Going Blind

Late one evening, a guest called to say his son had gone blind. That was beyond my expertise, I explained, but the guest insisted on a housecall.

Sure enough, the son, age 18, seemed blind although my exam was otherwise normal. He seemed only mildly upset. A stroke affecting a tiny area of the optic nerve can cause blindness with no other symptoms, but this would be extremely odd. It could be psychosomatic, but it’s risky to jump to this conclusion, and the family insisted that nothing stressful was happening.

I sent them to an emergency room. The doctor found nothing abnormal and summoned an ophthalmologist who concluded that the blindness was psychosomatic. You’re probably wondering if he was right, but this is a real story. They checked out, and I never learned what happened. 

Temptation

“Could you check out my ankle? I don’t want to go to an emergency room.”

These are tempting calls. I could make the housecall, solemnly examine the painful, swollen ankle, express sympathy, wrap it in an Ace bandage (universally agreed to be not much use), and tell the guest to see a doctor if he’s not dramatically better in a day or two. Happy to avoid rushing to an emergency room, the guest would consider his money was well spent.

Of course, I could have told him this over the phone. If walking on an injured ankle is painful, it requires medical attention. But unless pain is unbearable or the skin is mangled, it’s not an emergency.  

Furthermore, the medical attention should be delivered by a doctor who knows ankles such as an orthopedist. Going to an emergency room is a bad idea. You’ll get an x-ray, a bill for around a thousand dollars, and advice to see a doctor if you’re not better in a day or two.

A Better Medicine

“My doctor gives me Bactrim to take whenever I get another infection, and I need more.”

Antibiotic requests are good news to some hotel doctors who know that, provided they go along, the guest will happily hand over the fee. An easy visit.

When I see these patients and do my best and don’t prescribe an antibiotic if they don’t need one (usually the case), most are grateful, but a minority aren’t. It’s not a small minority, and I hate driving off to what might be an unpleasant encounter.

Hearing this request I go into “no-housecall” mode, perhaps mentioning that the illness is self-limited and doesn’t require medical attention or directing the guest to an urgent-care clinic. I don’t want to see them.

But I gave this lady her Bactrim.

There is a single exception to the rule that healthy patients are wrong when they decide that they need an antibiotic: the common, uncomplicated urinary tract infection. In fact, it’s OK to prescribe over the phone. Scientific studies show that this works as well as an office visit.

Better to Be Right Than Wrong

A guest told me she had a stomach virus, so I drove off in a relaxed mood. This is the second most common complaint that a hotel doctor sees and easy to deal with.

But it wasn’t easy. The guest was huddled on the bed, looking very ill. I could barely touch her abdomen. I wondered if she had acute pancreatitis or a gallstone.

The paramedics arrived and took her off.

When I called that evening, the husband answered. I learned that by the time the emergency room doctor saw her, she wasn’t feeling so bad. After several hours and many tests, he sent her out with a prescription and the diagnosis of a stomach virus. She was now better.

Naturally, I expressed pleasure at her recovery. He thanked me for my concern, but I admit to a touch of chagrin. A doctor must send a patient to an emergency long before he’s 100 percent certain there’s an emergency. Otherwise, he’d decide not to send some who needed to go: a much worse scenario. Still, it feels better to be right than wrong.  

Fear

Leafing through mail revealed a letter from a law office. I broke into a sweat and then calmed myself. Malpractice suit announcements rarely arrive in ordinary US mail. Sure enough it was simple request for records. Someone was having trouble with an insurance company. I get these once or twice a year, and they never fail to upset me.

Whether they win or lose, sued doctors rarely pay a penny, but it’s a horrible experience which they all dread. Doctors worry if something is not going right – say a patient who should get well is not getting well or seems dissatisfied. We all want to do better, but never absent from a doctor’s thoughts is that he doesn’t want to be sued.

You may wonder about the odds that this will happen. The answer: a hundred percent. Five percent of American family doctors are sued each year. The highest risk specialties are neurosurgery and cardiac surgery: 19 per cent sued each year.

To make sure your doctor has never been sued, find one who has just entered practice. If you want to investigate, most states make it easy. You can look me up at the California Medical Board site by entering my name. Feel free to do so. I’m clean.

But state boards are not terribly efficient, and many have time limits – say ten years – after which they drop the information.

Every bad thing that’s happened to a doctor is in the National Practitioners Data Bank in Washington. Hospitals and clinics query it when they’re checking out a doctor. When they don’t, you often read the results on the front page. 

