Random confuse the engine search

A friend and I are using Facebook to message this am and she says she hates that Facebook is mining for advertising all the time. I said we should do a random confuse the engine search every day. Something silly! I searched enamel zebra hamsters first…. And it’s fun to watch the internet try!

What silly search would you use to confuse the big data mining on the internet? Go wild! Confuse your feed!

Influenza 2016

No influenza cases so far this year in my clinic.

I watch the flu map faithfully each week, as I try to get my stubborn patients to get their influenza vaccine. It takes up to two weeks to get them immune, if it works. It works most years about 80% f the time. When it doesn’t work, it’s because either their immune system didn’t respond or because the influenza virus has traded genes enough that the guess six months before on which way it will evolve, is wrong.

Here is the CDC weekly influenza update link: http://www.cdc.gov/flu/weekly/fluactivitysurv.htm.

If you click on the FluView Weekly Influenza Surveillance Report, scroll down. My favorite to show patients are the Outpatient Illness Surveillance, which maps this year’s rise in influenza in the US each week, compared with past years. We are having a late year.

My other favorite is the next one down: ILIState Activity Indicator Map. It changes color each week by state as the influenza reports come in. Arizona turned red this year about a month ago, after Puerto Rico. Red is high activity level. The rest of the country was dark green, low, or light green, but has steadily been turning yellow green, yellow, orange…. Washington State is still green. But now only a few states are green and it’s still on the rise. If we continue to have unseasonably warm sunny days, like the last four days, we might avoid the influenza. But if it gets wet and cold again: boom. Like a sneeze, spreading. This is the first week we’ve had seven red states. I have been wearing a mask in clinic every time I see someone coughing. And I got a cold anyhow, but it is not influenza and I don’t think it’s strep A, thank goodness.

I said influenza is airborne but it isn’t. Or there is controversy. It is at least droplet spread, but sneezes count. Apparently influenza can get to people 6 feet away. Wear your space suit with the oxygen filter to the grocery store. http://www.cdc.gov/flu/about/disease/spread.htm — lots of information about the influenza virus. Is all of it 100% correct? Don’t be silly, this is science, not a religious text: science changes, just like the flu virus.

This year, a CDC alert was faxed to clinic on February 1: http://emergency.cdc.gov/han/han00387.asp. It is all very calm and clinical, with this sentence in the second paragraph: “CDC has received recent reports of severe respiratory illness among young- to middle-aged adults with H1N1pdm09 virus infection, some of whom required intensive care unit (ICU) admission; fatalities have been reported.” I called my son and said, “Get your flu shot now.” If you read the rest, it says ages 20-50 as the “young” and “middle-aged” adults. Not the group that we expect influenza to hit, but that is the group that got hit in the 1918-1919 influenza.

Get your flu shot… be careful out there.

 

I took the photograph two days ago with my phone: Boa was on my lap and I wrapped her in the shawl I’d knit, and she was so relaxed…. that’s how we need to take care of everyone with influenza.

 

Fraud in medicine: prior authorization III

I see a patient who has had prolonged sinus symptoms AND her right upper molar has been irritated for weeks, but then Saturday it started hurting. She saw her dentist. The dentist did x-rays and said it’s her sinus. “But my tooth hurts too.”

On exam, her gum is bright red above the tooth, but not swollen as it can be with an abscess. No fever. No bright red spot over the maxillary sinus.

I call our independent radiology service and ask for a limited sinus CAT scan. She is off on Mondays only, it is Monday, she is out of town next Monday. Can they do it today? Yes, but she needs a prior authorization.

I call her insurance, after looking up the CPT code for sinus CT on google. As usual I have to enter numbers before I talk to a human:
patient insurance id number
my tax id number
my national provider index number
and others until I get a human.
Then I have to give the numbers AGAIN because the insurance company deliberately makes it inefficient, even though I have entered them into the phone it doesn’t transfer to the representative and you know that it COULD.
I give my name
patient’s name
patient’s date of birth
clinic address
clinic phone
clinic fax number
tax id
national provider index number
and finally explain: we need a prior authorization for a limited sinus CT and she has five ICD 10 symptom codes.
“She doesn’t need a prior authorization.” says the rep.
“What?” I say, “So it’s covered.”
“We don’t guarantee coverage, but we don’t give prior authorization.”
“What do you mean, you don’t guarantee coverage. I am calling to check.”
“We review the chart afterwards and THEN decide if it’s covered.”
“No. That isn’t good enough. I want to speak to someone who will check the codes and tell us if it will be covered.”
“I will have to transfer you to the (patient something).”
“Fine. Transfer our information please too.”
We go on hold. Time passes.
We are back to a recording:

TALKING TO A REPRESENTATIVE DOES NOT GUARANTEE COVERAGE OF A TEST. PRESS ONE IF YOU ACCEPT THIS.

