I bought another brace, this time made by Mueller.  Mueller is another company which manufactures braces and supports for sports.  The pictures on their site are all of young athletes engaged in hard charging activities like tennis, running, and basketball.  Recently my husband’s podiatrist commented favorably on the brace, “Mueller makes some good braces.”

Mueller Hinged Wraparound Knee Brace Model 3333

This brace has worked out a lot better.  The main difference is its wrap around design, rather than a sleeve type design.  That means I have more versatility in the adjustment of the velcro to make it fit my body.  Again, the lower end of the brace that fits below my knee is slightly large and the upper end that fits around my thigh is a bit small.  Since the brace has velcro fastening, I can attach the top flaps to each other at an angle and with just the last half inch of the straps overlapping.  The velcro holds all right once the outside straps are fastened.

While the Mueller 3333 does not have McDavidness and mojo, it fits better and gets the job done.  I do like its slim profile.  The hinges do not rub my other knee.  Years ago I had an obscenely expensive Donjoy brace.  It was all metal and I got to pick the color (they even had leopard spots) but the hinge area bumped my other knee, altering my gait.  Also it was not adjustable for weight gain or loss over a certain amount.  I think movement was better with that brace, but overall versatility was less than these velcro adjustable over the counter braces.

So, to find the best fit, sometimes you have to try out a few different models and brands.  This Mueller brace works ok for me now.  I’d love to find one that fits a woman’s thigh better, though.

So, how is the donut hole defined?  According to Healthcare.gov the definition is simply this:

Most plans with Medicare prescription drug coverage (Part D) have a coverage gap (called a “donut hole”). This means that after you and your drug plan have spent a certain amount of money for covered drugs, you have to pay all costs out-of-pocket for your prescriptions up to a yearly limit. Once you have spent up to the yearly limit, your coverage gap ends and your drug plan helps pay for covered drugs again.

That doesn’t sound so difficult, does it?  For a bit more detail, see this explanation about 2010 costs on the Medicare.gov blog:

• You pay out-of-pocket for monthly Part D premiums all year.
• You pay 100% of your drug costs until you reach the $310 deductible amount.
• After reaching the deductible, you pay 25% of the cost of your drugs, while the Part D plan pays the rest, until the total you and your plan spend on your drugs reaches $2,800.
• Once you reach this limit, you have hit the coverage gap referred to as the “donut hole,” and you are now responsible for the full cost of your drugs until the total you have spent for your drugs reaches the yearly out-of-pocket spending limit of $4,550.
• After this yearly spending limit, you are only responsible for a small amount of the cost, usually 5% of the cost of your drugs.

Hmmm.  Ok, still says you spend a certain amount, then you’re in the donut hole, then when you spend some more you are out, right?  Perusing Medicare.gov (the official US government Medicare website), the information is much less specific, essentially directing you to the plan database to find plans offered in your area.  The key point not mentioned in any of these explanations is that the formula to figure the amount of money spent to get IN the donut hole is different from the formula to figure the amount spent to get OUT of the donut hole.

So why does that matter?  Well, it certainly affects your budget planning for the year.  Most articles I’ve found on the web on this subject deal mainly with strategies to avoid the donut hole.  For example, this article from AARP.  I wasn’t all that interested in those as my husband takes some high dollar drugs that we really can’t change at this time.  There is no way possible for us to avoid the donut hole.  When my husband became eligible for Medicare in November last year, it took one month to get in the donut hole.  This was after filling 90 day prescriptions for his two most expensive drugs.  I was in utter shock when this happened.  The only thing that saved us was the end of the plan year.  This year we strategized to fill prescriptions for cheaper drugs before expensive drugs to maximize our time before coverage dropped out.  My estimate for coming out of the donut hole was 2 or 3 months, when we again bought the expensive drugs.  WRONG!!!

You see the explanations I had read on the Medicare site and on various patient or senior advocacy sites never explicitly explained the calculations of the numbers.  Certainly the policy information we received from Humana for my husband’s part C (Medicare Advantage) policy did not.

Here is an example of the type of language generally encountered.  Ignore the specific numbers mentioned as this article is several years old.

