CONTACTS 

SUBJECTS
Coumadin Treatment Pulmonary Emboli Blood Clots Paused 5 Days Prior

1003 -
1003 -    ..
1004 - Summary/Objective
1005 -
100501 - Follow up ref SDS 11 0000. ref SDS 10 0000.
100502 -
100503 - Kaiser policy pauses coagulation treatment with Coumadin for pulmonary
100504 - embolism, and at most five (5) days prior to the date of surgery.
100505 - ref SDS 0 YV7Q  Coumadin treatments normally resume on the day of
100506 - surgery, and following the operation. ref SDS 0 5F43  Kaiser staff
100507 - prefer to avoid visibility and risk of reprisals by asking patients to
100508 - notify the doctors of Kaiser's policies. ref SDS 0 5F5W
100509 -
100510 -     [On 051007 Millie notified primary care physician of Kaiser's
100511 -     policy on pausing Coumadin treatments for pulmonary emboli, as
100512 -     related by Gloria today; the doctor cited Kaiser policy to treat
100513 -     patients for life, who, like Millie, are diagnosed with both
100514 -     cancer and pulmonary emboli, ref SDS 12 EQ7K; he then ordered
100515 -     Millie's treatment ended on grounds that pulmonary emboli is a
100516 -     side effect of Avastin treatments, which ended a year ago.
100517 -     ref SDS 12 XN7K
100519 -      ..
100520 -     [On 051021 called Gloria in the anticoabulation and explained the
100521 -     doctor's order that Coumadin treatments were ended. ref SDS 15
100522 -     RR9G
100524 -      ..
100525 -     [On 051025 Gloria called Millie and said the doctor withdrew the
100526 -     order to end Coumadin treatments, and that she is now to continue
100527 -     treatments again with Coumadin. ref SDS 16 DI9H
100528 -
100529 -
100530 -
100531 -
100533 -  ..
1006 -
1007 -
1008 - Progress
1009 -
100901 - Gloria is a nurse in the Kaiser Coagulation Clinic located in
100902 - Martinez, CA.  She manages Millie's Cuomadin treatments and blood
100903 - tests, and called this afternoon with a message for Millie.
100905 -  ..
100906 - Gloria's message explains having received a Kaiser internal order for
100907 - the Coagulation Treatment Clinic to pause Coumadin for seven (7) days
100908 - prior to biopsy surgery scheduled for Millie on 051012, previously
100909 - reported on 050929, ref SDS 11 PPUQ, and implementing planning to
100910 - evaluate mastectomy surgery which occurred with the surgeon on 050923.
100911 - ref SDS 10 4F5H
100913 -  ..
100914 - Gloria says in her message to Millie that Kaiser policy pauses
100915 - Coumadin treatments for a maximun of five (5) days for very severe
100916 - surgery, such as heart transplant or brain bypass.  Gloria further
100917 - relates that minor outpatient surgery for a biopsy with local
100918 - anesthetic should require fewer than five (5) days.  Gloria noted
100919 - objectives to minimize the number of days when Coumadin is paused in
100920 - order to minimize risk of pulmonary emboli causing death, previously
100921 - cited by Doctor Bailey in a 2nd opinion received on 050922.
100922 - ref SDS 9 6Z5Q  Gloria cites no authority for this issue in the
100923 - message.  Gloria asks Millie to call and explain the scope of the
100924 - biopsy surgery to assist the Kaiser Coagulation unit in determining
100925 - the number of days to pause Coumadin.
100927 -  ..
100928 - Background on 050729 reported the primary care physician planned to
100929 - pause Coumadin 10 days prior to standard mastectomy surgery.
100930 - ref SDS 7 5B5F
100931 -
100932 -
100933 -
100935 -  ..
1010 -
1011 -
1012 - 1348
1013 -
101301 - Called Gloria Coagulation Control clinic...
101302 -
101303 -                         925 372 1628
101305 -  ..
