Another Arab Prince

It seemed a routine visit for an upset stomach until I knocked at what turned out to be the penthouse suite of a Beverly Hills hotel. The man who answered identified himself as “the prince’s personal assistant.” I followed him into another large room where the prince, an elderly Saudi, lay in bed. It was five in the morning.

The assistant indicated the patient – not the prince but a young woman sitting nearby, looking wan. I took her into another room to deliver my care. She was an American in her twenties, and I wondered why she was in the prince’s room at this hour. Perhaps she was a prostitute, but she seemed nice.  

When I returned to the bedroom, the prince thanked me for coming, adding that he had a personal problem. He suffered crippling back pain and had run out of medication. Could I help? As we talked, I noticed the assistant waggling his finger in a gesture indicating that I should not pursue the matter. I took the hint.

Accompanying me to the elevator, the assistant explained that everyone preferred that the prince’s doctor handle the prince’s drugs. Then he pulled out a sheaf of bills and paid me far too much. I don’t decline tips from the very rich.

Most Arabs that I see are ordinary people, but over thirty years the occasional prince turns up. They pay generously and provide material for this blog .

Losing Two Out of Three

A guest at the Hollywood Heights with an upset stomach requested my services. I had barely hung up when an Englishman at the Shangri-La wanted a doctor for a respiratory infection. These hotels were not convenient – the Hollywood Heights is ten miles east, the Shangri-La in Santa Monica five miles west. But two visits make for a good day, so I drove off in a pleasant mood.

As I approached Hollywood, the phone rang. My heart sank when I learned the caller was the Sheraton in Pasadena, twenty miles away – thirty from Santa Monica.  
  

Having visits pile up, especially those with long drives, oppresses me, so this was one I’d prefer to skip.

This guest’s husband, who was driving to the hotel from the airport, was suffering a cough and sore throat and wanted a doctor when he arrived. Launching my no-visit effort, I explained that viral infections cause these symptoms in almost all cases, so a doctor can do little except relieve symptoms. I suggested that she discuss this with her husband when he arrived. She agreed. With that weight off my shoulders, I continued on to the Hollywood Heights.

After finishing, I reversed my course and headed for Santa Monica. As I neared the hotel my phone rang. “A friend of mine found a bottle of amoxicillin,” said the Shangri-La guest. “I think I’ll give it a try and save you the trip.”

Having lost that visit, I immediately called the Pasadena Sheraton. The husband had arrived, and they had decided to wait.

The Kiss of Death

Malpractice insurers look with suspicion on doctors who operate pain clinics or diet clinics or who perform botox injections or liposuction. My brother saved $12,000 on his premium when he gave up obstetrics – and that was thirty years ago. Doctors pay a fat surcharge if they engage in controversial practices, perform legitimate if risky procedures, or have personal difficulties such as numerous malpractice suits.

None of this applied to me. From a malpractice carrier’s viewpoint, I was easy money. I saw perhaps one fifth as many patients as an office doctor. Being travelers, they were younger and healthier than average. Even better, most were foreigners who don’t sue.

Except writing for a large check every year, I ignored this area until a letter arrived in 2003 from my malpractice carrier. It was a routine survey with questions about the nature of my practice: hours of operation, employees, office locations, number of patients, hospital affiliations, procedures.

I made certain they understood that I was a full-time housecall doctor who cared for a small number of healthy, nonlitigious patients.

A few weeks later I opened a certified letter cancelling my insurance. It was a terrible shock. When I applied to other carriers, all turned me down. I contacted an insurance agent who was very helpful and obtained a policy from a company in Illinois that specializes in difficult cases. It cost three times what I had been paying.

Each year when she applied to the regular malpractice carriers, they declined. They won’t insure a housecall doctor, she explained.

How did this affect my competitors? It didn’t. They cared for hotels as a sideline, usually from an office practice. If asked, none would deny that they make housecalls, but no carrier forbids them, and they’re so uncommon that applications for malpractice insurance don’t ask about them.

Boasting that I was America’s only fulltime housecall doctor produced flattering feedback but got me the kiss of death from my malpractice carrier. Perhaps they remember celebrities from Michael Jackson to Elvis Presley whose lurid final moments involved a doctor who made home visits.

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.

Can I Submit This to My Insurance?

The guest’s symptoms suggested a urine infection, one of my favorite diseases. They’re miserable but respond quickly to antibiotics. This looked like a good visit. I quoted my fee.

“Oh… I didn’t realize it would be so much.”

