help me address these comments

A patient comes in with a headache, you give him a smile and a Tylenol and he drops dead from a brain hemorrhage. A second patient comes in after him with a headache and you are going to order CT scans, MRIs and exploratory surgery.

As a lifelong headache sufferer, I can assure you that no PCP will order CT scans, MRIs, and exploratory surgery just because a patient comes in with nothing but a headache. They'll take a medical history. If the headache is similar to a headache that you have previously suffered at any point in your life and recovered from, you're going to be told that it's the same kind as the other one.

If the headache fits any kind of standard type of recurrent headache such as migraine or cluster or sinus or tension, you'll likely be told that's what it most likely is. They may do a bit of routine testing, but nothing like CT scans or MRIs unless there's another reason beyond the headache to suspect that there's something else going on.

Now, if the headache is truly novel and super severe---i.e. unlike anything you've ever experienced before, then yeah, it'll get attention and some tests might be arranged.

And if the headache contains any symptoms of a possible stroke or a mini-stroke, then of course it'll get the big time attention and the tests that it needs.

And if the headache has occurred after a possible head injury (in which case it is NOT "just a headache"), then yes, MRIs or CT scans will be ordered to in an attempt to rule out subdural hematomas and other such nasty things.

But the fact is that most of what PCPs deal with are not life-threatening emergencies. Rather, they deal with helping educate patients to deal with chronic, lifelong medical problems such as high blood pressure, diabetes, weight problems, high cholesterol, and so on that will, if left untreated, eventually negatively effect their quality of life (if it hasn't already), common everyday illnesses that for the most part of self limiting, but may respond to certain types of treatment, and common nonlife threatening injuries. Yes, PCPs have to always be prepared for a true emergency. But they're not usually dealing with them. And quite frankly a quality PCP cares about all those routine visits about the chronic lifelong problems because that's really where they're making a positive difference in their patients' lives by helping them live healthier lives, manage their chronic conditions to minimize future problems, and possibly prevent future emergencies from occuring.

And likewise many doctors in other specialties (including sleep medicine in my opinion) spend most of their time in dealing with medical problems that are not life-threatening emergencies. They may deal with life-threatening conditions on a day to day basis, but most of their patients are not being seen on an emergency basis. They're there for follow up care (perhaps to previously provided emergency care) or referrals from PCPs for initial diagnostic work or because their current treatment needs some kind of adjustment.

Hey everyone - Calist is a troll! He has been posting arrogant and obnoxious comments to get us annoyed. Why? Because he gets off on it! In another thread he even "registered" another user as a companion sleep tech viewtopic/p527240/Im-a-quotstomach-slee ... ml#p527240 ON this thread he apparently talks with "himself" and finds someone to agree with him.

Check out writing styles and attitude if you want to see for yourself. We've got to lose this guy. He is turning all of this into a joke at our expense.

I'm serious. This is me, trying to fix you albiet anonymously since you don't know who I am. Get retested at an accredited lab. I think you'll be surprised by the results.

jonquiljo wrote:Hey everyone - Calist is a troll! He has been posting arrogant and obnoxious comments to get us annoyed. Why? Because he gets off on it! In another thread he even "registered" another user as a companion sleep tech viewtopic/p527240/Im-a-quotstomach-slee ... ml#p527240 ON this thread he apparently talks with "himself" and finds someone to agree with him.

Check out writing styles and attitude if you want to see for yourself. We've got to lose this guy. He is turning all of this into a joke at our expense.

The reasons our writing styles are similar is because we are both RPSGT. The difference between us however is that I am obnoxious and she was not. Later on in the topic however I posted a huge section on Respiratory Distress. No feedback on that? Just jump in here and call me a troll? No "Nice job on the Respiratory Distress" thing?

A good physician is some one who marks everything which is irrelevant as irrelevant and focuses completely on the physical problems of the patient in an attempt to prevent further damage and to correct current damage.

A major part of preventing further damage from chronic, life-long diseases involves patient education. If a doctor demeans his patients by treating them like they are either idiots who are too stupid to learn or children who must to be protected from themselves, then that the doctor is failing to properly educate his patients about their condition. If a patient is made to feel that they are not allowed to ask questions about their condition, they will likely remain ignorant of the most basic and important facts about how to manage their condition, which in turn, will make it that much harder for the patient to correctly follow the doctor's orders. And if the patient does not understand why they need the proposed treatment, how the treatment is supposed to work, the possible side effects of treatment, and what the consequences of not treating or incompletely treating the condition, then that patient is being set up by his doctor for "failure to comply with treatment"---particularly if the treatment is either difficult to adjust to or has common, but medically minor, side effects that are bothersome in everyday life.