101306 - Left a message explaining the scope of minor surgery for biopsies
101307 - currently scheduled for 050912, as reported on 050929, ref SDS 11 PPUQ,
101308 - and previously planned with the surgeon on 050923. ref SDS 10 SZ6M
101309 -
101310 -
101312 -  ..
1014 -
1015 -
1016 - 1431
1017 -
101701 - Telephone operator called back.
101702 -
101703 - She needs Millie's Kaiser number, so she can forward the message to
101704 - Gloria to call Millie back.
101705 -
101707 -  ..
1018 -
1019 -
1020 - 1611
1021 -
102101 - Gloria called back.
102102 -
102103 - We reviewed the record showing the backup doctor in Oncology which
102104 - provides Millie's primary care prescribed Millie taking Coumadin for
102105 - life, reported on 041104 1030. ref SDS 5 1U5K
102107 -  ..
102108 - Gloria said that in this case of minor outpatient surgery with local
102109 - anesthetic Coumadin probably can be paused about 3 or 4 days prior to
102110 - surgery on 051012.  However, she recommends that since the surgeon has
102111 - ordered a seven (7) day pause, that Millie should take Coumadin
102112 - tonight, and then pause until the day of surgery, and resume Coumadin
102113 - treatments immediately after surgery, and on the same day.
102115 -  ..
102116 - Gloria will call the surgeon, and likely wind up leaving a message,
102117 - explaining that she told Millie to take Coumadin tonight and then stop
102118 - until surgery on 051012.  Gloria will further explain that a maximum
102119 - of five (5) days is recommended to pause treatment in order for the
102120 - body to fully discharge all of the Coumadin, and so for Millie's
102121 - current biopsy procedure on 051012, probably only 3 - 4 days is
102122 - required.
102124 -  ..
102125 - Gloria said that most surgeons are not familiar with specifics of
102126 - managing Coumadin, and generally follow suggestions from the
102127 - anticoabulant unit, however this is the doctor's call.
102128 -
102129 -     [On 051007 Millie notified primary care physician of Kaiser's
102130 -     policy on pausing Coumadin treatments for pulmonary emboli, as
102131 -     related by Gloria today; the doctor cited Kaiser policy to treat
102132 -     patients for life, who, like Millie, are diagnosed with cancer and
102133 -     with pulmonary emboli, ref SDS 12 EQ7K; he then ordered Millie's
102134 -     treatment ended on the grounds that pulmonary emboli is a side
102135 -     effect of Avastin treatments, which ended a year ago. ref SDS 12
102136 -     XN7K
102138 -      ..
102139 -     [On 051012 biopsies were performed without incident. ref SDS 13
102140 -     DG6J
102142 -      ..
102143 -     [On 051021 called Gloria in the Anticoagulation Clinic and
102144 -     explained the doctor's order that Coumadin treatments were ended.
102145 -     ref SDS 15 RR9G
102147 -      ..
102148 -     [On 051025 Gloria called Millie and said the doctor has not
102149 -     notified the Anticoagulant clinic to end treatments with Coumadin;
102150 -     Gloria coordinating to complete the record on notice requirements
102151 -     for ending Coumadin treatment. ref SDS 16 DI9H
102153 -      ..
102154 -     [On 051026 Gloria reported that the primary care physician changed
102155 -     the prescription on 051007 for ending Coumadin treatment, and
102156 -     ordered treatments resumed for pulmonary emboli, as required by
102157 -     Kaiser's guidance because Millie is a stage IV cancer patient.
102158 -     ref SDS 17 PO7J
102160 -      ..
102161 -     [On 060722 Millie's son diagnosed with recurrence pulmonary
102162 -     emboli, tests reveal family genetic disposition for pulmonary
102163 -     emoblism, ref SDS 18 3D9T, research indicates 45% of patients die
102164 -     who suffer recurrence. ref SDS 18 BI5J  Millie's stage IV cancer
102165 -     patient history fits Kaiser's policy to treat cancer patients
102166 -     diagnosed with pulmonary emboli for life. ref SDS 18 6G6O
102168 -      ..