This happens. I remember guests from the Four Seasons where room rates start at $600 who didn’t want to pay half that. In any case, once I mention the fee, I consider it tacky to refuse someone who complains. I quoted a lower fee. That was OK.

It was a good visit. I tested her urine, announced she had an infection, and handed over her medicine. She was grateful. As I left, she indicated my invoice.

“Can I submit this to my insurance?”

“You have travel insurance?”

“I think so. They made us buy something for this trip.”

It was too late to ask why, if she had insurance, she had objected to my fee. But this also happens. In every developed country except Russia and China, if you need a doctor you don’t first decide if you can afford it, so foreign tourists often pay little attention to insurance.

Really Good Luck

I was leaving the Universal City Hilton when the elevator stopped. The door opened, and a young man rushed in, blood dripping down his face.

“I have to get to a hospital. How do I get to a hospital?” he cried.

I told him to calm down and peered at his bloody scalp, but the light was too dim to make out anything. “I hit my head on the edge of a table,” he added. “I have to get to an emergency room!”

We left the elevator at the ground floor, and I looked more closely but couldn’t see anything alarming. Introducing myself as a doctor, I led him to the men’s room, and cleaned away the blood. There was no laceration, just a long scratch along his scalp that was oozing blood. I patted it dry, applied a dressing, and assured him that it was not serious and didn’t require a trip to an ER. He felt better.

Happiness is Fleeting

The owner of a West Hollywood boutique hotel called to explain that he was suffering another herpes outbreak and needed a prescription for Zovirax. He added that, since outbreaks occurred every few months, he’d like five refills. Would I fax the prescription? After sending it off, I decided I needed to examine him to justify such a large amount. He agreed, adding that he was staying at the Beverly Hills Hotel.  

I perked up. I’ve been the doctor for the Beverly Hills Hotel four separate times since the 1980s. But I don’t market myself aggressively, so four times a more enterprising doctor has snatched it away. It’s been years since it called. I hurried to the hotel; afterward the owner thanked me for my concern. Naturally, I didn’t charge him. Leaving, I stopped by the concierge to inform him that I’d seen a guest and to mention my availability.

“I remember you, Doctor Oppenheim. From the Bel Age a long time ago.” We had a short, pleasant exchange, and he accepted my business card. I walked to my car with a light step. Not only had I pleased the owner of one hotel, there was a chance I’d acquire the Beverly Hills again.

Happiness is fleeting. A few hours later, the owner called. Angrily, he informed me that he’d gone to three pharmacies which had refused to fill the prescription. I was puzzled, and then I realized what had happened. Early that year I had purchased the new, high-tech prescriptions that the law now requires. They look like ordinary prescriptions, but if a thief tries to duplicate one, “void” appears faintly on the copy. Faxing apparently triggers the same process. I apologized and telephoned a pharmacy to give him his medication.

A Guest From Hell

As I introduced myself, the guest suggested we not shake hands because he didn’t want to give me lice. He had lice.

I settled myself to listen. He explained that when he stayed in a hotel he always asked Housekeeping for the temperature at which they laundered bedding. To save money, they often kept it under 150 degrees, too low to kill the eggs. He was susceptible to lice, an affliction that mystified doctors. Treatment only worked for a short time, but this was a cross he had to bear. At home he laundered bedding and clothes daily. Although he fumigated his house once a month, this barely kept the infestation at bay. He concluded by handing me a sheaf of printouts from internet medical sites discussing lice and their treatment.

This was delusions of parasitosis: rare but not terribly rare. I’ve encountered half a dozen over thirty years. Confronted with a delusion, no one, doctors included, can resist the urge to point out the facts, a useless tactic. As anyone familiar with the debate over vaccination knows, faced with a deeply held belief, facts are worthless.

“Can you show me a louse?” I asked.

“I pick them off so fast they’re hard to find. But let’s look.”

I pulled out my flashlight, and together we peered at his pubic area.

“There’s a nit (egg),” he said after a long search.

“That’s a flake of skin.”

We turned up other bits of debris. Finally, I straightened up. “A louse infestation isn’t subtle, and I don’t find one.”

Having heard this from every doctor, he was not offended. “I need a prescription. Over-the-counter remedies don’t work.”

I wrote the prescription and held it out.

“Give it to the hotel,” he said. “They’ll pick it up and pay for it.”

“I’m not sure they will,” I said.

“They’ll do it. I’ve already told them I plan to sue.”

Doctors hate hearing that word. “That costs a lot of money,” I said. “And I doubt you’ll win.”

