Saturday, July 29, 2017


   I have been in medical practice for many years ,and over period of time I have seen lot of changes . The sole motive of the Insurance company is to control the cost and the sole motive of the regulations is to avoid fraud . But in doing so we have increased the cost of the health care and made it substandard and made it cumbersome . It is at a  point that I do not know a single medical person -nurse , respiratory therapist or physician, that is happy . I have one person just handling  the fax , one getting referrals, and one doing 50 % of time doing required forms for the DME- oxygen CPAP,nebuliser etc. The insurance companies deny claims and not pay and then any time -even a year down the road DEMAND the refund as they may have made mistake in paying when they should have denied and if we do not refund , then they cut it from next patent's bill!!.There is nothing I can do as no one care for the physicians -not even the physicians societies that I am a  member  of. But that is not my purpose of this blog . My problem is that these regulations and the behavior of the insurance companies has produced substandard care . That is the story about .

     I saw this young lady in my office . She was 59 years old and had some cough and shortness of breath. She had never smokes and was not taking any alcohol. She had no history of high blood pressure or diabetes or for that matter any other medical problem . She did not have asthma . Her chest X- ray was OK. On examination she was in no distress and her blood pressure was normal. She had no fever and her lungs sounded clear and her oxygen saturation was normal. She was little emotional as she was never sick in her life and now she was short of breath and had this cough that would not go away. Her heart rate was little high, but then she was quite emotional.

    So my impression was that most likely she had allergies and asthma . The chronic cough in non smoker , with normal chest X-ray is due to asthma and /or allergies in almost 80 % of the time . So I did the allergy blood test and the breathing test and did try her on inhaler for the asthma . I also did the walk test as many patients with asthma wheeze on walking or exercise. I also did what is called sum-maximal pulmonary stress test.
     She came for the follow up . Her allergy blood test was normal and the breathing test showed mild decrease in lung capacity , but did not show obstruction , which would have confirmed the diagnosis of asthma . Her walk test was OK and she did not wheeze and her oxygen saturation on walking was not decreased. Her stress test was abnormal and it was showing the problem to be HEART or cardiac.So I had asked for the echo cardiogram -or the ultrasound of the heart. She had called me in between and so I had also done the CT scan of the chest . The Ct scan showed some fluid /water around the both lungs .I did the CT scan to rule out any fibrosis -which was a long shot as differential diagnosis. The echo cardiogram done through the PCP office was reported normal. So when she came for the follow up I was puzzled. She was very short of breath . The inhaler had not helped . She could not even collect her mail without getting short of breath. And my tests had not shown any specific cause for it . Though she had some water around the lungs , everything else that could explain the cause of it was normal-the heart function.  She was so emotional that she started crying . She was never sick in her life and now she was so bad that she could not function doing day to dat activities . My tests were showing that most likely she had congestive heart failure and that had caused the water built up and so she was short of breath . But the ultrasound of the heart was normal . I was stuck .
     But like in my past medical life I take decisions based on MY heart than what tests show . So I told her that I am  going to get  her in the hospital and treat her for congestive heart failure with water pill and then see how she does . If she does not get better , then I will take out the water and may be do bronchoscopy to find out what was going on.
     I admitted her and started her on diuretic IV and ORDERED ANOTHER ECHO CARDIOGRAM , I saw her about 8 hours after she received the first dose of the diuretics . She was all smile -she hugged me and thought that I was the miracle man  as she was feeling so good that she has not felt in last one month. The echo cardiogram showed that her heart pumping action was 20 %!!!!!
This simply means one of the two things , one -the first echo was not of good quality or not interpreted properly  or secondly -n she developed the heart problem between the two echo. I tend to believe the first one . This is not the first time and it will be not the last time . The insurance companies want to save money . So doing and echo at radiology center or PCP office is much cheaper than a cardiologist consult and then doing echo in his office. So now a days routinely the echos are done by PCP or in a X-ray facility and they are not as good as done by cardiologist .

     So sometimes one has to go by what you feel than by the tests . She did very well after we treated her for congestive heart failure .  

No comments:

Post a Comment