How Much Does an Emergency Room Cost?

A lady had been vomiting for three days. She had felt better that morning but then relapsed. She sounded weary.

This was tricky. Stomach viruses are the second leading ailment a hotel doctor encounters. I consider them good visits because they rarely last more than a day. I deliver advice as well as an injection and pills. The guest recovers and gives me the credit.

When vomiting persists, doctors worry about more ominous digestive disorders. Worse, three days of vomiting produces some dehydration. This is not dangerous in a healthy person, but drugs don’t work well in its presence and recovery slows. Victims perk up when dehydration is relieved. 

I explained that it was probably too late for a house call. She needed intravenous fluids. After agreeing to go to the local emergency room, she mentioned that she was Canadian and had no travel insurance. I repeated that she should go.

I’ve found that it’s a bad idea to tell guests to go to an ER and then tell them how much it might cost.

My restraint was in vain because she googled the subject, perhaps turning up http://www.theatlantic.com/health/archive/2013/02/how-much-does-it-cost-to-go-to-the-er/273599/ to read that the average was over $2,000. Giving IVs would take hours and cost extra.

When I called the hotel that evening, I learned that she hadn’t gone, and she was still ill. She admitted that the cost had shocked her. I sympathized but told her she had no choice.

When I called later to reinforce this advice, there was no answer. When I called the following morning, she had checked out.

Losing the Chateau Marmont

The Chateau Marmont is a funky art-deco apartment converted to a hotel in the 1930s with nine nearby cottages acquired during the 1940s.  John Belushi died in a cottage in 1982, a few years before I became its doctor. 

I made 157 visits. My last, in 2002, was not at the request of the hotel but of a national house call agency, Concierge Care. Agencies pay me my usual fee, but they charge a good deal more. It rarely causes a problem because the guest has agreed to pay by the time I arrive.

Unfortunately, the dispatcher answering Concierge Care’s 800 number did not like to deliver bad news. As a result, he took down the caller’s information and cheerfully announced that a doctor would arrive but neglected to mention the fee.

The visit went well, but the guest’s jaw dropped when I handed her my invoice for $400. This was 2002 when the dollar was worth something. Hearing that I only earned $150 did not relieve her distress. Worse, she phoned the front desk to ask the hotel to put it on her bill, adding her displeasure at the size of “the hotel doctor’s” fee.

As the desk clerk counted out my money (probably more than his weekly pay), I explained that I was making this visit for a house call agency which was responsible for the fee. He nodded politely, but the Chateau Marmont has not called since.

Paramedics Versus Doctors

My personal encounter with paramedics occurred the day I fell (ironically during my morning health walk) and broke my leg. I might have lain there for some time because pedestrians in my middle-class neighborhood pay little attention to the occasional bearded old man lounging on the sidewalk. Luckily, I had taken a detour through an alley behind a restaurant where two Hispanic workers noticed and came to my aid.

I was not in great pain as long as the leg remained immobile. Any movement hurt terribly. When the paramedics approached with their gurney, I was frightened, but they scooped me up, drove to a hospital, and shifted me to another gurney with hardly a twinge. Never mind their medical skills; that showed talent.

While I admire paramedics, they have little use for me in my capacity as a hotel doctor. Paramedics almost never encounter a physician on their calls, and they don’t like it when they do. Most likely, they worry he might pull rank. As a result, when paramedics arrive at my hotels, I sit quietly, never speaking unless spoken to. In turn, they go about their business, pretending I’m not there.

Another Death

 “He’s over there! I think it’s an emergency!”

Emerging from the elevator, I did not want to hear this. Despite the impression left by television, cardiac arrests are usually fatal. Outside a hospital, between six and eleven percent survive.

The survival rate of the few I encountered is zero, and this did not look like an exception. An overweight security officer was kneeling clumsily on the bed, bouncing up and down as he pounded an old man’s chest. The guest’s false teeth had jarred loose and protruded from his mouth; I plucked them out.

Security officers learn CPR but rarely use it, so they forget the details. Cardiac massage on a soft bed doesn’t work. The officer should have dragged the guest onto the floor. One of his colleagues should have been giving mouth-to-mouth respiration, but it was almost impossible to persuade laymen to perform something they considered disgusting. Mouth to mouth respiration was essential until 2010 when experts decided that chest compression alone was OK.

I asked how much time had passed since the arrest.

“I don’t know. He was out when I got here.” gasped the officer.

I found no pulse, heartbeat, or respiration, and it was obvious the man had been dead for some time, so I told the officer to stop. Hearing this, an elderly lady in a nightgown hovering nearby burst into tears. At that moment, two paramedics and two firemen clumped noisily into the room accompanied by a man in a suit and a young woman, apparently the manager plus the concierge. Cardiac arrests attract too many people.

