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jmj11 last won the day on December 3 2017

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  1. This question came up to me yesterday, again. One of my cluster headache patients has been totally refractory to not only my treatments but has been followed by the best headache clinics coast to coast. He has three horrible attacks per day. He is near suicide. At least 1/3 of cluster headache patients have suicidal ideation. The first of the new CGRP antagonist antibody treatments, Erenumab, will be on the market in March/April. It will be FDA approved for migraine only. It has great hope in cluster headache but will not win that approval for at least 1 more year. I tried to get this patient in one of the cluster studies, but he was too old (65). Erenumab may cost as much as $3,000 per (once a month) dose. No insurance companies will approve it for anything but FDA indication, migraine headache. So, I had a long discussion with this patient about the ethical choices we have. I have to give him hope (or he might take his life). I have seen many headache clinics call things like post-traumatic headache, cluster headache (including this patient), TMJ, "chronic migraine" just so they can get Botox approved. I've never done that. If i is not chronic migraine I do't try to get Botox, mainly because it does not work in these other conditions so well.
  2. Okay, this is in theory, although I do face this question often. Imagine that an expensive treatment is FDA approved for condition A. However, several preliminary studies, and personal experience (as well as others in your same specialty) is that this treatment works well in condition B, profoundly improving those peoples' lives. Insurance companies will ONLY pay for the treatment for condition A, because it is the only condition that is FDA approved ( ad they like money and do not want to spend unless they have to). To get the treatment, you must fill out prior auth forms and submit chart notes confirming that the patient has condition A. Would you fudge your notes and he forms in order to get the treatment for condition B, in order to profoundly help that patient?
  3. Having worked with and fought with insurance companies for a number of years, when I owned my own practice, I will state a more cynical view of this process. Insurance companies are masters at denying payments for services. I do believe that this whole credentially process is one or their strategies for denying payments. It is ridiculous that in this day and age, that if a hospital or practice hires a new provider, it takes the insurance companies three months to "credential" them. If they see patients before (and often they do, sometimes my mistake) payment for those visits are denied. This process saves the insurance companies hundreds of millions of dollars per year. It is the state's responsibility to make sure a medical provider is qualified to provide medical services. There should be a class action lawsuit to take this government responsibility out of the hands of the insurance industry. I have never heard of or seen a lawsuit against an insurance company for contracting with a provider who had some disqualifying issue.
  4. Professional satisfaction for a PA is most experienced (surgery the exception) when you have your own patient panel, when YOU have a personal relationship with YOUR patients. It is only a matter of time before you will leave that job because the lack of professional satisfaction is not sustainable.
  5. I agree. We (in the headache medicine world) did not believe, it was real in the 1980s. There have been some landmark studies since 2003-4, mosting involving returning soldiers from war zone. The most amazing findings were an inverse relationship between the severity of the injury and the duration of the symptoms. It was the mild to moderate head injury patients who had the worst symptoms and they had no secondary gain. It is a microscopic, circuit issue, poorly defined, but the symptoms are consistent and believed to be real. As far as the headaches go, we say you treat them the way they look. If they look like migraine, you treat them like migraine and etc. There has been some experimentation with things like namenda for the cognitive changes with mixed results.
  6. However, this misunderstanding takes us back to the problem of our identity and how many people out there really knows who the hell we are.
  7. I've had this same thing happen to me at least twice. I was recently interviewed by the local newspaper. I went over and over with the reporter not to call me doctor and not to call me a physician's assistant. She thought I was paranoid but happens all the time. Maybe you can get them to print a correction (which I was unable to do in the past accounts, but allowed me to write a letter to the editor, which no one reads, after a local doctor complained that I was presenting myself as a doctor in the newspaper, which I never did).