“Right on both counts,” he responded pleasantly. “It costs five or ten thousand dollars to hire the lawyer and file the suit, and usually the hotels won’t settle. But I can’t let them get away with filthy bedding.”

How Many Pills Were in the Bottle?

“I came back to the room, and my Vicodin was gone.  The maid threw it out when she cleaned.”

“And how many pills were in the bottle?”

“Almost two hundred. I’ve had four back operations.”

“That’s a lot of Vicodin.”

“Check me out. I’ll show you the scars. I need your help.”

Plenty of drug abusers lead productive lives although it depends on the drug. You can’t do this for long with speed. Amphetamines and cocaine poison tissues, the brain most of all. Alcohol is also a toxin; alcoholics wreck their health. This doesn’t seem true for narcotics (Vicodin, Percodan, Oxycontin, heroin, etc). One can consume high doses for a lifetime with no noticeable harm except chronic constipation. Street addicts die from overdoses, contaminated drugs, disease, and violence. In countries that provide clean narcotics to addicts, they have a normal life expectancy.

Narcotics are probably OK for selected patients with chronic pain and a competent doctor. But there’s no denying that too many people are taking more narcotics than they need. Good doctors object because there are better ways of treating chronic pain. Moralists object on the grounds that doctors should make patients feel normal but never better than normal.

“As a hotel doctor, I encounter this problem now and then...”

“I swear I’m not a junkie, Doctor Oppenheim. I have chronic spinal pain, and I’m under a doctor’s care.”

“I’m glad to hear that, because I’ll have to speak to him.”

“He’s in New York. It’s midnight in New York.”

“I know. So I’m going to phone ten Naproxyn to the Walgreen’s at Santa Monica and Lincoln. Tell your doctor to call me tomorrow.” 
  
“The damn hotel threw out two hundred pills! They said you’d replace them!”

“I don’t work for the hotel. It sounds like the Naproxyn is unacceptable to you. So…”

“I’ll take the ten.”

This would satisfy him temporarily, but the odds were one hundred percent that his doctor wouldn’t call, but he would. There was a small chance he’d be in another hotel and pester another doctor. There was a large chance he’d behave in a sufficiently obnoxious manner that the staff would take any complaint about me with a grain of salt.

What Doctors Really Think (Maybe You Don't Want to Know)

If you want to learn our deepest thoughts, join an internet physician forum. Medscape and Sermo host the largest, but dozens exist. They restrict membership to physicians, but any intelligent person can figure out how to join. Think carefully before trying, because you may not like what you find.  

Most forums divide posts into clinical and nonclinical. The clinical section discusses treatments, techniques, and difficult cases. I find these stimulating; many doctors know their stuff.

Nonclinical posts deal with running a practice, patients, colleagues, and politics. I pray they don’t represent a cross-section because most forum doctors – say 80 or 90 percent – are extremely conservative and obsessed with money. Also, they don’t much like patients, cash payers excepted. For insured patients their feelings are ambiguous; they seem to believe that using insurance is a sign of weakness; real men pay real money.

They detest anyone on welfare. One persistent theme is the prosperity of Medicaid patients. They arrive in Cadillacs, own IPhones, wear expensive clothes. Since accepting charity shows a flawed character, they are irresponsible, demanding, rude to staff, needy, fond of drugs. The single mothers make an appointment for one child but bring them all (to these doctors, a single mother is the patient from hell).

Paradise is a cash-only practice, no insurance accepted. These are impractical except in wealthy areas, but doctors love to chat about them. If you can’t sign onto a forum, google “concierge practice” for a creepy dose of these doctors’ heaven.

They hate insurance companies and malpractice lawyers, opinions I share. They see lawyers as Americans saw communists during the 1950s:  (1) evil and (2) much cleverer than we are. As an example of their cleverness, lawyers bill for phone calls. It drives forum doctors crazy that they can’t do the same. “We’re running a business,” they argue. “We’re providing a service! We should charge for it. Sensible patients won’t object!”

They hate insurance because billing requires complex paperwork for less reimbursement than they’d like. Scores of carriers exist, all with different policies, exclusions, and requirements; sensible doctors pay a fulltime employee to handle billing.

Now and then a naïve doctor wanders onto these forums with the identical question. Why, instead of billing innumerable carriers, don’t we bill one? That would be the government. It would be simpler and cheaper. Private carriers keep ten to forty percent of premiums as expenses; Medicare keeps five percent. This is called the “single payer” system. Some physicians but almost no Congressmen support it, and mentioning it on a forum is a red flag. The innocent doctor is probably stunned to read an avalanche of abuse.