The NPDB is off limits to the general public. Activists yearn to change this, but every professional organization would fall upon any legislator who agreed.

Lost in Translation, Part 5

“My husband…  not good…”

“Tell me what’s happening.”

“….chest…. Not good.”

The desk clerk helped by repeating my words in a loud voice.

“She doesn’t speak much English,” he pointed out.

She wasn’t Hispanic, so there was no hotel employee to interpret. If she had travel insurance, someone at the agency office would help, but it was hopeless to ask about it.

“Would you like me to come to the hotel?”

“WOULD YOU LIKE THE DOCTOR TO COME TO THE HOTEL!!” 

She would. I then listened as the clerk informed everyone within shouting distance of my fee.

The scene in the room resembled absurdist theater. One guest made funny noises (?coughing). Another tapped various parts of the patient’s body. A third read from an English phrase-book (…“can you prescribe an appropriate medication…?”)

Everyone listened intently when I asked a question and then exchanged glances to see if anyone understood. Finally, all nodded agreement.

I’m exaggerating. Guests have simple problems, and there’s usually enough comprehension to get along. So far everything has worked out.

A Critical Feature

The Airport Hilton has a long entrance drive that accommodates perhaps twenty parked cars without blocking traffic. Le Mondrian has a tiny drive that fits three or four.  

These are critical features in hotels without parking lots. Desk clerks always validate my parking lot ticket, but valet tickets are a crapshoot.

My tactic where I’m not known is to park as far from the entrance as possible, walk briskly up to a valet, hand him my key, announce “I’m the hotel doctor; they let me park,” and hurry into the hotel while he’s digesting the news. 

I look like a Hollywood B-movie doctor (elderly, grey beard, suit, black bag), but this does not impress valets who may run after me. If they try to hand me a parking slip I wave it off, sometimes successfully.

If I accept it, the valet is likely to drive my car off into the basement where it will take fifteen minutes to retrieve while I argue about paying. It’s a hard life.

Things Guests Ask For That I Can't Provide

“A shot to put her out.”

More than once I’m called when a guest suffers a tragic loss such as the death of a child or spouse. Distressed to witness the misery, family members want me to put her to sleep. This works in the movies, but in real life tranquilizers can’t do more than make someone drowsy. Only a general anesthesia produces sleep. No one except celebrity doctors uses it on a housecall, and you’ve read the headlines describing what happened when Michael Jackson's doctor tried it.

“A note to change my flight.”

Now and then guests call after recovering from an illness and realizing that it’s expensive to replace a cancelled ticket. They offer to pay my fee if I’ll come and write a note, but I don’t like claiming that a patient is sick if he isn’t. My tactic is to fax a note that tells the truth:  “Mr. Jones states that he was ill and unable to travel.” No one has complained, so it might work. 

“A placebo!”

No guest asks for a placebo. What they say is “You absolutely have to give something to make me better!”

In most areas of life, it’s important to tell people what you want, but it’s risky in a medical situation. Doctors want to do the right thing, but they also want you to be happy with the encounter. Don’t tempt them.

The Sight of Blood

With one obvious exception, blood normally remains out of sight. Its appearance may not be ominous but always requires an explanation from someone with more experience than you. Here are some pearls.

Bleeding gums.  Asked for the cause, doctors think of leukemia and other sources of clotting deficiency. It’s true that if your blood clots poorly, this is often the first sign. However, the most common cause of bleeding gums is poor dental hygiene.

Coughing up blood. Anyone who reads the classics knows that this means you have tuberculosis. That’s rare these days. I’ve never seen it. Mostly it’s the result of an ordinary respiratory infection. Coughing up a few flecks of blood is usually not worth pursuing, but don’t make the decision on your own.

Blood in the stool. Accompanied by pain this usually means an anal fissure, a crack in the skin. Blood in the stool is one of the seven warning signs on cancer, but I encounter bowel cancer as often as tuberculosis. The blood I see is from a fissure, hemorrhoids, or colitis.

Vomiting blood is a serious matter and also urgent. I send guests to an emergency room although a few flecks may be the result of stomach irritation. When that happens, I may make a housecall, and sometimes what I see in the toilet is not blood. Again, don’t make the decision on your own.

What types of bleeding are always ominous?... That’s a question too depressing for this blog. Google it.   

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.   

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.