Mystery Photo 7: This is Mont Saint Michel, Normandy, France

   Mont Saint Michel is an islet just off the coast of France, where the Couesnon River flows into the sea. This river has always been touted as the border between Brittany and Normandy. However, the flow of the river has changed from time to time and the Mont is now in Normandy.

     In prehistoric times this area was all land. But the scouring of the sea over eons has removed the softer rocks leaving this hunk of granite.The natural shape of the islet served several different peoples as guardian fortresss over the centuries. Following the departure of the Romans in 460 AD, the Mont was held by the Amoricans, a Romano-Breton culture which extended into Britain. But it was conquered by the Franks.

     The origin of the monastery on the peak of the Mont is told in a very colorful legend. Supposedly the Archangel Michael appeared to St. Aubert, bishop of nearby Avranches in 708 AD, telling him to build a church on the islet. St. Aubert ignored him several times until reportedly the Archangel burned a hole in his skull with his finger. The church was built and eventually did become a monastery.

     In the above portion, at the right upper corner, the Mont is pictured in the famous Bayeaux Tapestry showing the conquest of Normandy by William in 1066. The monastery gave its support to William of Normandy in 1067 in his bid for the throne of England. Four centuries later after many changes in the relationship of England and France, England put the Mont to siege in 1423-24 but failed to conquer it. The monastery and its wealth and holdings were great for the next 4 centuries. But with the French Revolution, its influence faded. The French then made it into a prison. Many of the remains of that prison are still seen in the monastery buildings at the peak of the islet.  Among the remains is a large wheel shaped cage in which 4 prisoners would run like hamsters to power a hoist that would bring supplies from the sea up to the prison at the peak. The prison was closed in 1863 and gradually Mont Saint Michel attained its proper historical importance when it was made a historic monument in 1874. In 1979 it was declared a UNESCO World Heritage site.

     The islet has been connected to the mainland by a bridge of land at low tide which was obliterated at high tide. The bay silted up due to the lack of water motion in and around the Mont and also due to the grazing of sheep on the salt flats. In 1879 the land bridge was built up into a permanent causeway. One could drive out to a parking area to visit the islet. But it was thought that this was not historical and it was felt that the natural water motion in the area should be restored. Therefore a hydraulic dam was built across the River Couesnon and the causeway was obliterated starting in 2009 (after we were there). This project will be completed in 2012. There will now be a foot bridge to the Mont, and shuttles will take people from a parking lot on the mainland to visit the site.

     I found Mont Saint Michel to be very quaint. Climbing through the spiralling streets from the sea level to the Monastery at the peak, creates a sense of returning to Medieval times. One can easily picture what life was like here in centuries past.  That's one of the attractions to travel: the sense of history and identifying with and learning from what came before.

     "Stay tuned!" I have some photos of the Normandy Beaches to show you, maybe in the next posting or two. Viva La France!

Mystery Photo 7

     Here is another guessing game! I think this one might be easier than the Wind Palace in Jaipur. Hint, the profile of this place viewed from more of a distance is very well circulated. What is its name?

Coding, medical billing and the current use of my MD.