Green Is Not a Big Deal

One mystery I’ve never solved is why patients worry about green bodily fluids.

Guests with a cough tell me that they wouldn’t have called if their mucus hadn’t turned green. In fact, in an otherwise healthy person, green mucus is rarely a serious sign. Ditto for yellow. Everyone’s respiratory tract produces a quart of mucus a day. When it’s irritated, it produces more, and it can change color.

If you vomit on an empty stomach you might see bile which is green. This has no great significance. Many patients believe that they shouldn’t vomit if their stomach is empty, so something ominous is happening. This is not so. The signal to vomit comes from your brain, not your stomach.

Patients with diarrhea often save it in the toilet for my examination. I consider it bad manners to refuse to look, but normal stool can turn green.

There are exceptions. Blood from these orifices is never normal, so it’s OK to show me. If your stool or vomitus is black – pitch black, never dark brown – that’s usually bleeding.

A good rule (although my lawyer insists that I add that plenty of exceptions exist) is that you should see a doctor if you feel bad. If you don’t feel bad, it’s probably not necessary. Don’t pay too much attention to green stuff.

A Dog-Eat-Dog Business, Part 8

I was delighted to receive a call from a large Beverly Hills hotel that hadn’t called in years.

I hurried over and was attending a guest when there was a knock. The guest was not dressed, so I opened the door and found myself face to face with one of the young concierge doctors who had entered the field. I suspected that this was his hotel.

Hotels occasionally summon another doctor when the first is slow arriving. Since I’m never slow, I’m always the second doctor called, and I’ve usually come and gone by the time the original appears.

“Looks like a communications slip-up,” he said. “I’ll take care of it.”

I closed the door and went back to work. When I returned to the lobby, the concierge apologized for the mix up, blaming the impatient guest.

She handed me an envelope. This was one of the few hotels that pay the doctor directly, adding the fee to the guest’s bill. Since I hadn’t told her my fee, I was puzzled that she was already paying. Then she explained that she had given half the “usual” fee to the other doctor, and I was getting the rest. Since his is apparently a good deal more than mine, I didn’t do badly. 

Trying to Reach the Doctor

A three-month old at the Sunset Marquis was vomiting. I care for infants, but vomiting in someone so young is tricky. It would be a cop-out to send the parents to an urgent care clinic, because its doctor would be a G.P. like me – and, by the law of averages, less competent. Emergency room doctors have more skill, but inflicting an ER experience on this guest was overkill. Fortunately, I have a pediatrician colleague who’s helped out in the past.

I phoned his office. A message urged me to call 911 if I had an emergency but otherwise to leave a message. I dialed his cell phone but reached voicemail. It was 10 a.m. on a weekday, so he was in the office. I phoned the office again and hit “zero” to connect me with the answering service who agreed to page him.

After ten minutes, he phoned and agreed to speak to the guest. I phoned the guest half an hour later. No one had called.

I phoned the office and encountered the same rigmarole. Eventually, the pediatrician explained that the guest had been on the phone, so he had left a message. He agreed to call again.

Everything worked out, and the guest was happy.

I don’t understand why I have so much trouble getting doctors to answer the phone.  

A Hotel Doctor's Contract

People ask about my contract with hotels, but there is none. Concierges, operators, and bellmen call because they know me. 

Guests sometimes praise me, and their praise goes to concierges et al. If they decide to complain, usually because I’ve declined to give them something they wanted, they go to the general manager, often galvanizing him into one of several upsetting actions.

Referring the complainer to a competitor is tiresome. Anxious to make a good impression on his first call from Doctor Oppenheim’s hotel, he may relax his standards. 

If the manager consults the hotel lawyer, he always hears that he must never help a sick guest because guests who sue the doctor will also sue the hotel that suggested him. At any given time, about ten percent of hotels are in this my-lips-are-sealed mode, but it’s a changing ten percent because guests persist; employees want to help, and most competing hotels have doctors, so it’s bad public relations. 

Some managers make up a list, instructing staff to hand it to guests but to never recommend an individual. They believe (incorrectly) that this eliminates their liability. The employee who makes up the list mostly confines her research to the internet and in no particular order. As a result, it includes doctors who don’t make housecalls and walk-in clinics with limited hours. Fortunately once the list is made the hotel forgets about it. As years pass, it gradually becomes out-of-date, but my number remains.

Be Careful What You Ask For

“Could you come and give me some penicillin?”

Uh oh.  