I have, in the past known poor physicians. I won't name any names, but I have none some physicians that were not all that great at diagnostics. In order to make up for this they will attempt to entertain a patient, talk to them about football or baseball or tell them a story about something funny that their cat did. They basically stall for time while they desperately try to figure out what is going on with the patient.

You and I agree that these are examples of poor doctors. But I must also point out that none of these examples are examples of a doctor carefully taking his patient's understandable emotional state about receiving a diagnosis of a serious, chronic and potentially progressive condition into account when treating the patient. They are, in fact, all classic examples of ways to ignore what your patient's concerns about his condition and his ability to competently participate in the treatment of his condition. None of these examples are examples of a physician working with a patient to educate them about their condition so that the patient can master the task of the day-to-day management of their condition that must take place outside of the doctor's office in the privacy of the patient's own home.

robysue wrote:

A good physician is some one who marks everything which is irrelevant as irrelevant and focuses completely on the physical problems of the patient in an attempt to prevent further damage and to correct current damage.

A major part of preventing further damage from chronic, life-long diseases involves patient education. If a doctor demeans his patients by treating them like they are either idiots who are too stupid to learn or children who must to be protected from themselves, then that the doctor is failing to properly educate his patients about their condition. If a patient is made to feel that they are not allowed to ask questions about their condition, they will likely remain ignorant of the most basic and important facts about how to manage their condition, which in turn, will make it that much harder for the patient to correctly follow the doctor's orders. And if the patient does not understand why they need the proposed treatment, how the treatment is supposed to work, the possible side effects of treatment, and what the consequences of not treating or incompletely treating the condition, then that patient is being set up by his doctor for "failure to comply with treatment"---particularly if the treatment is either difficult to adjust to or has common, but medically minor, side effects that are bothersome in everyday life.

I have, in the past known poor physicians. I won't name any names, but I have none some physicians that were not all that great at diagnostics. In order to make up for this they will attempt to entertain a patient, talk to them about football or baseball or tell them a story about something funny that their cat did. They basically stall for time while they desperately try to figure out what is going on with the patient.

You and I agree that these are examples of poor doctors. But I must also point out that none of these examples are examples of a doctor carefully taking his patient's understandable emotional state about receiving a diagnosis of a serious, chronic and potentially progressive condition into account when treating the patient. They are, in fact, all classic examples of ways to ignore what your patient's concerns about his condition and his ability to competently participate in the treatment of his condition. None of these examples are examples of a physician working with a patient to educate them about their condition so that the patient can master the task of the day-to-day management of their condition that must take place outside of the doctor's office in the privacy of the patient's own home.

Heya, go back to the end of page three and read the part where I ranted about accredited labs while I read and reply to this one.

good night calist.

I've got to go back and put the cpap mask on and be compliant for the 16th night in a row. (That's 16 out of 16 since getting the dang machine.)

So try to remember I'm a *good* patient who's doing what the doctor's ordered even though I'm also questioning him all the way and resenting the fact that he didn't give me answers to reasonable questions right at the start.

And I'm willing to give him another chance too. If he answers my questions at my follow up, he'll get off the bad boy list and might find something other than coal in his christmas stocking this year.

Night night all

robysue wrote:

A good physician is some one who marks everything which is irrelevant as irrelevant and focuses completely on the physical problems of the patient in an attempt to prevent further damage and to correct current damage.

A major part of preventing further damage from chronic, life-long diseases involves patient education. If a doctor demeans his patients by treating them like they are either idiots who are too stupid to learn or children who must to be protected from themselves, then that the doctor is failing to properly educate his patients about their condition.

Granted. I will agree with that at least in theory but do you see where I am coming from? I have seen way too many physicians that would rather take the extreme opposite stance by rubber necking a patient, agreeing to anything they say and breaking down a layman's terms explanation so far for a patient that it borders on complete fantasy. There are two sides to this argument, one is that physicians should tell patients nothing and expect complete obedience regardless of their feelings and questions in favor of the medical science objective.

On the other side, the extreme opposite, we have the idea that physicians should pander for a patient's personal approval by talking to them, sympathizing with them, patronizing them, making them feel like they are a part of the process and all of this at the EXPENSE of medicine.