After $2250 in total drug costs is reached, there is a gap in coverage (the “doughnut hole”) and the enrollee must pay the full cost for their prescription drugs until they have paid $3600 out-of-pocket expense. (It has been erroneously reported that the $3600 out-of-pocket expense is in addition to what has been paid out-of-pocket towards the initial $2250. Actually, what has been paid out-of-pocket during the initial coverage phase also counts towards the $3600.)

After total true out-of-pocket (TrOOP) expense equals $3600, enrollees reach “catastrophic coverage” and their cost per drug drops to a small co-pay (usually $2 or $5) or 5% co-insurance, whichever is greater. During the period enrollees are in the coverage gap or doughnut hole, they must still pay their monthly premium.

The DMHC also sited Kaiser for other violations including providing it’s HMO members with “inaccurate education materials” which implied that the limits on mental health care benefits were more restrictive than permitted by law and “may have discouraged some enrollees from seeking and accessing medically necessary behavioral health services.”  These problems have evidently been going on for quite some time.  A November 2011 article in Huffington Post, “Kaiser Permanente Makes Billions in Profits While Overburdening Staff,” describes KP’s shoddy and deceptive practices, including forcing patients to wait weeks for appointments, providing inadequate new patient evaluations, and shunting patients into group therapy when individual therapy is indicated.  The Post cites findings of a report by the National Union of Healthcare Workers.

These alarming allegations and government oversight findings are likely the tip of the iceberg.  In my opinion, it is dangerous to allow an insurance company to also run the health services it requires its members to use.  I experienced this kind of abuse myself many years ago while a member of the Prucare HMO.  I was seeing a psychiatrist at the only psychiatric practice the plan covered. Routinely the doctor would order follow up in a certain amount of time, for example two weeks, and when I went to the appointment desk to schedule I would be told the wait for a follow up appointment with my doctor was many weeks longer than what he had recommended.  When I complained to the doctor, he said he had no control over that situation.  Eventually I gave up using the psychiatric services offered by my plan.  I did my psych follow up with a primary care physician who really did not have the expertise to manage my medications but was able to write for refills for my ineffective regimen.  I sought psychotherapy from an outside therapist and paid out-of-pocket.  This bad experience has left me leery of using insurance to cover my psychiatric care.  I have paid a psychiatrist who does not take insurance out-of-pocket for many years and have found her to be the most knowledgeable and thoughtful psychiatrist I have ever seen.

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) is a federal law requiring insurers to cover mental health and addiction treatment at a level equivalent to the coverage provided for other medical care.  Here is an excerpt from the United States Department of Labor fact sheet:

The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits.

This law has made it much easier for people to obtain needed mental health care both from a cost perspective and in terms of limitations of treatment.  Mental health care is just as important as other aspects of health care that we take for granted, such as being able to see a doctor for the flu or for high blood pressure or a broken leg.  Shame on Kaiser and the doubtless many other companies seeking to skirt the intent of this and other patient advocacy laws.  One of the main problems in our health care system and a huge drain of money and resources is this monster network of insurance companies and the accompanying regulatory bureaucracy we have created.  As long as we have profit makers in charge of our health care, we will continue to experience ever upward spiraling costs and fraudulent actions which drain resources from all of us and deprive us of the care we should be able to get here in the United States.  As someone who has worked inside the system, I have seen the results too many times: people putting off care because of cost, sometimes suffering much worse health consequences as a result.  I feel helpless watching this situation and listening to the rhetoric bandied about by politicians (who incidentally usually have great health coverage).  I don’t know what kind of catastrophe it will take to change things.  It seems like that is the only thing that will get the attention of people in power.

My husband’s doctor had determined by history and thorough physical exam that the most troublesome part of his pain appeared to be facet related.  Thus scheduling facet injections to confirm and get on the road to giving him more relief than he is currently getting on long acting morphine tablets.  Unfortunately, the insurance company denied approval for the procedure.  This caused us to get yet another MRI of my husband’s spine to prove what the doctor already knew.

So why was this procedure denied, then later approved after two more doctor visits and a $2000 MRI?  No one involved in my husband’s care had any question that he has facet pathology, including the neurosurgeon who actually looked at his facets while performing a 3 level laminectomy to remove a fatty mass from the epidural space two years ago.  The easiest answer is the insurance company was being cheap and hoped he would go away.  I’m sure Humana doesn’t see it that way, at least publicly.

