CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 4 0000, ref SDS 2 0000.
040502 -
040503 -
040504 -
040506 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Background...
040902 -
040903 -    1.  Millie fell and dislocated her shoulder
040904 -        at exercise class and was treated
040905 -        at Kaiser............................ 090122, ref SDS 2 CW6J
040907 -         ..
040908 -    2.  Shoulder was restored with
040909 -        reduction procedure.................. 090122, ref SDS 2 LV3O
040910 -        evaluation examination scheduled in
040911 -        Orthopedics 090129 1330.............. 090122, ref SDS 2 HW4H
040913 -         ..
040914 -    3.  Right eye above brow deep cut
040915 -        clean and suture remove stitches
040916 -        in Orthopedics Dep................... 090122, ref SDS 2 WX4M
040917 -        Special Instructions say remove
040918 -        stitehcs in 5
040919 -        days................................. 090122, ref SDS 2 4Y5K
040921 -  ..
040922 - We drove directly from UCSF in San Francisco to Kaiser on Walnut
040923 - Creek, and arrived about 1220, because the meeting at UCSF took an
040924 - extra 2 hours waiting for Doctor Rugo write the letter recommending
040925 - Millie's next treatment [reported in Millie's letter to the medical
040926 - team on 090130. ref SDS 6 AY9Q]
040928 -  ..
040929 - Before going to Orthopedics on the 1st floor, Millie visited Oncology
040930 - on the 2nd floor to coordinate with Doctor Johnson for timely respose
040931 - to the letter from Doctor Rugo this morning at UCSF, recommending
040932 - hyperthermia with Doxil for Millie's treatment to recover from the 6th
040933 - relapse of IBC. ref SDS 6 AY9Q
040935 -  ..
040936 - Jennifer said that Doctor Johnson had just left the clinic for the
040937 - day.
040938 -
040939 -            [On 090130 Millie's letter to medical team reports efforts
040940 -            to coordinate with Doctor Johnson for timely response to
040941 -            Doctor Rugo's recommendation that Kaiser refer Millie for
040942 -            treatment of 6th IBC relapse with hyperthermia at UCSF.
040943 -            ref SDS 6 AY9T
040945 -  ..
040946 - Jennifer will notify the Chemotherapy Infusion Clinic that Millie does
040947 - not need Neupogen treatment tomorrow and Friday, because blood counts
040948 - are high in the labs at UCSF today, ref SDS 5 QY6H, and on 090122
040949 - Doctor Rugo ended Millie's treatment with sunitinib and
040950 - cyclophosphamide. ref SDS 3 AT6N  Additionally, today, the doctor
040951 - prescribed hyperthermia treatment [reported in Millie's letter on
040952 - 090130, ref SDS 6 4S8O, which is a form of radiation that does not
040953 - affect blood counts, so Millie will not need Neupogen in the period
040954 - ahead.
040955 -
040956 -     [On 090206 Florida called and asked about Millie gettting
040957 -     Neupogen; explained notice today on 090129 that all treatments are
040958 -     cancelled, because Millie taken off of chemotherapy. ref SDS 9
040959 -     YX61
040960 -
040961 -
040963 -  ..
040964 - Orthopedic Examination Recovery Dislocated Shoulder
040965 -
040966 - Went to Orthopedics on the first floor, and arrived about 1310.
040968 -  ..
040969 - There was a sign on the counter saying everyone was at lunch until
040970 - 1330.  Turned out there was an interesting few people also waiting for
040971 - meetings at 1330.
040973 -  ..
040974 - Millie had a good discussion with a republican to voted for Obama.
040975 - Another woman said she was annoyed by the conversation, because she
040976 - was a conservative.  She however participated in the discusison,
040977 - which was civil and interesting until 1330 when the attendants
040978 - returned from lunch.
040979 -
040981 -  ..
0410 -
0411 -
0412 - 1338
0413 -
041301 - Meeting with Mike, a Physician Assistant.
041302 -
041303 - Mike initially objected to removing stitches from Millie's right eye.
041304 - He explained Kaiser policy for patients to return to the department
041305 - that made the suture, for removing the stitches.  Mike showed on his
041306 - computer screen in the examination room that the Emergency Department
041307 - did the work.  He feels Millie should go there to remove the stitches.
041309 -  ..
041310 - Millie showed instructions from the Emergency Department saying to
041311 - meet with Orthopedics today.
041313 -  ..
041314 - Mike looked through Millie's instructions from the ER and concluded
041315 - there was nothing telling the patient to return to ER for removal of
041316 - stitches.  He feels this was a mistake, and that ER should have
041317 - shcheduled Millie to go back to the ER for removal of stitches, and go
041318 - to the Orthopedic Department only to examine the dislocated shoulder
041319 - problem.  Mike attributed this glitch to a minor detail "falling
041320 - through the cracks," because everybody is very busy and under a lot of
041321 - stress in the ER Department.
041323 -  ..
041324 - Millie advised that experience working with the Emergency Department
041325 - on 4 or 5 occassions the past 7 years indicates that going to the ER
041326 - to remove 3 or 4 stitches would take several hours in the hospital for
041327 - work that can be done today at this time in a few minutes.
041329 -  ..
041330 - Mike said that even though the ER made a mistake not scheduling Millie
041331 - for a return visit to remove the stitches, eveidently not realizing
041332 - Kaiesr policy, Millie can go to the ER this afternoon, after he
041333 - completes follow up examination of Millie's dislocated shoulder.
041335 -  ..
041336 - Millie explained patient history on 061201 shows Kaiser consistently
041337 - applies an overarching policy of deference to doctor discretion acting
041338 - on medical necessity to balance time, cost, and effectiveness.