In America, which is where I currently live, we live in a society which is at that extreme opposite. Where more and more physicians are beginning to tell patients what they want to hear so that they can collect a check and be done with it. This is a really bad trend to endorse. And although I know you are not trying to endorse it, I'm sure you can see why I would immediately get defensive. We are trying to fight these physicians, not reward them. I knew an ER doc a while ago- in the ER we occasionally get drug seekers that come in and talk a bunch of off the wall stuff trying to get a particular bottle of... whatever. These people are easy to spot. I had one come in and tell me all about how he was after some oxycondone variant. The ER doc goes in and writes him a script for it. I was like "What are you doing? That was just a drug seeker" and he said "I know, I didn't want to have to deal with him."

This kind of thing goes on ALL the time and it is threatening the very fabric of American Medicine. When Complex Sleep Apnea was recognized as an actual sleeping disorder, there were thousands of labs that threatened to pull out of the AASM. It got ugly very fast and a lot of us didn't know what to think. On one hand we were enraged that a made up sleeping disorder would be validated by the AASM and on the other hand we were happy to see so much solidarity among the labs against it.

The truth of the matter is that typical patients can not, will not and refuse to ever learn the most basic elements of medical science. In spite of that there are physicians that will gladly give them oversimplifications of diseases and disorders with the intention of leading these people to believe that they have some comprehension of medicine. Then they bill these patients for consultation and justify it by calling it Patient education. It is not.... It is not patient education. Patient education is patient education. What they do SHOULD be criminal.

Sending a patient off with half-truths and rumors is one of the worst things you can do for a patient and I know first hand, that is what a lot of these guys do. That is why they get ostracized. That is why they get blackballed from all of the respectable labs and institutions.

robysue wrote: If a patient is made to feel that they are not allowed to ask questions about their condition, they will likely remain ignorant of the most basic and important facts about how to manage their condition, which in turn, will make it that much harder for the patient to correctly follow the doctor's orders. And if the patient does not understand why they need the proposed treatment, how the treatment is supposed to work, the possible side effects of treatment, and what the consequences of not treating or incompletely treating the condition, then that patient is being set up by his doctor for "failure to comply with treatment"---

With as hard as it is to educate, truly educate a patient, I would still wish for it to be that simple. The problem is that patients do not want to be treated for something they are not affected by. This is the central problem with preventive medicine. You can not treat a patient for something in which they do not yet have. A patient runs (primarily) in two modes.

1: I'm not in pain so I don't care.

2: Oh god I'm in pain, I don't care what you do just make it stop.

If it does not fall in between those two irrational modes of thought than patients will typically not use them. To be fair however I must admit that there is another mode of thought for patients and yes they can be educated. This is referring to patients with prior medical experience, training and/or education. They know enough not to use number 1 and they know who to go to with number 2. I have seen these guys before and interacting with them is usually a very pleasant experience. They will ask something about centrals or OSA and micro-seizures and then it is really just a question of filling in the gaps of their education. I will ask them how much they know about the Anterior tibiae or the respiratory system or just get a handle on how much they know about a particular area and fill in the sleep related portions and how they affect things. I might even go so far as to say that I love sleep patients who have prior medical knowledge. They are a pleasure to treat.

I have, in the past known poor physicians. I won't name any names, but I have none some physicians that were not all that great at diagnostics. In order to make up for this they will attempt to entertain a patient, talk to them about football or baseball or tell them a story about something funny that their cat did. They basically stall for time while they desperately try to figure out what is going on with the patient.

You and I agree that these are examples of poor doctors. But I must also point out that none of these examples are examples of a doctor carefully taking his patient's understandable emotional state about receiving a diagnosis of a serious, chronic and potentially progressive condition into account when treating the patient. They are, in fact, all classic examples of ways to ignore what your patient's concerns about his condition and his ability to competently participate in the treatment of his condition. None of these examples are examples of a physician working with a patient to educate them about their condition so that the patient can master the task of the day-to-day management of their condition that must take place outside of the doctor's office in the privacy of the patient's own home.

Agreed, but as I stated before, consider the extreme opposite.

robysue wrote:good night calist.

I've got to go back and put the cpap mask on and be compliant for the 16th night in a row. (That's 16 out of 16 since getting the dang machine.)

So try to remember I'm a *good* patient who's doing what the doctor's ordered even though I'm also questioning him all the way and resenting the fact that he didn't give me answers to reasonable questions right at the start.