Actually, Humana removes themselves from this process by hiring a company called OrthoNet: Integrators of Orthopaedic Care to review orthopedic claims.  OrthoNet reviews claims and looks for reasons the insurance companies should not pay for the care ordered by the doctor.  The way they word it sounds nicer:

Our innovative care management model integrates the needs of providers, payors, and members to ensure the delivery of high quality, cost-effective care while realizing substantial savings that keep the costs of healthcare down.

Essentially they are paid not just to say no, but to rationalize the denial in such a way that it is difficult for patients to appeal the denial.  Otherwise, why would an insurance company spend the money to outsource claim review?  The cost of hiring OrthoNet plus the claims paid would have to cost less than Humana reviewing the claims themselves.  They expect OrthoNet’s decisions to cost them less.

Here is an excerpt from the letter my husband received explaining denial of his procedure:

The records strongly suggest that you experience chronic pain that is related to radiculopathy.  These symptoms, however, appear to be responding to traditional medical management (75% pain relief with medicines).  Besides, your treatment history does not suggest that facet injections were safer and more effective for managing these symptoms.  Hence, we determined the request does not meet criteria. Therefore it is not approved for prior authorization.  We have also notified your provider of this decision.

OrthoNet is under contract with Humana to provide coverage of health care services as authorized and provided under the terms of the Humana Medicare Programs product.  We used Medicare guidelines for this decision.

Let me explain what is meant by radiculopathy.  This is dysfunction of a nerve caused by compression or interruption of blood supply where the nerve root exits the spine.  One common cause of

Herniated intervertebral disc compressing a lumbar nerve root.

radiculopathy is herniated intervertebral discs.  For a comprehensive discussion of disc herniation diagnosis and treatment, see this article on the American Academy of Orthopaedic Surgeons’ website.  One of the key

Straight leg raise test.

indicators of disc related radiculopathy is pain with the straight leg raise.  A negative straight leg raise test (absence of pain down the leg and below the knee) indicates a low likelihood of lumbar disc herniation.

So, despite negative straight leg raise and positive indicators of facet pain, previous documentation of facet pathology both by MRI and by direct visualization by a surgeon, and the treating doctor’s diagnosis of probable facet pain syndrome, a “medical director” at OrthoNet is diagnosing probably radiculopathy pain.  Also, would anyone consider 75% relief of constant, excruciating pain enough?  I know I wouldn’t.

Ultimately, my husband got the extra testing and got his injections.  He had dramatic relief of the constant lower back pain he has had for several years for a few days.  This is considered a positive diagnosis of pain originating in the facet joints injected.  The next step, if pain relief is short lived as in this case, is facet rhizotomy.  This is a procedure in which the nerve fibers transmitting pain signals from the facet joint are destroyed using radio-frequency energy through a small probe.  For a more detailed description of this procedure see the Mayfield Clinic site.  (For the record, I have no knowledge of Mayfield Clinic other than their website.  I have referenced their pages due to the high quality of their illustrations and explanations.)

So, all’s well that ends well, right?  For now, yes.  But taking just a brief look around the net, I see OrthoNet has quite a long reach.  They have (or have had) contracts with many large insurance companies besides Humana such as Aetna, Cigna, and Blue Cross Blue Shield.  This may save the insurer money, but I suspect in the long run it costs patients and Medicare more due to reduced function and quality of life, more diagnostic imaging and other tests to prove what the treating doctor already knows or strongly suspects based on actually seeing and talking to the patient and knowing their history.  I sure would prefer my doctor to make these decisions than some bean counter doctor that barely glanced at my records.  I doubt those doctors get bonuses for correctly approving procedures.

According to the Centers for Disease Control and Prevention (CDC), atrial fibrillation is the most common arrhythmia, affecting 2.66 million people as of 2010.  Incidence rises with age, so the older you get the more likely you are to experience this arrhythmia.  AF occurs more often in white people than African-Americans.  The risk factors for AF include  uncontrolled high blood pressure, heart failure and other heart disease, diabetes, hyperthyroidism, and advancing age.

