaction. Then I remembered that the Hollywood patient was not from International Assistance but World Assistance.

International Assistance had called the previous night at 1 a.m. and sent me to the Airport Hilton for a guest suffering a backache. I’d given an injection and left strong pain pills for later. I checked caller ID on my cell phone and, sure enough, I’d jumped to the wrong conclusion.

The Hilton was in the opposite direction. It took another twenty minutes to reach the freeway and join the rush hour creep. 

I Like Vomiting

A businessman at the Standard had been throwing up since the wee hours. I assured him I’d arrive within the hour. It was nine a.m., so the usual half-hour drive downtown might last longer.

Before leaving, from my medication closet I extracted a syringe, a packet of antinausea pills, and an antivomiting suppository and dropped them into my pocket. This enabled me to avoid restocking my bag after returning home. Sometimes I forget.

The drive was tolerable. The guest was miserable, but he hadn’t vomited in two hours, so I suspected he was over the worst. I left feeling good. I like vomiting.

People chuckle to hear this, but in an otherwise healthy person, most episodes don’t last long, rarely more than a day. My medicines help symptoms but don’t speed recovery. When guests feel better, often by the time the medicine wears off, they believe I've cured them. He felt better by evening.

Traffic

Bending over, a guest at the Georgian felt stabbing pain in his back. He could barely move.

Acute back pain usually doesn’t last long, so, over the phone, I assured him that he would be disabled for a day and then gradually improve. I was not anxious to make this visit because it was 4 p.m. I would be driving to Santa Monica and back during the rush hour, a tedious experience. But he wanted a visit.

It was a tedious drive, not improved by the sight of immobile traffic on the opposite side of the freeway. The guest answered the door himself, always a good sign in someone with back pain. I examined him, repeated what I had said over the phone, and handed over pain medication; it was an easy visit.

Returning, I settled into the rear of a nearly motionless stream of cars. I was in no hurry; it was suppertime, but I wasn’t hungry. After ten minutes, my phone rang. A guest at the Crowne Plaza in Beverly Hills asked for a doctor. His wife was vomiting.

I often delay visits, but people who are vomiting hate to wait. This would normally be a quick drive because the Crowne Plaza was only five miles away, and I was headed in that direction. But it was the rush hour. I left the freeway and crept for thirty minutes along Pico Boulevard to the hotel. The visit went well, and the drive home was tolerable.

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.

A Hotel Doctor's Database, Part 2

Men travel more than women but are less likely to call a doctor so I’ve seen more women (9833) than men (8483). My database contains 124 patients under age one and seventeen over 90, the oldest 97. The smallest of the small hours are not silent. I’ve made 858 housecalls between midnight and 5 a.m.

My leading diagnosis is the same as that of any family doctor: respiratory infections, 4700 visits. In second place are upset stomachs with vomiting and diarrhea: 2672.

I’ve been around long enough to see 77 patients with chicken pox, another 83 with gout, 12 with mumps, 61 with herpes, 29 with poison ivy, and 149 suffering a kidney stone. Victims of kidney stones rarely delay calling a doctor, and since they are rarely emergencies I visit a fair number.  I’ve seen 82 guests with chest pain and sent fifteen to the hospital. Far more of my 30,000 callers complained of chest pain, but I work hard weed out emergencies over the phone. Those fifteen were mistakes.

My most numerous foreign patients are from Argentina, 1854, barely surpassing Britons at 1821. That’s because South American travel insurers mostly began there and are still mostly based in Buenos Aires. But they are expanding, and since 2000 I’ve seen more Latin American guests from Brazil. 

I’ve cared for guests from Andorra, Tonga, Malta, New Caledonia, and Curacao but not from Latvia, Estonia, Yemen, and half a dozen African nations. Russians didn’t travel until the fall of the Soviet Union. I saw my first in 1991. The Chinese don’t appear until 1998. So far Cuba has sent one.

Six guests died – fortunately none in the room after my visit. One was dead when I arrived. Four died soon after I sent them to the hospital and one after the ER doctor (mistakenly) sent her back. I called the paramedics after examining sixteen guests. To my great distress (because that means no payment) paramedics were there when I arrived six times. Many more guests needed attention but weren’t urgent. Leaving after obtaining their promise to go to an emergency room is a bad idea. If the guest decides to wait, and something dreadful happens, I’m the last doctor he or she saw, a situation that focuses the attention of malpractice lawyers. When a guest needs an emergency room, I offer to drive them. I’ve done this 48 times.

