MEDICINE AND THE INSURANCE COMPANIES AND THE REGULATIONS

   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 .  

TRUTH AND ONLY TRUTH AND NOTHING BUT THE TRUTH

    In medicine and in life I often find that what could be considered as the TRUTH changes . medicine as such is as much science as art. So like in life or religion the search for the truth comes down to personal persistence .So one has to try hard and go withe the heart . That brings me to some patient;s story.

      I saw this patient , about 78 years old male who had lost 40 lbs of weight over period of 4 months . He had quit smoking 10 years ago and he had no cough or chest pain or shortness of the breath.The primary care physician sent him to Gastroenterology.   The specialist did the colonoscopy and the endoscopy The colonoscopy showed some polyps and they were benign. So he had no diagnosis as to why he was loosing weight. He had no fever , and no other  complaints.His cheat X-ray was reported as normal .
     And then one day he had  a bout of the cough and he noticed blood . His blood in the sputum continued for one day and so he called the primary care physician. He sent him to emergency room. In the ER they did CT SCAN of the chest. The CT scan showed that he had a mass in the middle part of the right lung and there was collapse of the right upper lobe . So I spoke to the patient and the family.
      He had normal chest X-ray. There was no evidence of cancer on the chest X- ray even though by looking back at the CT scan ,which had shown the mass or the cancer , I could not see the cancer , that was inoperable.
      I did the bronchoscopy and he has mass in the upper lobe -that was not seen on the CT scan , and it was causing the blockage of the right upper lobe and that had caused the collapse of the upper lobe.
    So I he had cancer of the lung and it had spread to the lymph nodes and had caused the collapse of the upper lobe , but NOTHING WAS SEEN ON PLAIN CHEST X-RAY!!

     I will tell story of the other patient where persistence on my part gave the diagnosis. 

SHAD RIPOO CONTINUED

         The next one of the 6 enemies is the MOHA or the Delusion. Our entire life is full of delusion . If one considers the difference between the EGO and the SOUL, we will realize that ego is pseudosoul. The soul under the influence of delusion is is ego. When the soul which is immortal and unconditioned confines or appear to be confined within the physical body, is called EGO. The ego is BORN and Conditioned. Under the effects of the delusion or MOHA one does thins or acts differently than he would if he was guided by Intellect.

          In MAHABHARTA, the SHAKUNI MAMA is the representative of the delusion. He was known to be deceptive and create illusion or delusion. Upon the advice of the Shakuni , the Duryodhana asked Pandawas to the geme of Gambling . The deception that was used by the Shakuni worked and the under the influanec of the delusion the Pandawas lost . They not only lost their kingdom , but also the DRAUPADI, their wife. In the symbolic way the Draupadi is KUNDALINI shakti . The Pandawas lost the contol over the KUNDALINI under the influence of the delusion. So when one feels that HE or SHE is the BODY and confined to the limits of the body that is delusion

.            The next one is MADA or the PRIDE.The pride is I , ME ,AND MINE . Because of the pride we do things that at times are deceitful ,cruel and immoral.The 'I' in us makes us do things and act in such a way that otherwise we would not do. The PRIDE in MAHABHARATA, is represented by SHALYA . The Shalya is the brother of Madri the mother of the NAKUL and SAHADEO. So he should have joined the Pandaws in the battle between the PANDAWAS and the KAURAWAS. But the DURYODHANA bribed him with flattery and with gifts . The SHALYA was coming to join the war, Duryodhana arranged the big welcome and the feast of food and gifts and the flattery . The SHALYA thought that it was PANDAWAS and then he came to know that the host was no there than the Duryodhana. he still could hve joined the PANDAWA'S side , but withe PRIDE and the EGO and the delusion , he joined the Duryodhana side. We see it all the time how the fights among the friend and the siblings and the business partners never get resolved due to the PRIDE .

        The last one is MATSARA or ENVY. We all know this quite well. We can not enjoy if something good happans to someone as 'it did not happen to us'. In fact it is due to MATERIAL ATTACHMENT. So if someone gets promotion in job or gets recognised for his or her work or courage etc , we are not happy as we are attached to the same material things. This is the MATSARA or envy. In MAHABHARAT this is represented by KRITVARMA . Hewas the only YADAWA,who belonged to the sama clan as KRISHNA , But KRISHNA was respected , adored and was on the side of PANDAWAS. He became the enemy of Krishna , when the bride that HE WANTED to marry was married to Krishna . This meterial attachment and not having the same success in getting recognizes as was KRISHNA , he decided to join the side of KAURAWAS.