  8. Here's the updated MRV report after I spoke to the neuro-radiologist. I will also try to attach one image. I have spent the last 30 minutes trying to get one image from our radiology file to my personal tablet and then in a form that I can attach here. I hope this comes through. I don't see any patient identifiers so if I've missed one, please let me know. PROCEDURE: ANGIOGRAM HEAD WITHOUT CONTRAS INDICATIONS: HEADACHES TECHNIQUE: Sagittal T1 spin echo through the brain. Coronal 2D time-of-flight MR venogram, with 3- dimensional maximum-intensity-projection (MIP) reformats of the intracranial veins then performed. COMPARISON: Island Hospital, CT, HEAD WITHOUT CONTRAST, 11/02/2017, 16:19. Island Hospital, MR, BRAIN WITHOUT CONTRAST, 11/29/2017, 10:05. FINDINGS: Image quality: Excellent. Veins: Sagittal, straight, transverse, and sigmoid sinuses all appear patent on the right. There is marked attenuated diminutive appearance of the left transverse and sigmoid sinus with extension into the jugular vein. Brain: Limited images through the brain parenchyma show no intracranial bleeds or mass effects. IMPRESSION: 1. Marked, diminutive appearance of the left transverse and sigmoid sinus with extension into the jugular vein as above. Findings are highly suspicious for venous thrombosis. Clinical history notes onset of symptoms to be late subacute/early chronic. This could represent partial recanalization. Followup imaging should include MRV as well as MRI brain with and without contrast. The above findings were discussed with Michael Jones PA, 11/30/17 at 12 PM. Dictated by: Kelley Cline, M.D. on 11/30/2017 at 16:55 Approved by: Kelley Cline, M.D. on 11/30/2017 at 16:58
  9. I had an experience once, early in my career, where I ran into a Milwaukee lawyer while kayaking around the Apostle Islands in Lake Superior. He was not just a kayaker, but a professional kayaker (guide). He made the decision to live where other people vacation and to vacation (back home in Milwaukee ) where other people have to live. He gave up his lucrative practice and settled for a 30k / year job, but loved every day. I made the same decision. I tried to work and live on Lake Superior for 10 frustrating years. I went from horrible job to horrible job (horrible attitude towards PAs in Michigan's UP during the early 1990s, different from Michigan in general). Finally, in frustration, I gave up that dream and decided to look for just a good place, professionally. I went to Mayo Clinic. It was a wonderful place to work with plenty of respect. However, I hated living in land-locked farmland for five years. So I came out to the beautiful San Juan Islands (kayak capital of the world). During the 1999 to about 2010 it was not a good place to work (low wages, low respect). But slowly, the PAs and NPs have fought our way into respect and now, 90% of the time, it is a wonderful place to work and live. I would recommend it. Our hospital has been looking for a PA for almost a year without success. The only PAs who are disappointed are those (in my opinion) who are new graduates and have an unreasonable view that they should be earning 130K per year their first year, for urgent care or Family Medicine.
  10. All I can say is that you must be better at it than me. Especially with the elderly, I could barely visualize the optic nerve with the old scope.
  11. I remember helping with my first D & C and the family medicine doc who was doing it told me the same thing. He put this big clamp on her cervix and she screamed. He told me it was just anxiety because she can't feel a thing.
  12. We were taught in school that a good clinician, even in a only partially darkened room, without the benefit of mydriatics, using the traditional Welch Allyn ophthalmic scope. should be able to assess: if there is any papilledema, the depth of the optic cup, if there is AV nicking, cotton wool spots, infarcts, macular drusen, or hemorrhages. I could not see those things at all once I started my clinicals, especially in the elderly (small pupils) or those who could not cooperate well (eg. kids). I felt like an incompetent idiot. Then one day, I had the chance to share a patient (with papilledema, which I did see) with a neuro-ophthalmologist. He told me that no one can see crap with one of those, UNLESS mydriatics are used in a really dark room and the examiner is very lucky and the patient very cooperative. Then I asked, "But my (PA) instructor said that he could." Then he laughed and said, "Every doctor or PA who says they see all these things are lying to you. They are pretending to do the exam." I now have a panoptic. I can tell if there is even subtle papilledema in virtually all patients, but I still can't see many of the other things unless they have naturally large pupils (in their 20s) and are very cooperative. We don't use mydriatics in neurology. I recently had a second year PA student. She also had been told that she should be seeing all those things with the old scope. I then had her look at the fundi of one of my patients using my panoptic and telling her what to look at. She, literally broke down in tears because she had felt incompetent before and now she could finally see those things she supposed to be seeing.