Symptoms of atrial fibrillation include palpitations, shortness of breath, chest pain, and fatigue or weakness.  How symptomatic a person will be depends on how many of the aberrant impulses are transmitted from the atria to the ventricles.  If many of the signals are transmitted through the AV node to the ventricles, the heart rate may rise into the 150′s or higher.  This is called atrial fibrillation with rapid ventricular response (A Fib with RVR).  Patients having rapid ventricular response typically have chest pain, shortness of breath, and other symptoms of poor perfusion such as dizziness and fainting.  This is a medical emergency which must be treated at a hospital.  Some people have slower conduction through the AV node, keeping the overall heart rate below 100 beats per minute.  This situation is not as dangerous, but still merits expeditious treatment.

Cardioversion, putting the heart back into a normal sinus rhythm with either medication or defibrillation, is usually the goal of treatment.  Much depends on how long the patient has been in A Fib.  When the atria do not contract as they are supposed to, clots can form in the left atrium, especially in the left atrial appendage.  This is an outpouching of the left atrium (LA) that forms a natural little corner that anything sticky can collect in.  The danger of clot formation in the LA is that pieces of clot may break off and be pumped with the blood into the left ventricle and then into the systemic circulation.  The biggest risk is that these emboli will end up lodging in one of the arteries of the brain, causing a stroke.  Cardioverting a patient who has significant mural thrombus (clot along the wall of the atrium) may cause catastrophic stroke as the clot is suddenly squeezed and breaks off.  To prevent this, doctors often perform a transesophageal echocardiogram (TEE) prior to cardioversion.  TEE is an ultrasound of the heart performed with an ultrasound probe placed in the esophagus.  Patients must be sedated for this procedure, otherwise the probe would never get past the gag reflex.  If significant clot is seen, then the patient is started on anticoagulant drugs that will be continued after going home for several weeks before cardioversion is attempted.  Heart rate will be controlled with medication in the meantime.  This gives time for the clot to dissolve and the anticoagulants prevent new clot from forming.  If there is not clot in the atrium, then cardioversion will be attempted at once.  If the patient has not already converted spontaneously with the medications given in the hospital, electrical shock will be used.  Again, for this procedure the patient is sedated and given pain medication.  Defibrillator pads are applied to the chest and electrical current is applied (shock) to reset the heart’s rhythm.  After a successful cardioversion, the patient is generally sent home on an antiarrhythmic drug to prevent recurrence.  If unsuccessful, anticoagulant drugs are started, usually Coumadin (warfarin) by mouth and heparin in shots or IV until Coumadin reaches a therapeutic level.  This takes several days.  Sometimes patients go home before reaching theraputic levels and need to continue injecting heparin at home for a few more days.

So, I’ve been talking about A Fib for a while here.  Atrial flutter (A flutter or AF) is similar to A Fib in that the atria are not beating properly.  In flutter, there is a rapid atrial rate but the firing of the cells in the atria are still coordinated with each other.  Thus there is still the regular squeeze of the beats rather than the quivering seen in A Fib.  The atrial beats are transmitted through the AV node to the ventricles at a ratio of 2:1, 3:1, or 4:1.Treatment of atrial flutter is essentially the same as for atrial fibrillation.  Often a patient will switch back and forth between these patterns, hence the term A Fib/Flutter.

A patient who has had one episode of A Fib or Flutter is likely to have another episode sometime during their life.  Often these recurrences are asymptomatic.  You should see a doctor regularly to monitor your condition.  These recurrences may be prevented or controlled with medications.  In patients with frequent recurrences, ablation may be an option.  In this procedure, an electrophysiologist (specialist in the electrical system of the heart) finds and burns or freezes sources of aberrant signals in the atria.  See the link above for a detailed explanation.

I found an excellent FAQ sheet on the American Heart Association website which explains this topic in easy to understand language.  Other resources include the Heart Rhythm Society, the National Stroke Association, WebMD Atrial Fibrillation Health Center, and TheHeart.org.

More later on antiarrhythmic drugs used to treat A Fib/Flutter.

My very first chest pain, I dismissed as heartburn, even though it was much more intense and went away much faster than any heartburn I had ever had.  It lasted less than a minute and didn’t trouble me again.  My second cardiac chest pain experience happened two weeks later.  It had the same intensity and sudden onset, but this time it didn’t go away.  In less than 2 minutes I knew we had to call 911 and I was almost completely incapacitated by the pain.  That was my heart attack.