28 guests cancelled while I was still driving. 47 weren’t in the room when I arrived. 60 refused to pay. 21 paid with a bad check, but not all were deliberate. I eventually collected on 8. Four times, when I arrived, another doctor was there.  I don’t record guests who get a discount but 173 paid between $5 and $50. 110, mostly hotel employees paid nothing. I will not deny that I have a category for “celebrity.” It has 95 entries although that includes their wives and children. I try to head off drug abusers, but 78 slipped through. The diagnosis on four was “drunk,” but that’s certainly too few.

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.

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 Luxurious Langham

Mid-level chains (Hilton, Hyatt, Holiday Inn, Sheraton) provide most of my business. I love luxury hotels, but these have traditionally formed the bread-and-butter of hotel doctoring, so my competitors love them more. The result is that when one of them notices an iconic Los Angeles hotel (Bel Air, Beverly Hills Hotel, Peninsula, Sofitel, Four Seasons) calling me too often, he steps in and points out the error of its ways.)

My colleagues don’t care to travel, so I’m the doctor for one of the most opulent hotel in the county: the Langham (formerly Ritz-Carlton) in Pasadena 25 miles away. It sits on twenty acres that includes a beautiful Italianate-style main building, luxurious Spanish Revival-style cottages, and a historic garden.

A Langham concierge once asked me to speak to a guest with an upset stomach. The guest sounded weary and hoarse after vomiting for several hours, but she was in good health, so odds favored the usual stomach virus, miserable but rarely life-threatening. Most vomiters want quick relief, but she preferred to wait it out. I gave the usual advice (don’t eat, don’t drink, suck on a piece of ice) and left my number. Fifteen minutes later the concierge connected me to another vomiting guest who also declined a visit.

This would have been a rare treat – two patients at the same hotel. Sadly, both were American. Since Pasadena lacks the international tourist caché of Los Angeles, the Langham houses mostly Americans who are less inclined to pay for a housecall.   

When I phoned later that day, both had recovered. They were grateful for my concern, but they would have been more grateful if I’d cared for them. Although you might not think so, I consider vomiting a good visit. It usually doesn’t last long, and the doctor gets the credit when it stops.

Things Patients Tell Us That Are Almost Never True, Part 2

“It tasted funny….”

Everyone with an upset stomach blames their last meal, and some are right. But the toxins that make you sick quickly (mostly staphylococcal) and the bacteria that made you sick after a few days (salmonella, shigella, campylobacter) have no taste.

“My pressure is up.”

Calls from guests to “check my pressure” arrive regularly. I can’t remember a visit in which high blood pressure was the problem because high blood pressure doesn’t cause symptoms. I won’t mention the symptoms it doesn’t cause because no one believes me.

A Useful Technique

“It sounds like a stomach virus. These usually don’t last long. You’re healthy, so vomiting for a while isn’t life-threatening, but it’s definitely miserable. I make housecalls, so if you’d like me to come….”

“It sounds like a stomach virus. These usually don’t last long. Here’s what I want you to do. Don’t eat anything. Don’t drink anything. Get some ice from the ice machine. Lay quietly with a piece of ice in your mouth. Don’t chew. Keep sucking on the ice. I promise to call back in two hours. If you want a housecall, I can come.”

I’ve given these two pieces of advice thousands of times. If, after hearing the first piece, a stoic vomiter decides to wait, I deliver the second, but sometimes I go straight to number two.

“The fish tasted funny, and I’ve been throwing up since two. Can you give me something?”  The caller was at the Beverly Garland in Universal City. It’s an easy fifteen mile trip but not at 6 p.m. on a weekday. I try not to drive long distances when the freeways are jammed. To avoid this, I use a technique we in the medical profession call “stalling.”

At least half have improved when I call back, so I lose a good deal of money, but I wouldn’t have it any other way.

Another Stoic

“She thinks her drink was spiked,” explained the caller whose friend was bent over the toilet.

I explained that alcohol is a toxic drug no less than aspirin or penicillin and occasionally provokes an oddball reaction. Common stomach viruses cause most vomiting. Did her friend want me to come?

“I’ll ask.”

I waited for a long time.

“She wants to know if we can buy a medicine.”

I said that there are no good over-the-counter antivomiting drugs, but most vomiting episodes don’t last long.

“I’ll tell her.”

I waited for a long time.

“Will you give her a shot to stop the vomiting?”

I explained that I carry antivomiting shots and antivomiting pills and that they work pretty well. It’s a bad idea for a doctor to make promises.

“Hold the line.”

I waited a long time.

“She wants to know what she can eat.”

“Nothing,” I said. She should suck on a piece of ice until she hasn’t vomited for a few hours.

By now I suspected that the guest was not inclined to spend money. This is common, especially in Americans. 

