I have not written for a while because so much of my time out of work is spent on appealing denial of payments by Novitas, the Medicare administrator for Texas.  They have denied care for patients who have had treatments that are considered as class 1 evidence for management by all the major vascular societies, including the American Association for Vascular Surgery/Society for Vascular Surgery, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease) endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation; National Heart, Lung, and Blood Institute; Society for Vascular Nursing; TransAtlantic Inter-Society Consensus; and Vascular Disease Foundation, and Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II).  In 25 years of doing this work, I have never encountered such nonsense.  I thought I was the only one going through this trouble.  Then I find out that a cardiology colleague of mine in South Dallas has the same issue.  By word of mouth, I talked to a cardiologist in Illinois who just went through the same  problem.  I bet there are more physicians that are being inappropriately denied payment for standard of care by Novitas.  Nothing against the profession, but I found out my cases were reviewed initially by a licensed vocational nurse (LVN).  Hell, even many physicians don’t fully understand what we do and why.  To add fuel to the fire, apparently Novitas keeps 12% of the amount of money that they recoup from physicians such as myself as a bounty.  When I reviewed a case with one of the Novitas nurses early in the course of this appeal, she told me “Well you know sometimes people need to have an amputation of their leg rather than an attempt at limb salvage.”  THERE IS SOMETHING GOING ON HERE, AND I WOULD LOVE TO HEAR FROM OTHER PHYSICIANS, BILLING PEOPLE, AND HEALTHCARE PROVIDERS ABOUT THEIR PROBLEMS WITH NOVITAS OR ANOTHER MEDICARE ADMINISTRATOR.


Peritoneal Dialysis

Another option that has been around for a long time, but is gaining increasing traction is peritoneal dialysis (PD).  PD is a method of cleaning the body of the toxins and waste products that are normally eliminated by the kidneys.  PD depends on diffusion, or the exchange of material along concentration gradients.  PD depends on the large surface area of the peritoneal cavity.  The peritoneal cavity is the space under your abdominal muscles and chest that hours the intestines and other organs.  In order for a patient to do PD, we have to insert a PD catheter into the peritoneal cavity and begin it out of the side of the abdomen.  This is an outpatient surgical procedure that takes about 45-60 minutes to perform and is not a very painful surgery.  The incisions are allowed to heal for about 2 weeks prior to the PD catheter being used or dialysis.

In essence, a large volume of dialysis fluid is placed into the abdominal (peritoneal) cavity, and allowed to dwell form some time, usually overnight.  During that time frame, due to the difference in the difference in concentration of electrolytes and other substances in the fluid as compared to the body, there is an exchange of products.  The fluid that was placed into the peritoneal saps a lot of the bad products that the kidneys would normally remove. This fluid is then drained out the next morning, resulting in “cleaning of the blood”, much like regular hemodialysis.

The good thing about PD is that is is much more physiologic than hemodialysis, meaning that it is gentler on your body because of the slower nature of the exchange.  The downside is that you have a piece of plastic tubing hanging out of your body, and you have to make adjustments to your lifestyle for it.  The other major risk of a PD catheter is the chance of infection.  An infection of the peritoneal cavity is called peritonitis, and can sometimes be treated with antibiotics in the dialysis fluid.  If the infection is severe, particularly if it s fungal infection, the catheter needs to be surgically removed in order to clear the infection.

PD requires  specialized training by peritoneal dialysis education centers, because it needs to be done correctly in order to reduce the chance of infection and other potential complications.  Patients who are significantly overweight, or who have had multiple pelvic or abdominal surgeries generally do not do as well with PD.

Carotid Artery Disease and Strokes

The carotid arteries are the main blood supply to most of the brain.  The right carotid artery supplies the right side of the brain.  A right sided stroke  symptom will include loss of vision in the right eye, kid of like those old movie theaters where a curtain comes down over part of the eye or all of it.  This event is called Amaurosis Fugax.  Another potential symptom of a right brain stroke is loss of motor control of the left side of your body.  You may be stirring a cup of coffee with your left hand, and all of a sudden you can lift your hand.  There is no pain associated with these events.  A left brain stroke will cause the opposite event to the right side, namely amaurosis fugax of the left eye and loss of right sided motor control.  In addition, most peoples speech centers are on the left side of the brain, so you may lose your ability to speak even though you know what you want to say, or it may come out as a string of non-sense words.