     As some of you regular readers may know, I am an MD, retired, but I still do have those letters after my name. Now I am having experiences in the medical field from the other side of the check in counter. That is -I have been a patient several times in the last 1 year. What these experiences have led me to believe is that you need an MD to decipher the EOBs (explanation of benefits) that come in the mail after a medical visit. AND more importantly you need an MD to know what was billed and to go to battle to get the coding corrected so that your insurance or Medicare will cover what it is supposed to cover.
     I will tell you about my specific coding blunders that I had to use my medical knowledge to fight. I think two of them are very common and should be argued with your doctor if you detect them.
     The biggest blunder and hardest to correct when I had my outpatient day surgery on my arm to remove the melanoma and at the same time, do a sentinel node biopsy. Of course, in preparation for my surgery, the anethesia resident came to my day surgery room to review my medical history, and discuss the anesthesia she was going to give me. And she started my IV. Standard practice calls for an intracath in the vein (a plastic sheath threaded into the vein, rather than just a small metal needle) because with an intracath the IV site is more stable and reliable even if the hand  is moved around during surgery. But the drawback is that it is more painful to place an intracath into the vein. So the anesthesiologist first infliltrated some lidocaine (xylocaine)  with a fine needle as a pain killer around the vein she planned to use for the IV. (As an aside, she couldn't get that IV started; the vein collapsed. So she had to try two different times in other veins and I didn't have the benefit of the pain killer for those veins anyway. But that is beside the point.) When my bill came back after surgery, it listed two drugs that were administered under a class called "self-administered pharmaceutical agents." I had heard about this one before. I was given a Tylenol with codeine pill after the surgery while still in the recovery day surgery room. Apparently Medicare and insurance do not cover oral meds given in these circumstances because they can be taken by the patient without the need for a nurse. So a charge is administered for these meds that is often quite large. I was charged $35.00 for that single pain pill. Medicare tells you that you could get a prescription through your doctor prior to the surgery and then take that pain pill at the day surgery site on your own and avoid that charge. However, it is also a known protocol that the day surgery people will not let you bring any of your own meds with you nor will they let you take them without a direct order that you can take your own meds, from your doctor. By the time you need this order, your doctor is long gone. So this issue is a well-known Catch-22 and you basicly just have to pay the large fee for that single pain pill that they administer. But in my case, along with that charge for the Tylenol with codeine, there was a charge for another self-administered drug, denied by Medicare. First I had to call Medicare to see what the code and denial applied to. Then I had to call the hospital and have someone look at my chart to see what that other self-administered drug I could have been given under that code. I didn't recall anything else. And it couldn't have been self-administered if I was already under the anesthetic. A couple phone calls showed that it was lidocaine. It was that infiltrated lidocaine used to deaden the site where my IV was to be started. Well, I certainly didn't administer that to myself with a needle from a vial of the medication. Clearly the use of this medication had been miscoded, denied by Medicare, and I was being charged about $65.00 for this, when it should have been part of the whole procedure and paid for by my insurance. Now that I had it sorted out from the codes, I had to call back the billing of the hospital, and tell them what needed to be changed so that that charge would be resubmitted and would apparently be paid for. It took about 2 months but it worked.
      The other two instances were pre op lab blood tests that were coded as routine. This happened when the surgeon ordered preops for my melanoma surgery and it happened again when my gastroenterologist ordered a pre procedure potassium and metabolic panel before my colonoscopy. In both cases the procedure was being done for diagnostic reasons: melanoma in case of that surgery, and symptoms before the colonosocpy which had to be coded using the number for the symptoms, not as routine. Medicare is very clear that it does not pay for routine tests. It now will pay for a routine screening colonoscopy but apparently will not pay for the labs that your doctor requires you to have before the screening procedure. Mine was being done due to some vague symptoms so those needed to be coded properly so that Medicare would pay also for the pre procedure labs. It took a phone call to the billing for my clinic to find out what the lab was and how it was coded; then a call to Medicare again to affirm that they would not pay for the tests under this code. It was a V code: V76.23. All V codes are routine tests done for some screening reason. That immediately told this MD that they had coded the lab tests as routine and they would not be paid for until we got those codes changed. Now I had to get a message back to my gastroenterologist directly for him or his assistant to change the code and replace it with a code that means "change of bowel habits" the symptom that required the colonoscopy, and then resubmit that to Medicare. That is now in the process of happening and I assume it will take a couple months for this to get straightened out. The total cost to be saved here was $88.00 for the lab test, and $24.00 for drawing the blood for the lab test.
     You see! You need an MD to be sure that you are billed properly and receive payment for all the medical items that you are entitled to. Most people would probably just pay the bill. But sometimes these errors add up to several hundred dollars or more. Be forewarned and be alert; examine your EOB carefully and call to ask questions that you don't understand.

Mystery Photo 6: Palace of the Winds, Jaipur, India. And other photos.

