Fatal Diarrhea

Coris USA, a travel insurer, sent me to see an Argentinean lady with diarrhea at the Beverly Hills Hotel. Diarrhea is usually an easy visit.

Arriving, I learned that her illness was entering its sixth day: too long to be the ordinary stomach virus. She felt weak and feverish, and she had recently taken antibiotics, so I wondered this was Clostridium difficile colitis, an occasional consequence of the avalanche of antibiotics consumed by humans everywhere.

Every antibiotic you swallow kills trillions of germs, mostly harmless, living in your bowel. They are immediately replaced by other germs that can grow in the presence of that antibiotic. Most bowels don’t harbor C. difficile, but if yours does, antibiotics may convert a small population into a large one, and it produces an irritating toxin that causes a severe, occasionally fatal diarrhea. 

Diagnosing Clostridium requires more than suspicion, and there were other possibilities. She needed a thorough evaluation.

Fortunately, Coris USA is a good travel insurer: meaning that it (a) pays promptly and (b) takes my advice. These sound unrelated, but I’ve found that good insurers do both, bad ones do neither.

I phoned Coris’s Miami office with the news and the name of the doctor I recommended. The dispatcher contacted the main office in Buenos Aires for authorization; it appeared within the hour, and the patient went off. If I were dealing with a bad insurer, authorization would be denied or remain pending indefinitely. I often send patients off, warning that they will have to pay up front and try for reimbursement later.

Tests were positive, and she began improving after a few days of treatment: an antibiotic but one different from the one that caused the problem.

Free Enterprise in Action

Visiting Disneyland, a couple’s two year-old twins fell ill. The parents consulted the concierge, and a doctor who wasn’t me duly arrived.

A week later, the family traveled to Hollywood to spend a few days before flying home. That’s where I came on the scene.

The children had recovered, and I wrote my clearance-to-travel. From the parents’ description, they had suffered viral upper respiratory infections with cough, congestion, and general miseries. The hotel doctor had diagnosed: “otitis, tonsillitis, bronchitis, and mild pneumonia.” He had given injections, handed over medication, and written prescriptions for antibiotics, cough medicine, and eardrops.

The parents showed me his invoices. The fee for one child totaled $495, for the other $390. The prescriptions and injections came to over $100, so they paid about a thousand dollars for a single visit.

Nothing I do in a hotel room costs much, so I quote a flat fee and never charge extra for anything. That doctor billed $30 for an injection; those I carry for common problems (vomiting, pain, allergy) cost less than a dollar a dose. A syringe costs a dime. He handed over small packets of pills, charging $20 apiece. I carry similar packets containing from three to eight pills. Each pill costs between a nickel and a quarter. A bottle of cough medicine costs $1.50. A week’s supply of antibiotics is usually less than $5.00. I pay about $3.00 for a bottle of antibiotic eye drops. Perhaps my most expensive drug is antibiotic ear drops at $8.00. Doctors may charge $30 for a urinalysis, but the dipsticks they dunk in your urine come in bottles of 100 at $40.00. That’s 40 cents a dipstick.

Medicine is a noble profession, but while I’m in favor of doctors earning a large income, it’s beneath their dignity to pay obsessive attention to it. This might not be a majority opinion. Doctors regularly claim that they are businessmen operating in a free market. As such, it’s reasonable to charge for every service. Sensible patients understand, they insist.

Another Second Opinion

“I need a second opinion about something personal,” said an elderly man at a West Hollywood hotel.

It’s always pleasure to visit a patient who isn’t sick, although this seemed an odd situation. But first, since he was American and over 65, I explained that I wasn’t a Medicare doctor, so Medicare wouldn’t pay for this visit.

“That’s OK. I need to see you.”

I drove to the hotel and listened as he explained that his scrotum hung too low. His family doctor hadn’t taken it seriously, so he wanted my advice.

On examination, his scrotum appeared normal although perhaps lengthy. I asked how this caused a problem.

“When I sit on the toilet, it dips into the water,” he said.

I scratched my head.

“A urologist could probably do surgery to shorten it, but I’m not sure Medicare would pay.... Why don’t you lower the water in the toilet bowl?”

Breaking My Rule

I was awake at 7 a.m. writing this blog when a guest called with symptoms of a bladder infection.

Being American, her first question was: do I accept her insurance. I explained that I didn’t, adding that there was an urgent care clinic a mile away that would.

“I’d probably have to wait forever,” she said. “I have meetings.”

“I’m definitely convenient,” I said.

“Do you bring the medicine?”

“I do.”