Carotid artery blockages are one of the many potential reasons for a stroke.  The risk factors for carotid artery disease are the same as the risk factors for other cardiovascular diseases.  These include   1.  Cigarette smoking

2.  Diabetes

3.  High blood pressure

4.  High cholesterol or triglycerides

5.  Age

6.  Family history of circulation problems

Most people with carotid artery narrowing do not know they have it.  If you have had a heart attack or has peripheral vascular disease, then you have a higher risk for carotid artery narrowing.  Most patients with carotid artery stenosis do not need surgery.  Age and family history you are stuck with!  Our goal is to prevent the narrowing becoming worse but making sure that your blood pressure, blood sugars, and cholesterol levels are well controlled, and that you stop smoking.

If you have been diagnosed as having carotid artery narrowing, the prognosis is really quite good.  Most people will never need their carotid artery repaired.  Th old standard for treatment of carotid artery narrowing that was 60% or greater was surgical intervention based on a study published in the New England Journal of Medicine.  However, this study was prior to the current era where we have Plavix which is like a super aspirin, and statin drugs.  Therefore, the management of carotid artery disease has changed somewhat to a more conservative approach, as outlined by the writings of Dr. Frank Veith, one of the most thoughtful and smart vascular surgeons who has been around a long time and seen  it all.  I personally discuss surgery in patients who have had a TIA or ministroke and carotid artery narrowing on the side of the TIA.  A TIA is a stroke like symptom, but by definition, you recover function within 24 hours.  If you have a TIA, and have severe carotid artery narrowing on the side that caused the TIA, then you have a high risk for a full blown stroke, and really should have intervention for the carotid artery narrowing.

In terms of treatment for carotid artery stenosis, as I mentioned most people do not need intervention, and can be managed with anti-platelet agents that thin out the blood such as aspirin or Plavix, as well as control of their cardiovascular risk factors, statin drugs as necessary, and smoking cessation.  Why not fix all carotid artery narrowing when it’s present?  Because the intervention itself carries a risk for stroke and even heart problems.  This business is all about balancing the risks versus benefits of everything we do.  If the risk of stroke is low with carotid artery narrowing, then it is better managed conservatively.  If intervention is required, the options are to either have a surgical intervention or a carotid artery stent.  There are advantages and disadvantages of both. I personally do not do carotid artery stenting; I think that is better left to someone who has experience in doing the procedure, but also in fixing problems that may arise both during and after the procedure.  If I think a patient is better served by a carotid artery stent rather than surgery, I will ask them to see a friend of mine who is a neurointerventional radiologist, basically a specialist in all things related to the blood flow to the brain.  He might come back and tell me “no, I think this case would be better served by surgery, or yes I think carotid artery stenting would be a good option.”  Remember the old adage “if your only tool is a hammer, the whole world looks like a nail.”


Principles of Life

I looked through my old notes that I had taken on my laptop this morning, as I thought about what I was grateful for.  I try and start out the day by spending a few minutes being grateful, it really does change something inside me, no matter how I feel when the alarm rings at 5 am.  I found some old notes that I forgot I had made.  Instead of writing something about medicine, I have copied them down here.  My apologies if they are plagiarized from someone, I don’t know what I was reading or thinking or even when exactly I made these notes, but they are just listed below


  1. There is only one important time, and that time is NOW. The present moment is the only time over which we have dominion
  2. The most important person is always the person you are with, who is right there before you (including yourself if you are alone), for who knows if you will have dealings with any other person in the future
  3. The most important pursuit is making the person standing at your side happy, for that alone is the meaning of life
  4. In whatever situation you are in, whether good or bad, have fun and be happy. That is a conscious decision we all make, for in between any stimulus and response there is an infinite time period; it is up to us and us alone to decide that response