No two. No other options are offered. I press one.
I talk to the new representative. “I have five diagnosis codes and want to know if the sinus CT will be covered. She is off and they can do it today. She is only off on Mondays.”
“We don’t do prior authorizations.”
“Isn’t there ANY WAY we can find out?”
“You can mail a letter to a PO box and we will review it and let you know.”
I am ….. hard to describe…. my head hurts.
“Would you like the PO box address?”
“How long does that take? Yes we want it. Don’t they have a fax?”
We get the fax number too. I hang up and look helplessly at my patient. “I think it will be covered. I would recommend we do it.”
“Ok.” She says. Her face and tooth hurt.

I call the independent radiology center and set it up for 2 pm.

They call back in the afternoon. She has a sinus infection and the tooth is bad too, they don’t quite look connected. I call the Ear Nose and Throat specialist who wants her on three weeks of augmentin if she tolerates it and then to see her. I thank him and get it rolling.

But….. ok, so the insurance companies contract with me and the patient say that they can change the benefits any time they want. They “notify” me with postcards with online links. Like I have time to read and remember the changes for …. 50 different plans? There are over 500 in the US.

When are we going to stop letting insurance companies take our money and refuse care and refuse to pay the physician and the radiologist? Medicare for all, one set of rules, I COULD LEARN THEM. I can memorize huge amounts of data: I am already busily memorizing the ICD10 diagnosis codes. There are only 48,000.

And I don’t know yet if her insurance will pay for the sinus CT…..

The picture is from Lake Matinenda in Ontario: no computers at our cabin, no outlets, phones mostly don’t work…. heaven.

Pink and blue

This is for Jithin’s Mundane Monday Photo Contest. I took this in the evening last week when I had a cold and was lying on the guest bed at home. I was nauseated when I stood up, so spent two days at home. I saw one patient on the first day and called the rest myself. If the doctor calls and sounds horrible and says they are contagious, most people are willing to reschedule….

Recovering from influenza exhaustion

Influenza can cause swelling in the lung tissue. This is different from pneumonia, in that it is not fluid in the lung air spaces and different from bronchitis, where there is swelling and inflammation along the tissues lining the lungs.

In really severe influenzal lung swelling, the air spaces swell shut, the lungs are bleeding and bruised, and the person dies. Young healthy recruits in the 1917-1918 influenza would literally turn blue as they were no longer able to breathe and they would die.

If a person is still feeling exhausted after the initial week of influenza, they need testing to find out if they have lung swelling. This can be done at home or in your doctor’s office.

To test at home, the patient should sit relaxed for 10-15 minutes. Take a one minute pulse count: normal is 60-100 beats in one minute. Then the patient should get up and walk until short of breath. Sit back down and repeat the pulse. If the pulse is jumping up 30 points or if it is over 100 after walking, there is still lung swelling. The treatment is rest.

To test in my office, I add a pulse oximeter. I get a resting oxygen and pulse level, walk the person and then watch the recovery. The oxygen level will often drop and then rise to the sitting baseline as the heart rate recovers. Most people do not need oxygen if they have a healthy heart and healthy lungs to start with.

You can see why influenza would be so dangerous to someone with an unhealthy heart or lungs, because the heart can’t make up the difference.

I had influenza in 2003 and had lung swelling to where I could not walk across the room without my heart rate going to 132. Sitting, my heart rate was 100. My normal heart rate is 65-75. It took two months for the swelling to subside and mostly I lay on the couch. Be reassured that if you rest when you need to, you will recover.

The photograph has my father sitting and Andy Makie standing with the harmonica, at a music party at my house in 2009. Both my father and Andy are gone in their 70s, primarily from lung damage from cigarettes. Miss them both. Thanks to Jack Reid too.

Adverse Childhood Experiences 3: Attachment Disorder

I ought to have an attachment disorder, which now is called “separation anxiety disorder” in the DSM IV, now redefined in the DSM IV-TR and then the DSM V. That is, they keep changing the definition of psychiatric disorders. It’s a bit unnerving, isn’t it? Not only the brain is “plastic” and can be rewired throughout our lives, but the psychiatric diagnosis manual is being updated.

When I went into allopathic medicine, I was under the impression that I needed to learn everything I could and apply it. Spectacularly wrong. I needed to learn everything and then track everything because at least one fourth of what I learned was wrong or was going to change. I just didn’t know WHICH 25% was wrong.

This is why older doctors have a healthy skepticism towards new medicines, new equipment, new ideas. Older doctors are more likely to use old cheap medicines and eschew the new-fangled samples. It’s not just that the pharmaceutical companies only give us samples of the new expensive stuff. It’s also that some of the new expensive stuff is not as good as advertised and has a chance of hurting people. I still would advise my patients to use coumadin (warfarin) if they have a clotting disorder. Yes, you can take the new drugs without doing a monthly blood test — BUT if you bleed, I can’t reverse the new medicines. So I wouldn’t take them: if I need a medicine to keep me from clotting, I want coumadin. I will decide about the new medicines in 5-10 years. Old and cynical, that’s me….

