M. P. Ravindra Nathan

When Arthur Clarke first presented in the Emergency Department, he was in heart failure. At only 58 years of age, this strapping former New York City police officer had an enlarged heart and severe left ventricular dysfunction. An echocardiogram showed a low ejection fraction of 25 percent.

It turned out that Clarke (not his real name) was suffering from dilated cardiomyopathy. (A disease associated with severe decrease of heart muscle function). Whether this was an idiopathic condition or a consequence of his moderate alcohol consumption, I couldn�t be sure. With good medical care he improved, shed a few pounds, and was soon ready to go home. Medications adjusted and dietary instructions given, he appeared on his way to recovery.

A few days later, he was back in the ED complaining of palpitations. This time we diagnosed ventricular tachycardia. He needed immediate defibrillation and was stabilized further in the CCU. Before he was discharged, I prescribed amiodarone, the effective but costly antiarrhythmic (A drug for treating heart rhythm disorders) drug, and asked if he could fill and refill the prescription as needed. �No problem, doc, I�m on my wife�s insurance plan, which covers drugs,� he said. About weight reduction, he bragged, �I�m going to lose 30 pounds in three months. You just wait.�

The next month, I saw him in my office for a follow-up visit. He looked well, although at 270 pounds, he was a mere 3 pounds lighter than he was the last time I�d seen him. And that small weight reduction was probably attributable to the diuretics he was taking.

A few weeks later he was in the ED again, complaining of dizziness and chest discomfort. We treated him for recurrent ventricular tachycardia, and referred him to an electrophysiologist for an Electrophysiology Study and AICD (Automatic Implantable Cardioverter Defibrillator).

Another two weeks went by, and I spoke with him in my office. �Do I have to take this ammodiarone or whatever you call it, now that I have this gadget?� he asked, pointing to the left side of his chest.

�Yes, you do,� I replied. �Otherwise, your AICD will discharge frequently. You don�t want that.�

He was put on a maintenance dose of amiodarone. With AICD and amiodarone, he should be OK now, I thought. But I was wrong. Not long afterward, there was that all too familiar call from the ED. �Your man is here with the same problem,� the ED doctor informed me. �He�s had a few more bouts of ventricular tachycardia, and the AICD discharged twice.�

�That�s strange,� I said. �He was well controlled on his medications.�

When I saw Clarke in the CCU, he appeared shaken. �What happened, Arthur?� I asked. �I didn�t expect to see you so soon.�

�Oh, doc, I�m scared. And I have a confession to make.�

�What is it? Have you started drinking again?�

�Oh, no. I stopped the ammodiarone weeks ago. It�s expensive, doc.�

�But you have insurance coverage for prescription drugs, right?�

�I did. But my wife doesn�t work anymore, so we have no health insurance now,� he admitted.

�Why didn�t you tell me?�

�Frankly, I was embarrassed to admit that I didn�t have enough money to buy medicine. Can you dig up some from the hospital pharmacy to help me get by?�

So, that�s what was going on here. Arthur was deeply concerned about his health, but he was too proud to ask for help in securing the life-saving medicine he needed. �Sorry, Arthur, we can�t do that. But I can help you get Medicaid benefits.�

First, though, we needed to get him at least three weeks� worth of medications to get him through until he got his Medicaid card.

I consulted our hospital social worker, and we went to work. First we asked the hospital administrator to come up with some money quickly. He got $100. That was given to a local charitable organization, which would buy amiodarone for Clarke when he showed up with my prescription. I didn�t want to hand him the money, for fear that he�d spend it on something other than medicine. He ultimately went home with 30 pills (a one month�s supply) and a big grin on his face. A month later, his Medicaid card came in the mail.

More than a year has passed, and I haven�t seen Clarke in the ED.

Often seemingly noncompliant patients are too proud to admit that they simply can�t afford life-saving medications. If you take the time to inquire into their circumstances, you might be rewarded with surprisingly useful information. You�ll then be able to give patients the help they need.

Reprinted with permission from Medical Economics, 129 -137, May 1999. Medical Economics is a copyrighted publication of Advanstar Communications Inc. All rights reserved.

Cardiologist Dr. M. P. Ravindra Nathan, director of Hernando Heart Clinic in Brooksville and editor-in-chief of the AAPI Journal, lives in Brooksville.

	Payal Patel

As the colder fall and winter months approach, the whole array of colds and allergies come into practice as a pediatrician. In this article, I would like to share some valuable information with most of the parents who have to deal with these common childhood illnesses.

GENERAL FACTS

A cold is caused by one of the 200 different types of cold viruses. Healthy infants and toddlers can get an average of 7-8 colds per year. Remember, this is just an average, so if your child gets 5-6 colds or on the extreme 10-12 colds per year, it is still considered normal. A cold usually lasts about 5-10 days. Usually, it starts with a runny nose which is clear in color but can progress to a yellow-green color before the cold is over. It may also produce fever as a symptom which usually subsides in 3-4 days.

AT THE PEDIATRICIAN�S

Most parents bring their child on the second or third day of the cold symptoms. In my experience as a pediatrician and as a mother, I have noticed that the cold symptoms are worst on the third to the fifth day and then gradually decrease thereafter. If these symptoms were to continue or worsen past 4-5 days then I tell the parents to return to the office. In these cases, a bacterial infection can be a possibility since the mucous that sits in the nose and throat can harbor bacterial growth.

One of the most common misconception that I encounter in my practice is parents wanting antibiotics for the common cold. I take my time to explain why antibiotics only work for a bacterial infection, and are not useful since a cold is caused by a virus. The only cure is time since the virus will slowly go away. TREATMENT

I recommend symptomatic relief with over the counter cough and cold medicines only as needed. If the child has a fever, I recommend Tylenol and Motrin. Otherwise, I encourage supportive measure like saline suctioning for babies or nose blowing for older children. Getting rid of the nasal discharge is a way of eliminating the virus from our body. Another helpful measure is a humidifier since this delivers moist air and will ease the child�s breathing.

Parents worry when their child is not eating much during a cold. I stress the importance of providing plenty of fluids, which include water, juice, pedialyte, and even milk, as a means to help the immune system. PREVENTION

Hand Washing- Since colds are spread by direct contact with a cold virus through touching someone�s hands, and also things such as toys, door knobs, etc. Remember, if your child goes to school, daycare, or even playgroups they are constantly exposed to many different viruses. Obviously, they are more prone to infections, but this exposure will also build their immune system. Also if the child has siblings that go to school or live in large family settings, they are at increased risk of exposure to infections.

WORSENING SYMPTOMS

If your child has yellow-green nasal discharge for greater then 10 days with no improvement.

If the child complained of earache, sinus pressure and pain, any vomiting or severe sore throat

If fever lasts more than 3 days or is higher than 102 degrees

If eyes are red and have yellow discharge

If there is breathing difficulty with uncontrollable coughing, increase in breathing rate, or use of chest muscles excessively

If child is clearly not drinking enough and looks dehydrated-decrease in urine, no tears when cries.

ALLERGIES

On the other hand, allergies are your body�s reaction to some type of an allergen. Most commonly noted is seasonal allergies to pollen, grass, or ragweed usually during the spring and fall months. The symptomatic way to differentiate it from a cold are clear nasal discharge, sneezing, sniffling. The child can also have itchy, watery, red eyes. Allergies are not associated with a fever, and usually occur around the same time of the year. The treatment is an antihistamine medication like Benadryl, or other medications such as Children�s Claritin or Dimetapp Non Drowsy for allergies, sometimes along with prescription nasal sprays. Stronger medications for severe allergies are available through prescription.

Dr Payal Patel can be reached at [email protected]