041339 - ref SDS 1 6H3J  She asked Mike if he has experience removing the kind
041340 - of stitches observed today?
041342 -  ..
041343 - Mike said he does this a lot.  He takes a lot of pride suturing
041344 - wounds, and removing stitches that provide effective care with
041345 - minimal discomfort to the patient.
041347 -  ..
041348 - Mike then said he would remove the stitches, and enter in his computer
041349 - that this was done at the patient's request for medical necessity,
041350 - despite conflicts with Kaiser policy.
041352 -  ..
041353 - Mike removed stitches from suture treating cut above right eye.  This
041354 - took about 2 minutes.
041355 -
041356 -        [On 090213 1140 primary care physician approved Orthopedic
041357 -        Department applying doctor discretion taking immediate action
041358 -        to remove stitches for medical necessity ref SDS 10 HG83
041360 -  ..
041361 - Mike asked how the separated shoulder occurred.  Millie summarized
041362 - events on 090122. ref SDS 2 CW6J
041364 -  ..
041365 - Shoulder was xrayed.  Mike advised that xray scan test today shows no
041366 - fracture, and that Millie's shoulder appears correctly positioned in
041367 - the socket for effective healing and recovery.
041369 -  ..
041370 - Mike asked Millie to perform several movements with her arm below the
041371 - elbow, and moving her fingers.  Millie did these routine movements
041372 - normally and without discomfort.
041374 -  ..
041375 - Mike was pleased that xrays show Millie's shoulder is still positioned
041376 - correctly a week after the injury on 090122.  He feels examination and
041377 - range of motion studies today show Millie is recoverying as well or
041378 - better than most patients with the severity of injury suffered on
041379 - 090122. ref SDS 2 CW6J
041381 -  ..
041382 - Mike asked why Millie was not wearing the harness immobilizer provided
041383 - at discharge on 090122? ref SDS 2 ST96
041385 -  ..
041386 - Millie advised that on Monday, her arm seemed better, there was less
041387 - pain, and the harness-sling is very uncomfortable, actually causing
041388 - increased pain, so she removed it.  Earlier this morning examination
041389 - at UCSF cited elevated vitals show Millie is suffering traumatic pain
041390 - from cancer, so she feels reducing discomfort from wearing the
041391 - immobilizer helps solve the problem.
041392 -
041393 -        [On 090130 Millie's letter to the medical team reports
041394 -        examination at UCSF on 090129 made findings of rising pain
041395 -        based on elevated vitals. ref SDS 6 AY7T
041397 -  ..
041398 - Mike feels Millie was lucky not to have injured the shoulder while not
041399 - wearing the immobilizer-sling.  He explained Kaiser's policy in the
041400 - Orthopedic Dpartment for patients recovering from separated shoulder
041401 - to wear the sling 24-7, including during sleep, for the next 2 weeks
041402 - until the next examination.  Mike explained that the arm needs to be
041403 - immobilized during the initial healing process, so that nerve cells
041404 - and support tissue regenerate correctly.  He prescribed a new
041405 - harness-sling, and sent Millie to the sling department.
041406 -
041407 -     [On 090201 immobilizer caused lymphedema recurrence left arm, and
041408 -     so was removed. ref SDS 7 KN4S
041410 -  ..
041411 - Mike said Millie can remove the sling to take a shower with
041412 - assistance.  He demonstrated how to keep the arm still in the natural
041413 - vertical hanging position, while showering with assistance.
041415 -  ..
041416 - Mike showed Millie on the computer the xray of the shoulder separated
041417 - on 090122. ref SDS 2 CW6J  The joint was moved by several inches
041418 - toward the top right chest.  Mike explained that all of the tissue,
041419 - ligaments, tendons, and muscles that holds the end of the arm in the
041420 - shoulder socket were torn and stretched by dislocation.
041422 -  ..
041423 - Mike indicated that Millie will suffer pain in the arm below the
041424 - shoulder because of tissue that was torn and stretched when the
041425 - shoulder dislocated extends down the arm to the elbow.  Initially,
041426 - broken nerves make the area seem numb.  As the nerves grow back, they
041427 - sense major trauma to surrounding tissue and signal pain during the
041428 - healing process.
041429 -
041430 -        [On 090203 Millie experiences increased pain while sleeping;
041431 -        tries to adjust by sleeping more upright, and taking more
041432 -        medication. ref SDS 8 KE5I
041434 -  ..
041435 - The immobilizer helps ensure that everything heals in the right
041436 - position.
041438 -  ..
041439 - Mike demonstrated several exercises Millie can perform 3 - 4 times a
041440 - day by releasing the hand from the restraint, and moving the arm from
041441 - the elbow in several directions for several repetitions, including
041442 - moving the hand and fingers.
041444 -  ..
041445 - Sees Millie in 2 weeks for follow up.
041447 -  ..
041448 - Mike took Millie to a work station for getting a new sling, and
041449 - submitted a prescription.
041451 -  ..
041452 - There were 2 technicians.  The both worked with Millie to configure
041453 - the sling.  One technician said patients do better by sleeping with
041454 - their back elevated to relieve pressure on the injured arm during the
041455 - healing process.  He recalled years ago having a dislocated shoulder
041456 - and slept in a reclining chair for awhile to comply with orthopedic
041457 - instructions to wear a sling.
041458 -
041459 -     [On 090201 immobilizer caused lymphedema recurrence left arm, and
041460 -     so was removed. ref SDS 7 KN4S
041461 -
041462 -
041463 -
041464 -
041465 -
041466 -
041467 -
0415 -