     Yah, this one was a tough one. Unless you have actually been there, or maybe by some chance recognize the Moghul architecture, you wouldn't have known this one. Someone thought this one was too difficult.

                                                    Wind Palace, Hawa Mahal, Jaipur, India

     Jaipur, also called the "Pink City" because of the pink sandstone that is used to build many of its buildings, was planned and built by Maharaja Sawai Jai Singh, the ruler of Rajasthan from the Kachwaha clan. The city was built in 1727. But it was this ruler's grandson, Sawai Pratap Singh who built the Palace of the Winds, Hawa Mahal in 1799 as an extension to the Royal City Palace. This Wind Palace is not a complete building but rather a 5 story facade. It is only one narrow room deep with lots of lattice work covered windows on both sides. It is connected to the Women's Quarters of the Palace where the royal harem lived. It was built right on the central square of Jaipur City so that the royal women who had to always remain covered (purdah) in public, could stroll from their quarters to this building and observe life in the city, and royal processions and other events without going into the public and having to cover up. Also due to its windows on both sides and small fountains in the middle of some of the chambers, it tended to be a cooler relief during the Rajasthani summers. The designer of Hawa Mahal intended the structure to resemble the headgear of the Hindu god, Krishna, who was a favorite of Pratap Singh. The white sandstone lattices covering the windows each carved from a single plate of sandstone are very characteristic of many Moghul palaces and buildings. Again they were intended to let in light and air but not allow people outside to see who was behind the lattice work.
     The photography in this city was absolutely phenomenal. It was a gorgeous clear day with bright blue sky. And the colors of the buildings with their sandstone, and painted stucco provide just the perfect color combinations. Also there are such nice Indian scenes.

  

     The city of Jaipur has many other interesting structures to see. Below are two photos from our hotel which was an architectural delight in and of itself. It is part of the Taj series of hotels and resorts. Notice the life size chesspieces in the gardens below our suite.

       On a hill overlooking the valley containing Jaipur is a large fort connected to a lengthy wall that winds up and down over the ridges, reminding me of the Great Wall of China. It is called the Jaigarh Fort named after the hill it sits on. Below that more primitive fort is the Amber Fort and Palace. This is a beautiful structure with many beautiful rooms, and gardens.  

     Inside the Amber Fort are wonderful courtyards, mixing the Rajasthani art work with the Moghul architecture. The Public Audience hall with all its arches, the Hall of Mirrors, and wonderful gardens all with other landmarks in the backround in these hills around the city of Jaipur.

Below is the Nahargarh Fort, also called the Tiger Fort on a hill overlooking Jaipur.

     Below is a view of part of the city of Jaipur from the Amber Fort. And below that is the Jal Mahal or Water Palace which is planted in the middle of a beautiful little lake in the middle of this arid location, located on the way out of the hills where the Forts are located.

                                                  Hindu Temple on way down to Jaipur from Amber Fort. 

                                

    

In the city of Jaipur is City Royal Palace, of which one extension is the Palace of the Winds. The royal family still occupies some of this City Palace (the multiple story pale yellow portion in the photo above). Also the City Palace grounds contain the Jantar Mantar, a large outdoor observatory that has a multitude of stone and metal structures that tell the time like very large and complex sundials. This was a favorite occupation of the Maharaja who built Jaipur. He was quite interested in the sun and the moon and the workings of the heavens. It is quite interesting to walk among these structure and observe with what precision the time is represented by sunlight and shadow. The photos below are of Jantar Mantar, the largest stone observatory in the world.

Real Life entered into my blog life!

