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.

I Just Need a Shot

A woman under treatment for infertility needed a progesterone shot every month. She had the vial. Could I send a nurse?...

Why do doctors cheerfully give patients medicine and send them off on their travels? It guarantees a hassle.

I don’t have a nurse, but I quoted $50, drove to the hotel and gave the shot. It was not a short drive, but she wouldn’t have paid my regular fee, and I wasn’t doing anything at the time.

This lady was lucky. In any other city, she would be in for a rude, expensive shock. I do hotel doctoring fulltime. My colleagues have other jobs, and they're not likely to drop what they're doing and make a visit at a discount.

Some guests think they can call a nursing service. Nurses earn less than doctors, but a visit from a nursing service is not cheap. It also won’t happen. A nurse won’t give medicine without a doctor’s order.

Going to a clinic or doctor’s office is not likely to work. In today’s malpractice climate, few doctors will give an injection on a patient’s say-so. Carrying a note is also a crapshoot. As I have recounted more than once, doctors look with deep suspicion on patients who arrive with notes. See my post from April 20.

I Encounter a Rare Disease

A man suffered a headache on his flight. After arriving at the hotel, his left ear began hurting and soon became excruciating.

When he opened the door, I noticed that the left side of his face drooped.

Nothing pointed to the usual ear infection. He had no cold symptoms. The plane’s descent did not aggravate symptoms. He didn’t swim or use q-tips. He did not have a fever.

When I looked inside the ear canal, I saw blisters.

Painful blisters in the canal and a droopy face….  In forty years of practice, I have never seen a case of Ramsay-Hunt syndrome, but there it was. The poor man had shingles inside his ear.

Shingles is a viral infection of skin nerves. It’s fairly common and usually appears as a patch of blisters on the chest, abdomen, or back, sometimes the face. But there is skin in your ear canal. An additional complication occurs because the nerve supplying the ear canal also feeds muscles of the face, so victims suffer facial weakness on that side.

Treatment is an antiviral drug and a course of cortisone which is modestly but not dramatically effective. Chances are he would recover completely, but he would have an uncomfortable few weeks.

Blood Clots

Jogging on Santa Monica’s beach, a traveler twisted his ankle. He went to a clinic where an X-ray revealed no fracture.

That was two days ago, he informed me, and the ankle was healing. He was to fly home tomorrow, and his doctor in Switzerland had suggested he get an injection to prevent a blood clot. I receive a sprinkling of these requests, all from foreign travelers. They began a few years ago when the media began reporting clots in travelers after long plane flights. The risk in healthy people is tiny but not zero and concentrated among those who fly more than four hours.

Drugs to thin the blood such as Coumadin and heparin have been around for decades but are too dangerous for healthy people. In 1993, the FDA approved Lovenox, a refined form of heparin, safe enough for use outside a hospital. My wife gave me six weeks of daily injections after I broke my leg in 2003. It was still under patent and wildly expensive, but generics have appeared, so it may soon become fashionable to get a shot before a long flight.

So far no Americans have mentioned the subject, and I give foreigners the traditional advice: walk around and drink plenty of fluids. Techniques that don’t work include compression stockings (unless fitted by a professional they may make things worse) and taking aspirin. Aspirin prevents clots in arteries, but clots from immobility occur in veins.

A Letter from His Doctor

A VIP had forgotten his medication. Would I prescribe it, asked the manager of a Sunset Strip hotel.

“He brought a letter from his doctor,” she added helpfully.

That was bad news. About twenty percent of guests with letters have complex medical problems that require an explanation. The rest are drug abusers under the impression that an official document will persuade us to prescribe something we ordinarily wouldn’t.

Sure enough, it was a popular narcotic. This guaranteed tedious consequences. The most critical was that, after my refusal, he might ask the manager to suggest another doctor, explaining that I had heartlessly rejected his appeal.

I listened as he described the complex pain disorder he and his doctor were wrestling with. Perhaps I could examine him, he added. While this sounds reasonable, such visits involve an unspoken agreement that if I came and took his money, I would give the prescription. That felt too much like selling drugs. I countered that I would call in a prescription for a good non-narcotic while he contacted his doctor who would phone me to discuss matters.

His doctor wouldn’t call, and I suspected the guest wouldn’t care for my prescription, so I could expect to hear from him in a day or two. But the clock was running. He might check out and return home or move to another hotel and bother another doctor.

A Mysterious Seizure

Airport security confiscated a tourist’s glaucoma eye drops, so he called his insurance who called me. 

The drops come in a tiny 2½ cc bottle, so the seizure seemed puzzling. On the other hand, ten years ago the examiner took my tweezers, a beautiful needle-nosed instrument perfect for removing slivers. It cost $20. Later, I checked the Transportation Security Authority web site and learned that tweezers are permitted. I’m still fuming.

Usually, I offer to phone a refill to a pharmacy when a traveler needs a legitimate prescription, but business has been slow, and the insurance had already told the guest I would come. Ironically, medical experts unanimously frown on giving prescriptions to an unfamiliar patient without an examination. They never explain how an examination in a hotel room can prove that a patient has, for example, glaucoma, osteoporosis, emphysema, acid reflux, or epilepsy. If he takes high blood pressure medication, and I find a normal pressure, must I refuse the refill?

"The Crab Tasted Funny...."

“No one but my wife had crab cakes in the hotel restaurant last night, and about 4 a.m……”

A miserable problem for the guest’s wife but also a difficulty for me. The caller had no doubt that his wife was suffering food poisoning although no one can make that diagnosis unless more than one person gets sick. In developed countries, viral infections cause most upset stomachs.

“She says the crab tasted funny…” That was not helpful because common food-borne toxins are tasteless.

I expressed sympathy, quizzed the husband for details, assured him that these illnesses were usually short-lived, and gave suggestions for relieving her symptoms. I would have made a housecall if asked, but on calls like this I hope the caller doesn’t ask.

If he asks, I mention the fee. My worry is that the guest, certain the restaurant poisoned his wife, will insist that the hotel pay. News that I am not a hotel employee never changes matters. Suggesting that the guest take this up with the manager never helps. Sometimes management refuses responsibility, so I’m confronted with an angry guest who suspects, despite my disclaimer, that I’m in cahoots with the hotel. I hate accepting money from a resentful guest, so I don’t.

Sometimes the manager tries to mollify the guest by agreeing to pay. A hotel manager is an exalted figure. I rarely meet one, and I want the first encounter to leave a good impression, so I wave off the money. They always appreciate it, but don’t assume I earn their undying gratitude. I did this in July of 2015 to the manager of the huge Doubletree in downtown Los Angeles. The hotel hasn’t called since.