In the days after my heart attack, I had frequent pains in my chest.  In fact the pain was never completely relieved until my last day in the hospital.  This seemed odd to me, as I had cared for many people who received stents during an acute cardiac event who did not complain of any more pain.  I told the nurses and doctors and the docs changed my meds around until I got some relief.  It was Imdur, a long acting nitrate that made the difference.

I remember lying in bed reading while hospitalized and noticing chest pain while holding my paperback book in the air.  When I lowered my arm and leaned the book on the bed, the pain went away.  In my mind, I couldn’t imagine having exertional chest pain  from lifting a book that weighed only a few ounces.  I dismissed it as paranoia.  Similarly when I had pain with emotions, I tried to differentiate between “anxiety” and angina.  I didn’t want to be labeled hysterical by doctors.  Later at an appointment with my cardiologist, I described the pain I was having.  If it wasn’t exertional, he said he didn’t think it was cardiac in origin.  I was confused because the pamphlet in his waiting room clearly stated strong emotion is a known angina trigger.

On my daily walks I would try stretching my arms, back, and chest to see if my pain was musculoskeletal.  Over time, I came to accept that this pain was rarely musculoskeletal and usually relieved by nitroglycerin.  I became certain that emotions could trigger my chest pain after waking with severe pain the night after a particularly bad family dispute involving my stepchildren and having to go to the hospital.

As time went by, I learned the feelings I was having.  I realized that the times I was taking a walk and had this overwhelming feeling that I couldn’t go any farther but no pain or shortness of breath, it was pressure in my chest I was feeling.  The pressure took longer to learn to recognize than outright pain.  I learned that the pinching feelings I sometimes had in my left armpit or elbow while walking were also angina.  Over a long period of time, I learned to trust myself even when it felt like doctors didn’t.  I kept going back to the cardiologist early with my pain to see what else we could do.  He kept repeating the words “maximal medical management” which made me feel I had to accept this daily pain.  As it turned out, I was far from “maximally” managed.  One year and several med changes later, I have less pain than I used to and function better.

It took around a year and a half and many hospitalizations to gain confidence that I knew what was going on in my body.  One cardiologist I saw before I lost my insurance said he expected 2 or 3 hospitalizations in the first year as people learn what is “normal” angina for them and what is unusual.  He made me feel more like a normal patient.

During the following year, my understanding of the sensations of my heart has continued to evolve.  I’m less frightened by angina and have a good feel for what is “normal” for me.  I know what is likely to trigger angina and can avoid some triggers and use my nitroglycerin prophylactically for others.  For example, if I am walking farther than a quarter mile, I use my nitro spray before I start.  This makes pain less likely and when pain does come up, it is easier to treat.

For a while I have known I have what is sometimes called “variant angina.”  This is angina that occurs in the absence of stenotic lesions (narrow places) in the coronary arteries.  In my case, spasm of the LAD has been documented in two of my angiograms.  As far as we know this is what causes my angina.  Another possibility which we lack the ability to check on is coronary microvascular disease, where the small vessels, arterioles and capillaries, do not dilate appropriately with increased cardiac demand.  These are vessels that cannot be seen on a normal angiogram.  The tests needed to check this possibility are only available at a few research centers at the current time.

So for now, I am more at ease with my chronic cardiac pain.  I do hope for advances in treatment to improve my functioning, these would be years away.  In the meantime, we just adjust my medications periodically and I keep using my nitroglycerin.  It’s the best we can do for now.

Since the beginning of winter this year, maybe around Christmas time, I’ve had enough pain that I’ve had to walk with a cane.  Using the cane reduces weight bearing on the knee by about 25%.  In January, my pain management doctor (a physical medicine and rehab guy) suggested trying a brace.  Since I began using a brace, my pain has been reduced significantly so that most of the time I can walk without feeling like I’m getting stabbed in the kneecap with every step.

My new knee brace.

My first brace was an adjustable knee support with spring steel stays in the sides, providing lateral stabilization, that I bought at a drug store.  That one has now about worn out after use many hours a day for around 2 months, so time for a new brace.  I decided to go with a hinged brace that would offer better range of motion and more lateral support.  I did lots of research, mostly on amazon.com.  I love the huge number of reviews you can find for most products there.  I ordered my new brace yesterday and with the fantastically low priced Amazon Prime one day delivery, I received my brace this morning.

