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.

A Special Service

“Someone needs to check my nephew. He’s shaking and really upset. How quick can you be here?”

This was a bad call in many ways. I managed to learn that the child was in good health before a fire alarm roused everyone from bed at 11 p.m. He seemed to be frightened, perhaps more than usual. I had no doubt that he would recover, but that was hard to communicate.

I try not to make housecalls for anxiety attacks because many guests begin recovering while I’m on the freeway and cancel. Keeping the guest on the phone works better. After a half hour of to-and-fro and reassurance they admit they’re not feeling so bad.

This was one time that being reliable got me into trouble. The lady had called the front desk pleading for a doctor. Within seconds she was talking to a doctor. Weird!

She undoubtedly assumed that I was a special service provided by the hotel. Perhaps I was sitting by a phone in the lobby.

In any case, my efforts to keep her talking didn’t work. People are very protective of children. She insisted that a doctor must come. Reluctantly, I agreed. Then I had to mention something I never mention until it’s necessary. When I make a housecall, there’s a fee….. 

She was shocked. “I’m not going to pay that!” she said. “We’ll take him to the hospital!” She slammed down the phone.

This has happened before. I had to speak to her, not only to negotiate the fee but to assuage my fear that she would denounce me to the hotel. But the fire alarm was still in progress. She was not in her room, and it took fifteen minutes before the hotel could track her down. By that time she admitted that the child was feeling better.

Little Red Bumps

 “They’re little bumps all over… Sort of red.”

“Could you be more specific?”

“Little red bumps over my body… spots. Some are raised. They sort of itch…”

Americans, even with a college degree, are painfully inarticulate. Can you describe the face of someone familiar? Novelists do it all the time, but I bet you’d have trouble. Words like nodule, pustule, blister, wheal, plaque, ulcer, scale, and fissure are not obscure medical terms. Educated people know what they mean but can’t seem to use them.

If a caller said “I have dozens of one to three millimeter pustules surrounded by a red base, mostly on my back and chest, not so many on my arms and legs,” my diagnosis is “chicken pox.” But “red bumps” is the best many can do.

I’m happy to make diagnoses over the phone, and guests are eager not to pay for a visit. I have little trouble with respiratory infections and upset stomachs, but skin problems frustrate me.

“I worry about bedbugs. Do you think it’s bedbugs?”

“What do they look like?”

“Little red bumps….. Do you think it might be an allergy?”

“Could you be more specific?”

“Bumps…They’re raised, some of them, and they're red….”

The Upside of Cheap Motels

Cheap motels have many advantages from a hotel doctor’s point of view.

Valets are absent, so I can park inside and safely ignore the threatening signs. Security is absent, so elevators respond to whatever floor I push, and I don’t have to explain myself to the front desk. Americans are absent because they can’t afford the fee. I love America but I also love foreign patients. They’re deferential, and they don’t sue.

On the downside, customer service declines with the price of the room. I often need to call in a prescription or consult with the insurance. When I pick up the hotel phone and punch “9” for an outside line, I may hear a busy signal because many hotels require a deposit before opening the phone. If I identify myself as a doctor, larger hotels open the line, but clerks in cheap hotels refuse unless the guest comes down and pays.

Insurers send me to hotels that don’t call, so I take the opportunity to introduce myself. In mainline hotels, staff remember their manners. They smile, listen intently as I make my pitch, agree that my service sounds wonderful, and thank me effusively for my business card. Then they probably forget about me. It’s rare to pick up business, but I always leave feeling good.  

In cheap motels, clerks don’t disguise their lack of interest. “Nobody gets sick,” they say.   

Lost in Translation Again

“Spik Spanish?”

Not a phrase I like to hear. Ninety percent of Latin American guests speak enough English to get along, and Hispanic hotel staff are usually available. Unfortunately, this visit occurred at a small Super 8, and the single employee on duty was American. Under these circumstances, I shake my head apologetically and proceed in English.

“Tell me what’s going on,” I asked.

As usual when something exotic like an American doctor appears, there was a substantial audience. Usually someone volunteers to interpret. Sure enough, a man stepped forward. He tapped patient’s abdomen and then whirled his finger around his mouth.

“Is she vomiting?” I asked.

Blank looks from everyone, a bad sign. I waited, hoping someone else would contribute, but the man merely repeated his gestures.

I phoned the insurance agency’s 800 number. Its employees are Hispanic and willing to interpret.

“Would you ask what’s bothering her and tell me what she says?” I said after explaining the situation.

I handed over the phone and the lady began a long monologue. When she finally handed back the phone, I listened to the insurance clerk. “She is sick from eating. She give medicine from Argentina, but it does not help. She wants a medicine to help.”

That was too little information. I tried to be specific. “Would you ask what are her symptoms?”

Another long conversation followed by a short, unsatisfactory translation. Eventually I learned enough to thank the clerk, adding that I would examine the patient and then call back for more interpreting.

At the end I gave instructions and medication, and everyone seemed happy. I always leave with the uneasy feeling that the interpreter has left out a great deal. Fortunately the ailments I encounter are usually easy, and the occasional exception is obvious.