The guest had a sore throat. He was fifty years-old. The only throat infection that antibiotics cure is strep, largely a disease of children and adolescents. Strep in a fifty year-old is so rare that I’ve never seen a case.

Doctors who prescribe unnecessary antibiotics claim that patients “demand” them. In fact, after I’ve seen these patients, ninety percent are perfectly happy with good medical care. About ten percent seem puzzled but remember their manners. Only a tiny minority give me a hard time.

But a tiny minority of a minority does not equal zero. Over thirty years, plenty of patients have lost their temper or (in the case of women) burst into tears. While not as mortifying as being sued for malpractice, it’s in the ballpark.

Unlike doctors in an office, I have the advantage of a phone conversation before seeing the patient. If a guest hints that he requires an antibiotic, I discuss his symptoms, suggest that antibiotics might or might not work, and try to gauge the likelihood that he won’t take no for an answer.

In this case, the guest seemed particularly assertive. I didn’t want to take the risk, so I referred him to a local walk-in clinic where he’ll probably get his penicillin.

Converting Two Visits Into No Visits

A man at the Bonaventure was suffering an earache. The pain was not severe and had been present several days, but he wanted it checked. This seemed like an easy visit.

But it was 5:00 on Friday. My traffic app showed a solid red line for the ten mile freeway drive downtown, converting a half-hour trip into… I hated to contemplate it. I explained that I could be at his room between 8 and 9. That was fine with him.

I had barely hung up when the phone rang again. A guest at the Warner Center Hilton had diarrhea. The Hilton is fifteen miles in the opposite direction from the Bonaventure with an equally red freeway. I could have scheduled it for later, but if a third call arrived….

The guest was not terribly ill, so I pointed out that most diarrhea is self-limited. I gave dietary advice and recommended an over-the-counter remedy that was a good as the one I hand out (actually the same), and suggested we talk again in a day. Happy to get free medical advice, he agreed.

At 6:30 the Bonaventure operator called to inform me that the guest wanted to cancel the visit. When I phoned both guests the next day, they were doing fine.

You'd Better Ask How Much

Before leaving on a housecall, I tell guests my fee, but this is not universal among hotel doctors. Guests may learn when the doctor hands over the invoice at the end of the visit.

It’s often a bombshell. I recall a guest who showed me a bill for $1140, and I’ve seen higher. It takes huge balls for a doctor to do this, but it works. People who will quarrel with an unreasonable charge that arrives in the mail may keep quiet face-to-face with a doctor in a room far from home. 

Long, long ago I made visits for a national concierge agency that boasted it would fulfill a hotel guest’s every need. It was a luxury service, but not everyone in an upscale hotel is filthy rich. After collecting an immense fee from several resentful guests, I stopped accepting the agency’s calls.

Calling Paramedics

If you want reach a hospital as fast as possible, get in your car and drive.

Paramedics are slower. They’re essential if a problem might be life-threatening or requires special handling such as a fracture. They sometimes transport even if their expertise isn’t required, but it’s not guaranteed. If you have a bellyache or high fever, they might leave and tell you to take a cab.

Phoned in the middle of the night, some hotel doctors determine that everyone requires paramedics. With no office job I don’t mind getting out of bed and do so regularly, but if the guest sounds like a genuine emergency, I have difficulty persuading the hotel that it has an urgent problem.

“I just talked to a guest, Mr. Elwood, in 435. He’s confused and can’t get out of bed. He needs paramedics.”

“I’ll send a bellman up right away.”

“No, you have to call the paramedics.”

“I’ll call Security. They’ll send someone to the room.”

“You have to call the paramedics.”

“Maybe you should talk to the manager on duty.”

At any hour, the noisy arrival of the ambulance followed by a train of fire engines disturbs everyone, so convincing a hotel to make the call often takes an effort.

Sometimes This Job is a Snap

I saw a man at the Hollywood Roosevelt with a numb arm. That’s an odd complaint but unlikely to represent something serious in a 26 year-old.

He had fallen asleep on the plane, resting his head on his palm with an elbow on the arm rest. On awakening he felt numbness down his forearm. This was easy.

The ulnar nerve that supplies the hand passes under your medial epicondyle, the knob you can feel inside your elbow. It’s a poor design because the nerve is exposed. Hitting it produces tingling down your arm to the little finger. It’s the “funny bone.”

Cab drivers who spend the day with one arm resting on the door often suffer the same symptom. Once they change position, the discomfort disappears in a few days.