This is a McDavid Dual Disc Hinged Knee Brace.  It has polycentric hinges (whatever that means) and hyperextension stops (that means it won’t let my knee bend backwards, always a good thing in my opinion).  The reviews were generally favorable and suggested going up a size if your knee measurement was between sizes.  Following this advice, I bought an XL for my 17 inch circumference knee.  The brace fits snuggly, with nice compression from the neoprene sleeve.  Just the weight of it when I pulled it out of the package had a satisfying feel.  The velcro is industrial strength, though the straps are just a bit long for me.  If needed, I can always sew extra length of the hook side of the velcro so it connects fully with the loops.  The hole in the middle is to support the patella (knee cap) and help its alignment during movement.  That’s a feature my doctor particularly wanted me to use.

Explaining the McDavidness!

What inspired me to write this post, was not just excitement over new orthopedic equipment.  Along with my brace came this awesome card advising me of my good fortune now that I am a McDavid insider!  I especially like that they are refreshing their “McDavidness” and ramping up their “McDavid Mojo.”  I feel so incredibly included with this news and have utmost confidence in the McDavidness and the mojo of my brace.  I can imagine myself hobbling a mile or so down the hike and bike trail, knowing I have this maker of orthopedic products behind me all the way!  This also gives me a feeling of youth, like I can pretend I need this brace to protect my knee while snow boarding or rock climbing.  I don’t have crippling arthritis because I’m getting old, some jerk ran into me with his car and then fled the scene, and I don’t have enough money to continue my visco-supplementation injections.  I am all set for football or martial arts or whatever the world throws at me, including walking the dog.  Watch out, Shawn White, here I come!

My experience at the Specialty Clinic, while it has its annoyances such as long waiting time and staff that sometimes act like you should be so grateful to be there you shouldn’t complain about anything, has been far better than at the primary care clinics run by CommunityCare.  I was pondering what the difference was yesterday and decided it is the quality of the doctor I see that is the difference.  The cardiologist, Dr. David Hayes (and sometimes Dr. Paul Roach), is attentive, understands my condition, and manages my medications appropriately.  Visits with him generally feel productive and successful.  This is despite the severe limitations of treatment at this clinic.  For example, I had contacted the Texas Heart Institute in Houston, Texas, regarding the possibility of participating in studies relevant to my condition if such were being done there.  I received an email requesting I have my cardiologist contact them.  Because of the time constraints and lack of access to a full medical record at the Specialty Clinic, Dr. Hayes told me he would be unable to do that for me but encouraged me to pursue it on my own.  Ironically, it is because of the lack of resources available in the MAP program that I was seeking studies to participate in.  My doctor said (of the MAP program), “It’s better than nothing…but not much.”  We both laughed.  What else can I do?  If I don’t keep my humor and optimism, it would be easy to sink into despair.

When I first saw a primary care doctor at CommunityCare almost one year ago, I requested referral to cardiology (for near constant angina), orthopedics (for knee and ankle arthritis that flares periodically), and pain management.  I was informed MAP does not cover pain management and that CommunityCare lacks resources to manage pain medications. (I now pay out of pocket for my pain management doctor visits, but that is another long story.)  I would be referred to cardiology but was warned by the doctor that she had no control over getting me an appointment and she had no idea how long it would take.  She did not order EKG or lab work.  Ortho didn’t even enter discussion.  So, the way I got my cardiology appointment was yet another emergency hospital admission complete with EMS limo service plus crying pitifully while telling my story to the poor, kind, inexperienced intern at the hospital.  I finally got my ortho referral after five months of showing up to clinic repeatedly complaining about my pain.  My appointment is next July, a grand total of 15 months from my initial request.  Meanwhile my current primary care doctor, Dr. Nagavarapu, seems to believe my primary health problem is arthritis.  I think she actually knows next to nothing about my cardiac condition.

I now avoid the CommunityCare clinic as much as possible.  The clinic itself is actually quite nice.  It is in a brand new building, with lab and radiology services under the same roof.  It is clean and well appointed, with nice furniture and huge flat screen TV’s in the waiting rooms.  The staff are generally very nice, though obviously overtaxed.  The waiting time is highly variable with a visit averaging 2 hours.  One time I actually slept for over an hour precariously curled up on one of those exam tables with the little section at the end that pulls out if you need the patient to lie down while waiting for the doctor to come into the room.  I was too fatigued to sit in the chair all that time.  Every time I go to the clinic now, I have chest pain and develop migraine headache.  I think it is because visits to this clinic are generally unproductive and frustrating.  I leave feeling like the doctor has no clue what is going on with me and that she discussed the limitations of what she could do more than anything else.  It has gotten to the point that in my mind the name of the place is *expletive*ing-CommunityCare.