102169 -     [On 061002 Millie diagnosed pulmonary emboli recurrence; Kaiser
102170 -     resumes treatment for life. ref SDS 19 MI5I
102171 -
102172 -
102173 -
102174 -
1022 -

SUBJECTS
Patient Asked to Notify Doctor of Policy Because Staff Fears Reprisa

2103 -
210401 -  ..
210402 - Fear Reprisals Frustrates Team Care Collaboration Communication Fails
210403 - Patient Asked to Notify Doctor of Policy Because Staff Fears Reprisal
210404 -
210405 - Gloria asked during the call today that Millie explain Kaiser's
210406 - requirements on Coumadin during the meeting tomorrow with the primary
210407 - care physician, so that the Coagulation Treatment staff can avoid
210408 - making formal notification to the doctor of the date for pausing
210409 - Coumadin treatment, and to mention that a maximun of 5 days pause is
210410 - required for major surgeries, such as a mastectomy being discussed in
210411 - Millie's case.  This adjusts planning on 050729 when the primary care
210412 - physician planned to pause Coumadin treatments 10 days prior to
210413 - mastectomy surgery. ref SDS 7 5B5F
210414 -
210415 -     [On 051007 Millie notified primary care physician of Kaiser's
210416 -     policy on pausing Coumadin treatments for pulmonary emboli, as
210417 -     related by Gloria today; the doctor cited Kaiser policy to treat
210418 -     patients for life, who, like Millie, are diagnosed with cancer and
210419 -     with pulmonary emboli, ref SDS 12 EQ7K; he then ordered Millie's
210420 -     treatment ended on the grounds that pulmonary emboli is a side
210421 -     effect of Avastin treatments, which ended a year ago. ref SDS 12
210422 -     XN7K
210424 -      ..
210425 -     [On 051025 Gloria called Millie and said the doctor has not
210426 -     notified the Anticoagulant clinic to end treatments with Coumadin;
210427 -     Gloria coordinating to complete the record on notice requirements.
210428 -     ref SDS 16 DI9H
210430 -  ..
210431 - Medical organizations face challenges for staff to avoid reprisals
210432 - when presenting requirements to busy physicians, who often are less
210433 - familiar with details of coagulation treatment, but object to formal
210434 - notification called out in published policy and procedures.  Striking
210435 - a balance between diplomatic notification to avoid conflict and
210436 - negative consequences on job ratings, pay raises, and keeping your job
210437 - by being a team player, while, also, making notifications clear and
210438 - timely to save the life of the patient is not easy.  When the patient
210439 - explains technical limitations on prescriptions to the doctor, then
210440 - employees are removed from the "line of fire," i.e., from direct
210441 - communication with the doctor.  This reduces risk to the employee for
210442 - reprisal, because the doctor has time to recover emotional control,
210443 - i.e., "cool off" after discovering the need to change a prescription.
210445 -  ..
210446 - Using patients for "risk management" to the save the jobs of the
210447 - staff enables the Coagulation Treatment team to perform "risk
210448 - management" for the doctor to save the life of the patient.
210450 -  ..
210451 - Gloria's call today reflects communication constraints that cause
210452 - projects to get fouled up, reported on 011006, ref SDS 1 O99K, and
210453 - later reviewed on 040203 discussing the burden of bureaucracy that
210454 - resists truth, ref SDS 4 E44K, reflecting testimony before Congress by
210455 - Sean O'Keefe explaining the cause for loss of the Columbia space
210456 - shuttle, reported on 030826. ref SDS 3 8K4G   Supports study on 020504
210457 - showing ignorance, fear, and denial drive good people ignore
210458 - requirements for good management in laws, regulations, industry
210459 - standards and policies, shown by study on 020504. ref SDS 2 NS6F
210460 -
210461 -     [On 051018 patients equally resist giving doctor's notice to
210462 -     perform Time Out requirements for due diligence for fear of losing
210463 -     entitlement to treatment. ref SDS 14 RR5I
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210472 -
2105 -