“Does she want me to come?” I asked.

After the usual wait, I learned that she planned to take my advice and call back if she needed assistance.   

An Unsatisfied Customer

A Quantas flight attendant was vomiting, so I drove 49 miles to the Radisson in Newport Beach.

Fortunately, she was already getting better. She hadn’t vomited in six hours but was still queasy. I told her that she should continue to improve and advised her to suck on ice chips. I went to the ice machine and filled a tub. Normally, I would have left antinausea pills, but she was pregnant. She thanked me effusively as I left.

Soon after, a nurse from the airline phoned. Tactfully, she explained that the Quantas crew member had expressed concern. In her original call, the crew member had requested medicine for vomiting. A doctor had come but left without giving anything.

I explained that she was recovering and didn’t need medicine. In any case, she was pregnant, so taking drugs was not a good idea. The nurse expressed complete sympathy.

Later, the director of the housecall agency phoned. Tactfully, he explained that a nurse had passed on some concerns expressed by a flight attendant. I repeated my explanation, and he expressed complete sympathy. The following day he phoned again to assure me that I had done the right thing and that he was working hard to make Quantas see the light.

Satisfying and Unsatisfying Problems

A guest interrupted my questioning to dash into the bathroom, and I heard the sounds of gagging as she vomited.

While waiting, I took a vial of ondansetron from my bag and began filling a syringe. After a few minutes I heard the toilet flush.

“Why don’t I give the vomiting injection now?” I said when she reappeared. “You’ll probably want one.” She agreed with enthusiasm.

I finished my exam, made a diagnosis – the common stomach virus – and delivered advice and a packet of pills. I also went to the ice machine down the corridor and filled her ice bucket, so that she could suck on the chips for the next few hours. She was very grateful and equally grateful the following morning when I phoned to learn she had recovered. Most stomach viruses don’t last long, a day or so.

Vomiting and diarrhea are usually satisfying problems for a doctor. Most skin problems are easy. I rarely have a problem with earaches, backaches, minor injuries, common eye inflammations, even most urinary and gynecological complaints. A hotel doctor’s patients are healthier than average, but serious problems occur. It turns out that these are not necessarily “hard.” When I encounter someone with chest pain, eye pain, sudden weakness, difficulty breathing, or an injury that may be serious I know what to do. At the end patients receive the care they should receive, and we both know it. That’s a satisfying feeling.

What is the most unsatisfying problem a doctor faces? Rare diseases? Puzzling symptoms? Neurotics? Drug addiction? None of these. Most doctors would agree that it’s the common viral upper respiratory infection. About twenty percent of everyone who consults a doctor suffers. Hotel guests are no exception. No one tries to educate me about heart attacks, but everyone is an expert on these. Patients tell me how they acquired theirs (“I got caught in the rain”), or why (“I’m not eating right; my resistance is low”), the proper treatment (“my doctor gives me a Z-pak”), and what will happen if I disagree (“It’ll go to my chest”). These explanations are always wrong.

You catch a virus from another person. The illness lasts from a few days to a few weeks. If you see a doctor, he or she will prescribe an antibiotic at least half the time. The antibiotic is useless. Doctors know this but prescribe them anyway.

No patient agrees. “I have a good doctor,” they reply. “He would never do that.”

My response is that prescribing useless antibiotics is not necessarily a sign of incompetence. It’s so common that good doctors do it. One expert calls this avalanche of unnecessary antibiotics one of our greatest environmental pollutants. It’s producing a growing race of “superbugs:” germs resistant to all antibiotics.

Here’s a professional secret. When doctors chat among themselves, we often bring up the subject. Challenged by colleagues like me, prescribers never claim that antibiotics cure these infections. They know they’re a placebo, but they respond with a powerful argument. “When I’m finished, I want patients to be happy, and they are happy. One hundred percent. What’s your experience?”

It’s not as good. When I deliver sympathy, advice, and perhaps a cough remedy to patients with a respiratory infection, most seem genuinely grateful, but a solid minority drop hints (“Isn’t there something to knock this out….?” “My regular doctor gives me…..” “I have a meeting tomorrow, and I can’t be sick…”).

Doctors love helping patients. That’s why we went into medicine. Equally important, we want you to feel “helped,” and we are super-sensitive to your gratitude. Almost everyone is too polite to argue with a doctor, but we can detect the tiniest trace of disappointment as you leave. It hurts us. Every doctor knows that he can eliminate this pain and produce heartfelt gratitude by prescribing an antibiotic. This is terribly tempting, and after a few dozen or few hundred or few thousand disappointed patients, most doctors give in.