A friend in Australia wrote me this week comparing care options:

We have ‘public’ clinics at some of our big hospitals too. They are terrible – staff treat you like rubbish, long waits in uncomfortable settings and no choice of doctor. Often you are seen by registrars. If you get to see a specialist they are usually good but the whole thing is very demeaning.

This pretty much sums up my experience.  I have complaints, but the sad truth is I have much more available than most uninsured Americans.  I’d like there to be improved access for everyone, but living in a state whose governor seems to take great delight in turning down federal funds to help more people get Medicaid, such hope seems fruitless.  Yes, I’m talking about you, Rick Perry.  The previous link is the self-aggrandizing campaign website for the governor.  For a more balanced account see NBC’s take on the governor.  For the critical version, see Huffington Post’s info page.  I am lucky to live in such a liberal bastion here in Texas that actually tries to help low income people get health care, even if the quality is not so good.  All I can say is I am looking forward to the start of my Medicare coverage in April 2014.  As my cardiologist said, it will open a lot more doors for me.

Thank you, Katie, for sharing your experience with us.

So what causes irregular heartbeats?  There are many reasons the heart may beat irregularly, too fast, or too slow.  Some of these reasons have to do with damage to the electrical conduction system.  Events or conditions which damage the heart muscle may also damage the conducting fibers.  These include chronic high blood pressure, ischemia (lack of blood flow) from coronary artery disease or myocardial infarction (heart attack), cardiomyopathy (changes in the heart muscle sometimes caused by a virus), problems with heart valves, or surgical scarring.  Other causes of arrhythmias include electrolyte imbalance and certain drugs.

Probably by far the most commonly ingested drug related to abnormal heartbeats is caffeine.  Caffeine is found in many of the foods and drinks we enjoy daily such as coffee, chocolate, tea, and soft drinks such as Coca Cola, Mountain Dew, Dr. Pepper, etc.  Caffeine is also added to various supplements touted for weight loss or alertness.  It is the mainstay of “energy drinks” such as Red Bull or 5 Hour Energy.  Excessive caffeine intake can lead to rapid heartbeat and palpitations (fluttery or thumping feeling in the chest).  These palpitations are usually caused by premature atrial contractions (PAC’s).  These are extra beats that originate from foci in the atria (upper chambers of the heart).  Other supplements or herbs which have stimulant properties can also be pro-arrhythmic (cause arrhythmias).  These include ephedrine (found in Ma Huang), Guarana (contains high levels of caffeine), and Kola Nut (contains caffeine).

Nicotine, found in tobacco products, is another common stimulant drug used by many people.  Tobacco is smoked, chewed, held between lip and gum, or sniffed into the nose.  Ingesting an excessive amount causes increased blood pressure and heart rate due to its vasoconstrictive and stimulant properties.

Drugs such as cocaine, crack, and amphetamines having stimulant properties cause increased blood pressure and heart rate as well.  Note that amphetamines are also the active ingredients of medications such as Adderall and Vyvanse, used to treat ADHD.  Methylphenidate (found in Ritalin and Concerta) has similar properties.

As you can see, there can be many reasons for irregular heartbeats.  I’ve mainly focussed on faster heart rates, but slow heart rates (bradycardias) can be a problem too.  Like other abnormal heart rhythms, bradyarrhythmias can be caused by damage to the heart such as scarring from myocardial infarction (MI), post surgical changes, cardiomyopathy, etc.  Drugs and supplements can also slow heart rate.  We commonly use beta blockers such as metoprolol or carvedilol for this purpose.  Calcium channel blockers such as diltiazem or verapamil slow heart rate to a lesser extent (depending on dose).  Decreased oxygen in the blood, which can be caused by sleep apnea, illness such as pneumonia, or drugs with respiratory depressant effects like opiates (morphine, heroin) may cause lower heart rate.

This is a complicated subject.  I will write more soon!