I wanted to finish writing and eat breakfast, so I told her I’d arrive at 9 a.m., thereby demonstrating that, despite my wisdom and vast experience, I do stupid things.

It’s a rule of hotel doctoring to go as soon as possible. Guests who wait often reconsider, so I knew what to expect when the hotel’s number popped up on my caller ID at 8:00.

“I’m feeling better,” she lied. “I won’t need to see a doctor after all.”

“You won’t save much at the clinic,” I pointed out. “They’ll charge extra for the urine test and extra for the culture, and you’ll have to find a pharmacy and pay for the prescription.”

“Oh, no! I’m feeling fine,” she insisted. “Thank you for your help.” She hung up.

When patients cancel, I console myself if the illness seems likely to produce an unsatisfying encounter. For example, guests are often disappointed when I can’t cure their respiratory infection. But urine infections are easy to treat and treatment produces dramatic improvement. I hate to miss one.  

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.

A Hotel Doctor's Database, Part 1

Few things besides wine and cheese improve with time, but a personal database is among them.   

It didn’t seem significant when I began in 1983, but now I can look over 18,316 visits. So when I claim to have made more housecalls than any doctor now alive, I have the evidence . It’s a fascinating trove of information. I saw 967 patients from Brazil, for example; 42 of them suffered skin problems. Of those calls from Brazilians, 70 arrived between 11pm and 6am, getting me out of bed.

Of the 18,316 nearly 12,000 (11,849) were of calls directly from a hotel. The remainder came from four other sources. 

The second source is agencies that insure travelers visiting America: 3490 visits. Few come from Europe or Australia whose insurers follow the American strategy of insisting that clients pay up front and apply for reimbursement later. Asian and Latin American carriers do better. Their clients phone the 800 number of the agency’s US office; the agency phones me; I make the housecall and send my invoice to the agency which pays exactly what I bill (American carriers undoubtedly roll their eyes at this archaic behavior).

Inevitably some insurers are less easy to deal with than others. Some have adopted the American system of requiring elaborate forms, itemization, and codes for every procedure. Others pay slowly and only after many pestering phone calls. When my patience runs out, I stop accepting their calls.

This doesn’t mean I stop seeing their clients, because they transfer their business to my third source of calls: competitors with 1760 visits. That includes other Los Angeles hotel doctors who ask my help or cover for me when I’m busy as well as one of the national housecall services. They have names like Expressdoc, AMPM Housecalls, Hoteldoc, Global Med. If you live in a large city, they may be available, but be warned that some are reasonable but others charge fees that will take your breath away.

Foreign airline crew make up the fourth source: 913 visits. American airlines have no interest in crew who fall ill when laying over. They have medical insurance but with no transportation or knowledge of facilities in a strange city, they are out of luck. Occasionally I deal with their pitiful calls and treat them as charity cases. As with American insurance carriers, it’s hopeless to bill an American airline for a housecall. 

A minor fifth category is what I call “private-parties:” 293 visits. These are people who learn about me from another source. That includes locals as well as former patients who return to the city and call me directly.

Night in a Hotel Room

Patients are often suicidally reluctant to wake a doctor, but I don’t object. Traffic is light, parking is easy, and since I have no office, I can sleep late. I’ve made a thousand housecalls that got me out of bed.

Callers awaken in the dark, certain something terrible is about to happen. I try to handle anxiety attacks over the phone using sympathy and calm reassurance. I never point out that nothing terrible will happen because guests know that; it’s why they’re upset. I explain that no one is perfect; sometimes our brains go haywire, but it never lasts long. If I keep the guest on the line, this almost always works. Making a housecall is risky because guests often feel better and cancel before I arrive or feel worse and insist that the hotel call paramedics.

Some hotel doctors use paramedics as a substitute for getting out of bed, but I reserve them for emergencies. Mostly, these are obvious. Heart attacks can rouse victims from sleep, but they are not subtle. Niggling chest discomfort doesn’t qualify, and chest pain in a young person is probably something else. 

I see a cross-section of ailments, but guests with an upset stomach seem overrepresented. I consider a wee-hour visit for vomiting a good call (i.e. not life-threatening; I can help; patients are especially grateful). The latest antivomiting drug, ondansetron, is superior to the old standby, Compazine. It was once wildly expensive and used only for vomiting after cancer chemotherapy, but its patent expired a few years ago, and the price has plummeted.

Most upset stomachs don’t last long. I assure guests they’ll probably feel better when the sun rises, and (a perk of being a doctor) when that happens, guests believe I’ve cured them.