Observing the corpse and the weeping woman, the senior paramedic flipped through his clipboard. “Is that your husband, ma’am? Could you give me his name?”

She couldn’t. Disobeying my rule about staying out of the way in the presence of paramedics, I comforted her. Lowering his clipboard, he waited patiently. This is the single activity paramedics are happy to leave in the hands of a physician. After a few minutes, she became calmer.

Disposing of the dead guest took a while. Two police arrived and transcribed the wife’s story a second time. One by one, the staff left, followed by the police and paramedics. The medical examiner’s ambulance drove off with the body. The lady couldn’t find her sleeping pills, so I provided some. I left my phone number and promised to call in the morning.

A Bad Year for Conjunctivitis

At one point years ago, I had to discard half a dozen bottles of antibiotic eye drops when they reached their expiration date.

I carry thirty-two drugs. I don’t like to send guests searching for a pharmacy in a strange city, so I hand out whatever they need whether it’s a week of antibiotics or a tube of cream. I’m also generous with cough medicines, decongestants, expectorants, laxatives, and other over-the-counter remedies. I know that many patients including you don’t expect medicine whenever you see a doctor, but we in the profession get that impression.

When I restock, my order must be large to avoid a big handling fee. This becomes awkward when I run low on a critical drug such as prescription eye drops. I can’t allow myself to run out, and I can’t order other essentials such as antibiotics or injectables until I need them because of the expiration date. 

This is where useless drugs come in handy (I’m stretching a point; it’s not certain that cough remedies, decongestants, expectorants et al don’t work, but researchers who conduct studies have trouble showing that they’re superior to placebos).

As I run low on important drugs, I become more generous with these. This is easy because respiratory infections are every family doctor’s most common ailment. For weeks, I loaded up guests with sniffles, colds, “sinus,” “bronchitis,” flu, and similar bugs with every elixir, gargle, capsule, or lozenge in my possession. Soon I ran low on enough medication to eliminate the handling fee when I restocked.    

A Better Shot

 “Is he a VIP?”

“All our citizens are VIPs” said the consul for Qatar, referring to a countryman at the Airport Hilton.

Sick guests from small nations often call the local consul. Asked to find a doctor, he usually phones the hotel.

Once a consul has my number, he tends to remember it, so these calls are good news. On the other hand, guests who phone the consul feel worse than usual.

A woman in a headscarf answered door, and indicated a young man, curled up in bed. It was their honeymoon. Back pain is usually an easy visit from my point of view. Most acute backs are not so bad after the first day, and they steadily improve.

Unfortunately, this was not the first day. Pain had come on three days earlier in Las Vegas. A hotel doctor had dispensed the usual remedies, and pain had diminished only to return the following day.

I delivered the largest injection and strongest pills in my possession, adding that he would need more evaluation if this didn’t work.

At midnight, he phoned to say that he had improved, but now pain made it difficult to sleep. He agreed to go to an ER but wanted to wait until morning. There was no answer when I called that morning or that afternoon.

The ER doctor had performed the usual tests and then given a shot, the guest said that evening, but it was not as good as mine. Desperate to return home, he had booked a flight. Would I give another shot before he checked out?

So I did. Handing over a business card, he urged me to visit if I came to Qatar. Then, supported by the wife and a cane, he hobbled off.

My Last Bad Check

A guest at the Hyatt had fallen ill and cancelled a flight. He had recovered, but the airline insisted on a doctor’s note before allowing him on board.

Determining if someone is healthy enough to fly usually requires only a few questions, but I do an exam. He delivered a steady patter as I worked, describing himself as a venture capitalist with an exciting but stressful life as he prepared for an important meeting in Japan.

As I composed the note, I saw him writing a check and immediately announced that I accept credit cards.

Apologizing, he told me that it would be a hassle unless payment came out of the company account. Seeing my hesitation, he added that he had credit cards and would give me a number in case there were a problem. He pulled one out and scribbled on my invoice, getting one number wrong. I noticed and made the correction. 

I’ve received a few dozen bad checks but only rarely after 2000 when I began accepting credit cards.

You can imagine my feeling later as I stood watching a teller fiddle at his computer…. and fiddle…. and fiddle… and finally explain that it wasn’t accepting the check.

Naturally, I felt stupid. Single males write almost all bad checks, and this guest fit the pattern.

Now came the tedious process of trying to recover the money which occasionally happens. As I expected, the address and phone number on the check were wrong. Asking the hotel for contact information sometimes helps, but in this case I learned that it must respect the guest’s privacy. The credit card was certainly worthless.

But it wasn’t! When I phoned the computer and entered the numbers, it approved. Some things are hard to explain.