     So Sorry Dear Readers! I have not posted for 12 days. First of all I have left all you Mystery Photo Followers up in the air with the Wind Palace in Jaipur, India. And I haven't posted the other great pictures I have from this city. I still plan to do that.
      Why haven't you posted lately, you ask. Well like I said Real Life entered in.
     First of all, I had signed up for a free two weeks of usage on Ancestry.com, the greatest genealogy website in the world. I have not been on it in a year or so. And low and behold, I found all kinds of family pedigrees that extended several lineages by a generation or two. But the most exciting was finding a lineage on my mother's father's side that goes back to the 1700s in Maryland, USA. But then by crossing over to the female line and following it back a couple generations, I could again jump to the male line taking this line, the Winder family back to Lancashire, England in 1635. Wow. That was impressive. I reviewed this pedigree quite extensively and it does seem to be my line. John Winder was born in 1635; his son John Jr was born in 1668 and had a 3 year old son with his wife, when he died in Y, Somme, Picardie, France. First of all that town, Y (pronounced E) is the shortest town name in the world. But what was this young man doing in Y, Somme., Picardie, France in 1688 that made him die there. England and France were not friendly then, so this would not have been a tourist trip. But they also were not at war, so he was not there in a military capacity at least that had to do with war. 1688 was the year that Charles II abdicated his throne, and escaped to France in December. William and Mary from Holland were invited to take the English throne. Charles II was Catholic and fled to France after he abdicated. But he would have come ashore near Calais, and Picardie is well inland. Someone suggested that perhaps John Winder Jr. was engaged in something nefarious such as smuggling. It is possible. I am going to try to find out what happened here. At any rate, his 3 year old son Thomas grew up and came to the US, to New Jersey along the Delaware River, eventually moved west to western Maryland. That's where his descendents married into my Spielman family line. Anyway if you understand a genealogist's addiction and excitement at finding these lines, I had to use up that free Ancestry.com membership before it ran out.
     Secondly, we are getting our two downstairs bedrooms and their walk in closets recarpeted. So we have been emptying those rooms and the closets. And I really don't want to put all that stuff back in the closets, so I am trying to weed out a lot of stuff and throw it away. This has been occupying me for some time now. The carpeters are coming on Tuesday next week. Then I will have to work to get the stuff back where it goes.
     And thirdly, lastly, but not leastly, my son's family was here this last weekend and I had to sort of get ready for them, with some food and with the house and my toy collection rady for my grandson's onslaught. It was great having them here and we (Grandma, and the two little boys) played with those toys all weekend.
     So now I am back to normal. Expect a posting with photos of Jaipur, India soon.

Colonoscopy Over! And a bit about Lord Dunsany!

     The colonoscopy. Everything went fine. I didn't go to sleep this time either, but I was told that my gastroenterologist likes to use light sedation so that the patient isn't totally a zombie afterwards and doesn't have to spend a long time in recovery. He just wants to make sure that the patient is comfortable, even if he/she is awake. He used 8 mgm of Versed which is what I had the other time, but he used quite a lot of Fentenyl as the pain reliever. I still had more cramps this time than before. There were a couple of times that I thought I would have to say something to the attendants, but I made it through, and he got into the cecum, so we don't have to do this again for 10 years. No polyps were found. Yea! As for next ime, well a lot can happen in 10 years. Maybe medical science will advance and we'll have something like the StarTrek wand to assess people. I have been waiting for that wand my whole adult life, first as a provider of medical care and now as a consumer of medical care. Dr. McCoy never had to get his hands dirty no matter what the injury or illness. Then again in 10 years, maybe I will not be here, who knows?

     I am reading a book, no a tome, entitled Greetings Carbon Based Bipeds: Collected Essays 1934-1998 by none other than Arthur C. Clarke, prolific visionary and my favorite Sci Fi Writer. His first essay in this book introduced me to a writer that I had never heard of before; Edward John Moreton Drax Plunkett (1878-1957). He is otherwise known as Lord Dunsany as he is indeed a Lord, of the inherited Irish property, Dunsany and other properties. He had quite a full life in many other ways, but was a prolific writer of fantasy, essays, poetry, plays, and science fiction. He is noted for his remarkable way with words. His fantasy would influence such better known later writers as C. S. Lewis and J. R. Tolkien. You can read more about him and some others of his works at the following links: www.dunsany.net/18th.htm  and  http://pweb.jps.net/~sangreal/ld.htm. Other copies of his works are on the Internet at various other sites that you can glean from the above two web addresses.