  13. I don't know when Narcan is coming back and if he/she knows the answer. I will post the rest of the story below. I'm not at work today, but if can figure out how to save the images without the name attached, I will try to post them when I'm back at work next week. So, I will tell this story in real-world, the things that we all have to put up with. When I saw her on November 20th, as I alluded to, my differential was 1) postpartum status migraine (by far most common), 2) possible persistent dural leak from an epidural, that accidently went subdural, as least during the placement. and 3) peri-partum central venous thrombosis. I was worried enough about # 2 (but the headache was never positional) and # 3 (no real personal or family history of migraine and not positional to support # 1 or # 2 so # 3 plausible as she was quite distressed with 8 weeks of significant pain. Her CT was negative and she had none of the dismal associated symptoms with a central venous thrombosis, including infarct, seizure, other neurological signs. I started her on a prednisone burst and daily naratriptan, (expecting # 1 above) and ordered a brain MRI / MR-venogram and scheduled her back in four days because she was not doing well. Her insurance rejected both the MRI and MR-V. I started a prior authorization appeal (we rescheduled her until the MRI / V could be done). Second time around, both exams rejected by the insurance. At this juncture, I came very close to giving up on the exams. I asked for a "peer to peer" with a AIM radiologist (AIM contracts with insurance companies to try and disapprove of radiological exams). I spoke to the radiologist and came in with my guns a blazing. It turns out that the exam was ordered by the hospital prior auth department as "Migraine." Nowhere, except in my billing sheet for the visit, did I list status migraine as one of three diagnoses. On the radiology request form, along with a brief HPI I ordered the MRI for "New worsening, daily headache." For the MR-V I listed central venous thrombosis. I have no clue why the exam was then sent to the insurance as "migraine," but I'm looking into it. So, the AIM radiologist approved the MRI, but chuckled at the MR-V, stating that only big, university settings and said he is not approving it. I argued for it. We immediately schedule the MRI and to see me back the following day (yesterday). Just before her visit, I went to look her images online. First I noticed that the MRI and MR-V were both done and read as normal. I again came very close to moving on and treating this as status migraine. I pulled up the images and viewed the MRI. I didn't see anything abnormal. I viewed the MR-V. It is typical to have a dominant transverse venous sinus. Her right was much larger than her left. However, one segment of the left was very small and I saw no patent lumen. I called the reading radiologist and spoke to him. He said again that the MR-V shows a normal right-dominant transverse sinus. I pointed out that I see no patent lumen. He (in the "reading room" with HD screens and more views than I can see) looked closer and commented that in his view he can see a tiny flow, but started to agree that it was tiny. He asked if I wanted it sent to the neuroradiologist and I said I did. I saw the patient in the meantime. The prednisone and naratriptan did help for two-three days with the pain much less, but by the third day, it was back to thes status quo and no new symptoms. I had her wait while I saw another patient. When the neuroradiologist never called back, so I called her. She reviewed the image in real time with me on the phone. She agreed that the left transverse venous sinus was not normal and appeared to have a clot, a clot that was probably fully occlusive (her guess listening to the story) in the beginning and now is starting to recanalize. I called her OB, who is also my hospital's Chief of Medicine. I do not feel comfortable managing this patient. I wanted to send her out of town to a stroke neurologist to follow her. Her OB, who had only seen one other case his entire 45-year career, wanted me to send her to the hospital internist for management. Unfortunately, later in the afternoon (I had the patient still in my office) the internist said he could not see her (too busy) and that there is no reason her PCP could not follow her. If this had been the first couple of weeks, she would be admitted and heparinized or even directly "clot busted." I did research and apparently, at this stage, with recanalization and no neurological complication, it is reasonable to treat with oral warfarin. I order coag labs, D dimer and started her on 2 MG of warfarin. I will see her back in five days with an new INR. I hope that her PCP has seen her by then to take over management. So, one take home is to look at the patient and not the image report. I almost let this go twice. For the other take home, I will leave a link to remind us to thing CVT in peripartum patients with new headache. I'm not at work but will try to insert the images next week.
  14. My first treatment, thinking that it was status migraine, was steriods + daily naratriptan, did give her 2-3 days of much relief, but then the headache came right back. My # 1 differential (status migraine) was not correct. Her CBC was slightly elevated (I'm not at work and can't remember the numbers) and her D Dimer was elevated (again, can't remember the numbers). All other labs were normal.
  15. I have given it partially away that is one of Narcan's six. This is where this gets tricky. I will tell you the data that came in and explain at the end. Her fundi were normal without any evidence of papilledema. An opening pressure was not done. The MRI and MR-V (very hard to get them prior authorized) were read by the local radiologist as normal (notice the emphasis on read).