As previously written, I had five “experiences” under age three that left me not trusting adults. However, the adults seemed to love me, even though they kept abandoning me to other adults. At under three, this did not make sense. I could have decided never to trust anyone and presumably would have really gone off into some sociopathic bad place, but I didn’t do that.

The clue to what I did is in my mother’s stories. My sister was born five days before my 3rd birthday. She came home right by my birthday, at Easter.

My mother said, “You asked if you could dress Chris. She was two days old. She was nearly ten pounds and had a triple chin. You wanted to put a lacy dress on her. I decided that you could try and told you to be very gentle.

You put Chris into the newborn baby dress. She was so big that it barely fit and in fact, that was the only time she ever wore it. You had to stuff her arms through the sleeves. She cracked her eyes and looked at you, but she did not object at all. You were gentle.”

That doesn’t seem like much. Next story:

My mother said, “You would meet visitors who came to see Chris at the door. You would say “Come see my baby.” I let you open presents for Chris because she didn’t care. You would show the visitors your sister.”

My baby. That is the key.

I think what happened is this:
1. The adults who took care of me did seem to love me.
2. Even though they loved me, they kept abandoning me, or giving me to other adults. I really really disliked this.
3. I thought that adults were misguided and wrong to give me away. I thought there must be some explanation. I would try to figure it out. Meanwhile, I was going to take care of my sister: she was MY BABY. I was going to show those stupid, loving, confused adults how to take care of a baby and NO ONE was going to give HER away. I could love adults but no way was I going to trust them.

That was my crisis brain wiring by age 3. Adults are loving and untrustworthy. You can love them back but they may abandon you to someone else at any moment. You can’t predict what they will do. They may be even LESS trustworthy if they are loving and you know them, than if it is a stranger.

My mother again, “When I got you back at nine months, you didn’t know me. You wanted to be as independent as possible. You missed your (maternal) grandmother. In the grocery store, you would cry if you saw a white haired woman. We couldn’t comfort you.

I thought that you didn’t like us at all until you ate a cigarette butt and got really sick. You let us take care of you. Then we left you with friends for a night. You were absolutely furious when we got back and I thought that you really did like us….”

Poor young mom, 23 and recovering from tuberculosis and still not strong, with an angry and grieving nine month old who really didn’t want much to do with her and didn’t trust her at all…..

Changes from the DSM IV-TR to the DSM V: http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf

The DSM IV criteria for separation anxiety: http://behavenet.com/node/21498

Theme song: The Devil Makes Three “All Hail”

Taking care of Ebola is hard

“We may never know exactly how [transmission] happened, but the bottom line is that the guidelines didn’t work for that hospital,” said Frieden. “Dallas shows that taking care of Ebola is hard.”

From the Huffington Post: http://www.huffingtonpost.com/2014/10/20/ebola-hospitals-us_n_6018372.html

And for me, a lowly rural Family Practice physician, from the American Academy of Family Practice: “The first steps in preparing your office for a possible Ebola case are to make sure you have all referral contact information ready to go and that you educate each staff member on his or her role should a case present.”

There is only me and a receptionist. We don’t have hazmat suits. Actually I’ve been off sick, lung and vocal cord problems, for all of October.

We have masks, gloves, I do have a white coat that I almost never wear.

Also from the AAFP:”Appointment clerks and front-desk personnel taking calls for appointments should inquire about African travel history in patients calling for appointments for fever, headache, weakness, diarrhea, vomiting, muscle aches or bleeding,” said Mahoney. “Anyone with a positive travel history should be contacted by a provider to gather additional history and determine if public health authorities need to be involved before a patient even presents to the physician office.”

http://www.aafp.org/news/health-of-the-public/20141017eboladisprep.html

We are both going to get our influenza shots this week. Please get your influenza shot. There is a lot more influenza around than risk of ebola in the United States, and influenza kills many many people every year. And even if you “never get colds” and “have a strong immune system”, you might get a mild case of influenza and pass it on to someone who then dies of it. If you tell me “I got flu the last time I got the shot”, excuse me, but that is hooey. First of all, it takes two weeks for your immune system to respond to the shot, so if you got symptoms the next day it could be influenza but not from the shot. Maybe from being exposed to someone with influenza at the grocery store or your doctor’s office. Secondly, people say “flu” and often they mean stomach flu. Stomach flu is not influenza. Third, influenza changes all the time, so about 80% of the vaccinated people are protected most years. That’s right: two weeks after my influenza shot, I am about 80% protected. Not 100%.

Why are we getting vaccinated? For one thing, we are health care workers and we get exposed. And for another, the initial symptoms of influenza are the same as the initial symptoms of ebola. Actually the United States is really rather lucky that the ebola case happened before influenza really hit, because they look too much the same initially. Suppose that three of the quarentined people had come down with influenza….. confusion and panic initially.

So please get your influenza vaccine, because you not only help to protect yourself, but protect others and prevent panic.

Blessings!