Drugs are Cheap

Getting a syringe from my supply closet, I noticed that only a dozen remain. I’d better order more. A hundred syringes costs $12.

I buy from an internet medical supply company. For orders under $200 it charges a fat “handling fee,” so I try to order enough to exceed it. Most of my purchases are drugs, but that presents a problem because they’re so cheap.

I notice other hotel doctors charging $50 to $150 for an injection. I carry seven injectables. The content of a single shot of all seven rarely cost more than a dollar.  

What do I need?..... I stock B12 not because it’s necessary but because guests ask for it. This doesn’t happen often, so my bottle is almost out of date. The price has gone up, but it’s still $31 for a 30cc vial. That’s thirty injections.

I’m down to a few dozen Ondansetron tablets, the best nausea remedy. Ten bottles of thirty will set me back $37.

It never hurts to stock up on loperamide (Imodium is the brand), my favorite diarrhea treatment, but I was surprised to discover the price has jumped to ten times what I paid a few years ago: $104 for five hundred. Many old but important drugs such as penicillin that once cost pennies a pill have skyrocketed to dazzling levels. The weird thing about loperamide: it’s sold over-the-counter. Walmart charges $5.00 for a bottle of 72. That works out to $35 per five hundred. I’ll buy loperamide from Walmart.

I’m not short of many drugs, and buying too many is dangerous. At over ten dollars a bottle, my most expensive is antibiotic drops for swimmer’s ear. Swimmer’s ear has been unexpectedly rare, and I recently discarded five bottles that expired in January. My remaining three expire in May. Should I buy more?  Doctors have to make tough decisions…

A Miracle

The sales manager of the Hyatt Regency was preparing to address a convention when her head turned to the right and stuck.

I had no idea what to do. Her head seemed immovable. She was in perfect health. Hysterical conversion was a possibility, but I was too polite to mention it.

The consultation took place in an alcove off the hotel’s main ballroom. I could hear the crowd murmur. Inside gathered half a dozen worried employees including the general manager who had phoned another hotel to get my name. Failure in this situation would be distressing. The sales manager vehemently denied feeling upset, and I had no reason to doubt her.

“Did you do anything recently you don’t ordinarily do?” I asked, grasping at straws.

She considered then admitted she had felt queasy an hour earlier and taken a pill a colleague had offered. It was Compazine, a common nausea treatment.

That meant nothing. Then it did. I could barely contain my exhilaration. Phenothiazine drugs - Compazine, Thorazine - occasionally cause a weird dystonic muscle spasm. It’s so rare most doctors never see one, but I remember a case that arrived when I was hanging out at the Bellevue emergency room as a first year medical student in 1969. In that incident, the patient’s tongue stuck out, and he insisted he couldn’t retract it. The residents on duty confidently diagnosed hysteria, and it took a while before they changed their minds. Treatment is the familiar antihistamine, Benadryl.

I carry Benadryl. Within minutes of the injection, her head came unstuck. Everyone was delighted.                                                                                                  

A Serious Liability

After shaving, a guest at the Ramada in Beverly Hills reached for a hairbrush and struck his nose on a clothes hook with enough force to bring tears to his eyes and blood to his nose. He noticed that the hook had been installed at nose level -- clearly a poor design decision and dangerous. A hotel that tolerated such an unsafe condition was irresponsible and perhaps legally liable. The guest was, of course, a lawyer.

As I entered the general manager’s office, the guest interrupted a harangue as we exchanged introductions.

This was awkward. My sole obligation is to my patient, but it was obvious the manager wanted help in fending off the furious guest. When I suggested privacy for our consultation the guest told me to take care of things on the spot.

Young doctors love to blurt out a diagnosis as soon as the patient walks through the door (which is possible more often than you think). Not only do patients find this offensive, they don’t believe it, so doctors learn to give the impression they are thinking deeply before announcing an opinion.

I examined the nose from several angles. I carefully palpated it. I pulled out my otoscope and peered up his nostrils. Finally I announced that he had suffered a nasal contusion that, fortunately, had done no harm. He needed no X-ray, no treatment. He could go about his business.

According to the law, a person has no grounds to sue unless he has suffered damage, but a competent lawyer can discover damage in any situation. I doubt visions of profit had brought the guest to the manager’s office. He was upset at his pain and wanted sympathy. The manager had offered to comp the guest’s bill but had maintained his dignity when a humble apology would have worked better.

Still fuming, the guest asked my opinion of the danger in installing clothes hooks at precisely nose level. I agreed the matter deserved attention but added that noses come at many levels.