SHAD RIPOO ENEMIES OF THE MANKIND

      In the last one we talked about the first of the six enemies of the mankind which was KAMA OR LUST . The next one is KRODHA or ANGER. In today's world one need not saay anything more about the anger . The road rage , so common that we hear about it everyday. The anger in politics is seen everyday and has paralyzed the function of the government .
      In MAHABHARATA, the anger is represented by DUSHHASAN. We all know the famous story from the epic of how he dragged DRAUPADI and tried to disrobe her . When the Pandawas lost in gambling and in doing so they lost their wife too. So she was brought to the Darabar and then DUSHHASAN tried to disrobe her . She asked Lord KRISHNA to help her as none of her husbands would or could get up to help her. The Lord Krishna provided her with unending saries . This dded was done in anger . Whenever there is anger it paralyses rational ,intellectual thought process. Some one had said that that getting angry is punishing our self for the mistake of the someone else. The anger can come due to greed, lust ,disappointment and can lead to violence either physical or verbal . Even if anger is justified , say for example when terrorists killed hundreds of innocent victims in the name of religion , one should allow a rational thought process and channel it in such a way that we can catch such terrorists before they can do another act of violence and prevent it in future.

     The next enemy is LOBHA or GREED. In today's world we see it all the tie in our politicians and in common day to day life . People that have billions of dollars will cont to do things that are illegal , immoral and unethical to get MORE. Otherwise how do yo explain the selling of uranium mine to Russians or collecting billions of dollars under the name of charity and spending less than 10 % for the charity. At our level we see this when we see people indulging in food at party or drink at a party. We all eat MORE than we need and we drink much more than we need and can handle .
In MAHABHARATA, this greed is represented by KARNA and VIKARNA. Karna is representative of RAGA which is attachment to things that we like and repulsion from the things that we don't like. This attachment is so strong that it leads to GREED. The funny part of this equation is that we are never satisfied when we get what we want . This is called CIRCLE OF MIND . When we DO an action , it leads to IMPRESSION , which leads to DESIRE and the desire leads to ACTION which again causes the impression and so on and so for. When we do repeated actions , the impressions that it leads to are much DEEPER and the DEEPER the impressions , more intense is the DESIRE . So satisfing the DESIRE does not lead to calmness but in contrast it leads to more intense DESIRE. These desires are stored not in our physical brain , but are stored in abstract form in our ASTRAL
AND  CAUSAL BRAIN.When the physical body dies the desires are not gone as they are still there in astral and causal bodies . So we are reborn to SATISFY our desires . When these desires are not satisfied , we get ANGRY -KRODHA and under the impression of anger we loose the rational thought process and ACT violently.
    I will try to do other ones in next blog.   

SIX ENEMIES OR SHADRIPOO IN HINDUISM

    This blog is non medical. I was re reading the GEETA shloka 9th. As I have stated in the past that it is difficult for me to understand and accept that the Lord KRISHNA would spend or for that matter SANJAYA would spend the time in describing various warriors on the battlefield . So in the shloka 9th Duryodhana says that there various warriors ready to fight for me with there weapons.
    If one considers the symbolism of the real war to WAR WITHIN ONESELF,we have to consider the various obstacles that one faces in the meditative practice.Here comes the other warriors -which are 6 enemies of the practice of the meditation or called SHAD (SIX)  RIPOO(ENEMIES).
These are 1. KAMA (LUST),
2. KRODHA (ANGER)
3. LOBHA (GREED),
4 MOHA (DELUSION)
5.MADA (PRIDE ) AND
6.MATSARA (ENVY ).

     In MAHABHARATA, we have several characters, that could qualify to represent each one of these enemies of the mankind. In today's world we can find many people that could be considered to represent each of these 6 enemies-certainly one can have different opinions about certain figures that are known to all of us , but we will not have much debate on certain other characters,e.g North Korean leader , who probably represents more than one .
   The LUST is not always sexual .It is attachment to sensory pleasurable activities which can never be fulfilled.  It is intense attachment to material world, which is mortal and so are we. But we are holding on to the material things as if we are going to 'take them ' with us when we die. In Mahabharata, the DURYODHANA represents this LUST. He had such a attachment for the land , that he refused to give 'Even the amount that could be on the tip of a needle,' to the Pandawas. This lust is at the level of the mind  and the Intellect, is paralyzed.The physical sense organs are gross and the perception is at micro level , but still in physical body . But the mind is sutler and the intellect is still sutler. The EGO is higher than that. So when we have lust we can't THINK and we ACT at much lower level. The story of the Tulasidas, who wrote the TULASI RAMAYAN , is well known . He was married and his wife went to her parents for short period. He could not live without her so at late night he decided to go to her parent's place . They lived across the river . But he did not care . He went to the banks of the river . The water levels were very high due to rains. So the boatman refused to take him across the river in boat as it was too risky. Tulasidas decided to swim. He saw a wooden log passing by and so he jumped and with the
 wooden log he went across the river. he went to his in law;s place . it was two story house and the wife was in upstairs bed room . he called her , but she was asleep . His desire or lust was so intense that he decided to climb up to the window . He grabbed a rope that he saw hanging from the window  and went to the window and knocked on it , the wife opened the window and the was surprised to see her husband. She was not very happy as it was too embarrassing for her that her husband could not live without her for one night. So she told him to go back . She made a comment that if he would have such an intense DESIRE for the GOD , he would  be better off and would have perceived God by now.When he came to his senses he realized that what he thought was a wooden log was a dead body or corpse, what he thought was rope was a snake and so from that point onward he became a devotee and you know the rest. So if we have the LUST for GOD , it will be better.