And I'm willing to give him another chance too. If he answers my questions at my follow up, he'll get off the bad boy list and might find something other than coal in his christmas stocking this year.

Night night all

No wait! Forget what I said! Get retested! Go to an accredited lab!

Calist wrote:

robysue wrote:In REM there were NO apneas of any type detected and there were NO hypopneas with desaturation detectd. There were 7 hypopneas with arousal detected. REM AHI = 0.0 [The center scores AHI as (#apneas + #hypopneas with desaturation) per hour]. REM RDI = 17.5 [The center scores RDI = (#apneas + #hypopneas with desaturation + #hypopneas with arousal) per hour].

That is not AASM standard, they should not be using RDI.

Calist wrote:Your referring doctor (for reasons unknown) sent you to this unaccredited lab. I know they are unaccredited because they are using RDI. Accredited labs are not permitted to use RDI.

That is SO not right.

Here are the current Clinical Guidelines for the Manual Titration of Positive Airway Pressure in Patients with Obstructive Sleep Apnea

http://aasmnet.org/Resources/ClinicalGu ... 040210.pdf

where the only time they refer to AHI is when they say they are NOT going to use AHI:

Mild, moderate and severe OSA are defined according to following criteria in adults: mild, RDI 5 to ≤15; moderate, RDI 15 to 30; and severe, RDI >30.

The pressure of CPAP or BPAP selected for patient use following the titration study should reflect control of the patient’s obstructive respiration by a low (preferably <5 per hour) respiratory disturbance index (RDI) at the selected pressure, a minimum sea level SpO2 above 90% at the pressure, and with a leak within acceptable parameters at the pressure. (14) An optimal titration reduces RDI <5 for at least a 15- min duration and should include supine REM sleep at the selected pressure that is not continually interrupted by spontaneous arousals or awakenings. (15) A good titration reduces RDI ≤10 or by 50% if the baseline RDI <15 and should include supine REM sleep that is not continually interrupted by spontaneous arousals or awakenings at the selected pressure. (16) An adequate titration does not reduce the RDI ≤10 but reduces the RDI by 75% from baseline (especially in severe OSA patients), or one in which the titration grading criteria for optimal or good are met with the exception that supine REM sleep did not occur at the selected pressure.

Hey hey hey! RDI is crap and you know it!

No self respecting lab would ever use RDI to order the titration of a patient. Arousal based scoring is the bread and butter of CPAP factories and whether or not the AASM will back me up on that, we both know that Medicare sure as hell will.

Heh... die CPAP factories... DIE.

All this is wrong, too:

calist wrote:"Respiratory Distress is a mechanism in which the brain realizes that it is running out of oxygen. It does this not by examining oxygen molecules but instead by counting carbon dioxide molecules. If you have 3% c02 (or carbon Dioxide) then the brain assumes you have 97% oxygen. If you have 7% c02 then it assumes you have 93% oxygen.... and so on. This is actually how people die from gas leaks in their home as well. 7% c02, 90% Methane and 3% Oxygen looks perfectly normal to the human brain because it is only counting carbon dioxide. If however the carbon dioxide climbs above 12% (88% Oxygen) then the brain will begin the process of initiated the Respiratory Distress mechanism.

That might loosely be referring to carbon monoxide but the patient response is nothing like you describe.

Calist wrote:RDI is crap and you know it!

The only thing I "know" is you have NFI what you're talking about.

NotMuffy wrote:

Calist wrote:RDI is crap and you know it!

The only thing I "know" is you have NFI what you're talking about.

Any lab that practices arousal based scoring is not only a corrupt business model looking to scam patients but soon they will be a relic of the past when the medicare thing kicks in. (not naming any names) but you and I both know who they are and they've been suffering. Every town has at least one and so far they've been able to refer to themselves and keep everything quiet by running a DME out of their closets, hiring traveling techs to avoid notice from local communities but after Jan 1rst they can't even do that no more.

So I don't care what AASM says about RDI. No one does. If they want to move their entire scoring criteria over to an RDI model, they'll only be hurting themselves in the long run.

The International Classification Of Sleep Disorders (ASDA pocket edition) clearly states...

Diagnostic Criteria: Obstructive Sleep apnea syndrome (780.53-0)

D: Polysomnographic monitoring demonstrates:
1: More than five obstructive apneas, greater than 10 seconds in duration, per hour of sleep and
2: arterial oxygen desaturation in association with apneic episodes

Reconcile that with AASM's whining about RDI.

Wait a moment... your not muffy!