     Being the frustrated writer that I am and my attempts to forward that writing ability in this blog, makes me read what others have written about writing and take it to heart. Two quotes from Arthur C. Clarke's first essay struck me. They apply to writing but they also apply to life in general and our aspirations before we die. Both were written by Lord Dunsany. You can certainly see his way with words.

     Of all materials for labor, dreams are the hardest; and the artificer in ideas is the chief of workers, who out of nothing will make a piece work that will stop a child from crying or lead nations  to higher things. For what is it to be a poet? It is to see at a glance the glory  of the World, to see beauty in all its forms and manifestations, to feel ugliness like a pain, to resent the wrongs of others as bitterly as one's own, to know mankind as others know single men, to know Nature as botanists know a flower, to be thought a fool, to hear at moments the clear voice of God.

     I spoke above briefly about the end of life. One doesn't know if one will be here 10 years from now to schedule another preventative colonoscopy or even if I will be here tomorrow to go to my water aerobics class. The following poem from Lord Dunsany was written about writing as a pursuit. But I heard the words with respect to life in general. It is a short but sweet admonition to Carpe Diem.

     So much, there is to catch,
     And the years so short,
     That there is scarce time to snatch
     Pen, palette, or aught,
     And to seize some shape we can see,
     That others may keep
     Its moment of mystery,
     Then go to our sleep.

    

Colonoscopy! What Fun!

     Well, tomorrow I have a colonoscopy scheduled for Monday, March 7. Have any of you had one or more of those? This is my second one. My first was done 5 years ago just for colon cancer screening purposes. I was prepared for the preparation as they say. No eating and lots of laxatives to clean that colon out. Most of my patients had a great deal of trouble drinking down the gallon of ethylene glycol that flushed the colon out. If you have had one of these before, you know that you need to start this about 4 in the afternoon the day before your test, drinking this gallon down in 8 ounce glasses every 10 to 15 minute. And as you can imagine this stuff is not the greatest tasting stuff in the world. Some people would get very nauseous when drinking this stuff. My gastroenterologist uses a slightly different prep which may be slightly easier. He precribes 4 Dulcolax laxative tablets by mouth at 11 AM the day before. These start to work later in the day simultaneously with the ethylene glycol. Therefore he uses only 1/2 gallon of that solution. For most people anything that can reduce the amount of that fluid that you have to take is better. From about 5 PM on that night before the subject (my patients in the past, me this time) will basicly be in the toilet. There is usually not pain with this preparation but there is certainly lots of rumbling and going on in that belly. Usually it is over by bedtime though. Then you get up bright and early and go have the test.
     The first time I had this test 5 years ago, I did not respond to the sedative. In addition to Demorol for pain, they use a drug called Versed to sedate the patient. Though it allows the person to follow minor commands during the procedure, the person usually does not remember the procedure afterwards. It is called conscious sedation: you have amnesia and are not "awake" to what is happening almost immediately after the injection until you arrive in the recovery area. Then you feel fine and once it is certain that your stomach is OK and you are fully awake, you are allowed to go home where you might be kind of drowsy the rest of the day. You do need someone to drive you home in case your reactions are slowed by these drugs. That is what is supposed to happen. However, in my case last time, I never "went to sleep." I remained conscious, fully aware, and remembered the whole procedure. I even watched the action on the monitor screen. My procedure also took quite a while because the gastroenterologist was having trouble getting the scope into the right end of the colon, the cecum. He tried every method he knew, taking the scope back a long ways and trying to get it to enter the cecum several times, pushing on my belly to try to advance it from the outside of the body, turning me over even on to my stomach, etc. Nothing worked; he never could get into the cecum. He said he could see it but couldn't enter it to be sure he was seeing everything he should. This is why I am having the procedure again after only 5 years. So I am hoping that the same thing doesn't happen again. That is I hope he can get into the cecum and that it doesn't take such a long time to do the test. And I hope that the Versed works for me this time. I received the same drug when I went for my melanoma surgery, administered in the day surgery prep room and I was out before they even wheeled the gurney out of the area. So we will see.
Wish me luck.