  About the other five enemies , we will do another blog.
   

BUREAUCRACY ??

      I was reading an old book by one of the Indian authors. There was a story in which there was  a subplot . They had mentioned a story from a book of stories called 'ISAP NITI'. Isap is a slave and he had ability to understand the languages of the animals. So he had these narrative stories , in which the birds and the farm animals and the jungle  animals talk .Each story was telling some moral. So the story which was mentioned in this book was as follows . There was a bird's nest in a tree and the the the new ones had hatched. So one day the farmer comes in and looks at the trees and tells the servants that  the trees need to be trimmed. After listening to the talk that the tree will be cut , the little ones in the nest got scared and so when the mother came home, they told her the story and told her that they have to move , The female asked them as to who was going to do the job . So the birds say that the servants of the farmer. She tells them to relax. This is repeated and each time the servants are ti=old to cut the branches the mother tells the little ones to relax . One day the kids tell mom that the farmer had come again and this time he said that 'I am going to cut the tree tomorrow!" The mother tells the little ones that they have to move right away ! .The moral of the story is that if you want something done , you have to do it yourself if you want to be sure that it gets done . This brings me to my patient story.

       I was called to see 35 years old male , who had chest pain and so he came to ER. He had chest x-ray done  and it showed collapse lung.to rule out heat attack. He had a chest catheter inserted and then he had a CT scan  of the chest . The CT scan showed that his lung had partially expanded and there was still significant air out side the lung . He was doing better and was not short of breath and was not needing the oxygen.
      So I saw him and saw the CT scan too . He was more than a pack a day smoker and the CT scan showed  that there were several blebs or blisters on his lung . My feeling was that one of these blisters or bleb ,ruptured and so then the air leaked and the so the lung collapsed. With all these blisters on the lung I was concerned that this can recur and since his lung has not expanded completely , he may need additional chest tube or even surgery. I was worried that trying to insert new chest tube with all the blisters could ,one of them could rupture and then there would be major air leak.

      So i told him that he should be seen by chest surgeon and may be he can do new chest tube or just take him to surgery and clip the blisters and put in some talcum powder .To do this he needed to be transferred to the other hospital. So I called the hospital doctor. and also called a lung specialist in the other hospital and also called the chest surgeon . the surgeon felt the same thing and was willing to accept the patient .
    In doing all this 18 hours passed by and then 24 hrs , since I mentioned to him about the transfer . The next thing I knew was that the hospital doctor calling me telling me that the patient left the hospital with the chest catheter without telling any one . I did not know what to do . He had threatened the same before when different lung specialist had seen him and they did not get along and that is how I needed up talking over. But I had talked to him and the family extensively and printed pictures and told him that he will not do well without medical help. So my hunch was that he will show up and show up at the other hospital .

       I got a call from the other hospital that  he was in the ER !!!!

(In this story the patient decided to do the transfer on his own  rather than waiting for others to do it . I am happy that nothing went wrong , but this was not right thing )

FOLLOWING THE GUIDELINES

         In my last blog I talked about the guidelines that are given by the medical society and the insurance companies and the Medicare. but then I realize that even when one follows the guidelines , there is no guaranty  that we can succeed . I have seen this in many cases and the today's story is one of the similar one.
          I saw this 80 years old patient with cough .He had the cough for few months and so the usual tests were done by the family doctor. The chest X- ray was OK and the antibiotics and the other medicines did not help. So he came to me. I was treating his wife for several years and so I knew the patient though not as patient., He was not a smoker and the lungs sounded clear. He had normal chest X-ray and the lungs sounded clear.I ordered the pulmonary function tests  and it was OK There was minor abnormality that could go for the mild asthma.So I tried the medicines for the asthma. It did not help.. He gave me the history that the cough was getting worse with the eating and drinking water. So I suspected aspiration , which means that the liquids or the solids would be going in the lungs rather than the food pipe. So this causes chemical irritation. and that leads to the chronic cough. So I did the swallow study and it did confirm the aspiration . But the speech therapist gave him some instructions.

      The cough was better but was not gone. He had  follow up chest X-ray and it was OK. I had done the CT scan before and it was OK. He continued to me for next couple of months and then stop coming as he  was OK.
        I did not see him for just over a year. He was followed by the family doctor. But then he started loosing the weight. His appetite was down and he had lost weight. So the family doctor did the work up. He had CAT scan of the belly. The CT scan did not show any abnormality in the belly. But it showed mass in the lung .So he came to me . I did the CT scan and then the PET scan as the CT scan showed mass in the lung. The CT scan showed 8 cm size mass. I did the bronchoscopy and it showed lung cancer blocking the left lower bronchus.

    He was referred to radiation doctor for the treatment .
    So the mass that was not seen 14 months ago was now 8 cm .So even if he had chest X- ray done in a years , the cancer would have been diagnosed 2 months ago. But certainly not soon enough to be small enough for resection. (With his age and other issues , he was not surgical candidate. But he was younger still it might have been not the earliest stage .So following  the guidelines of doing X-ray would not have been enough.