CONTACTS
0201 - US Department of Veterans Affairs
020101 - Ms. Karen B Rehder, NP MPH; Administrator
020103 - Cardiology Department
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 7 0000. ref SDS 6 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 - ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 090916 VA performed stress test, which indicated possible heart
040902 - and circulation problems.
040904 - ..
040905 - On 091002 met with Doctor Egan, Cardiologist at the VA. The doctor
040906 - advised that 10 of 11 test points in the stress test showed positive
040907 - for circulation problems, and so the doctor ordered angiogram.
040908 - ref SDS 3 1W5I
040910 - ..
040911 - On 091006 0843 Karen called and scheduled angiogram test on 091020 at
040912 - the VA in San Francisco. ref SDS 4 1W5I Received a letter from Karen
040913 - on 091006 at 1045 confirming schedule for the test which requires
040914 - arriving at the VA on 091019 to do prep for the test on 091020.
040915 - ref SDS 4 GK8L
040917 - ..
040918 - On 091007 0021 sent a letter notifying the medical team that Doctor
040919 - Egan's treatment plan is being implemented, and asked a question about
040920 - the cause of pain based on level of effort. ref SDS 5 4Z75
040922 - ..
040923 - On 091007 0818 received letter from Karen at VA in San Francisco
040924 - responding to the letter this morning asking the medical team for
040925 - cause of chest pain that correlates to level of effort. Doctor Egan
040926 - has not had time to respond. Karen attributes pain to possible
040927 - angina, but does not explain what causes pain. ref SDS 6 A68H
040929 - ..
040930 - 091019 1300 meeting at VA in Cardiology for blood test to prepare for
040931 - angiogram test tomorrow, ref SDS 7 X59F, per Karen's letter on 091007
040932 - 0818. ref SDS 6 A68H
040934 - ..
040935 - 091020 0700 meeting at VA in San Francisco for angiogram test,
040936 - ref SDS 0 YQ9L, explained in the record on, ref SDS 7 VH6Q
040937 -
040939 - ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Meeting at VA Surgery Department at 0700. Got a wakeup call from
041302 - Millie at 0530.
041303 -
041305 - ..
0414 -
0415 -
0416 - 0615
0417 -
041701 - Visit VA Surgery Department. Check in and fill out forms inventoring
041702 - belongings.
041704 - ..
041705 - Met Pastaveia St John, the receptionist. She performed administration
041706 - required to be admitted for the angiogram test.
041708 - ..
041709 - Went down the hall and found a place to work until 0745.
041710 -
041711 - [...below, Pastaveia turns out to be an MBA student, also,
041712 - working at the VA; discussed correlations with Welch work on
041713 - Communication Metrics. ref SDS 0 XE8G
041714 -
041715 -
041717 - ..
0418 -
0419 -
0420 - 0800
0421 -
042101 - Mariela took vitals, and then dressed for surgery.
042102 -
042103 - IV started. For some reason, Mariela used the top of the left hand,
042104 - after inspecting the upper left arm. Evidently she did not see a good
042105 - vein, despite having blood drawn on the right arm inner elbow
042106 - yesterday. The IV was painful getting started. Also presents a
042107 - hinderence using the left hand for using the keyboard to work, while
042108 - waiting to be whelled into the Cath Lab for the procedure.
042110 - ..
042111 - Mariela advises that another patient just started the first angiogram
042112 - test today, so the procedure ordered by Doctor Egan in this case will
042113 - be next, and may occur from 20 minutes to 4 hours later, per meeting
042114 - with Kurt yesterday, on 091019 1300. ref SDS 7 VH55
042116 - ..
042117 - While working with Mariela being prepared for the procedure,
042118 - overheard several other patients getting care by other nurses. It
042119 - seemed odd to hear several times things along the lines...
042120 -
042121 - Hello Fred, nice to see back. How have you been?
042122 -
042123 - Hey Bob, good seeing you again.
042125 - ..
042126 - Asked Mariela how often patients and staff see each other, enough to
042127 - know their names from prior procedures?
042129 - ..
042130 - Mariela seemed to say that many patients require return visits every
042131 - few years more or less surgery to place new stents and to repair or
042132 - replace prior stents. Some return 2 or more times, so the nurses get
042133 - to know them.
042134 -
042135 - [...below on 091020 0700 at 1324 Karen, the Administrator
042136 - for Cardiology, explained some patients require repeat
042137 - procedures on stents. ref SDS 0 3C9J
042139 - ..
042140 - [...below on 091020 0700 at 1324 Doctor Quinn also asked
042141 - patient about prior angiogram/stent procedures. ref SDS 0
042142 - C46L
042144 - ..
042145 - [On 091021 0716 meeting with Doctor Shunk during angiogram
042146 - procedure in Cath Lab - doctor recommended heart bypass
042147 - surgery (CABG) to repair 3 blood flow blockages,
042148 - ref SDS 9 G15L; approved CABG as more reliable, safer
042149 - procedure in this case. ref SDS 8 H87F
042151 - ..
042152 - This was a tiring thought, so instead of working, decided to sleep.
042153 -
042154 -
042156 - ..
0422 -
0423 -
0424 - 1000
0425 -
042501 - Woke up.
042502 -
042503 - Rene Ruiz offered to get the computer. She was terrific lugging
042504 - everything from patient locker storage into the Pre-op waiting area.
042505 - Rene made all the connections, and configured extra blankets to keep
042506 - warm, and provide a pad for the keyboard.
042508 - ..
042509 - Was able to work while waiting for the 1st test to be completed.
042510 -
042512 - ..
0426 -
0427 -
0428 - 1214
0429 -
042901 - Renee advised that the medical team had to treat an emergency case
042902 - from the hospital, and so this may bump the test to tomorrow or
042903 - another date in a few weeks.
042905 - ..
042906 - She will have Karen stop by to review scheduling options.
042907 -
042909 - ..
0430 -
0431 -
0432 - 1324
0433 -
043301 - Karen visited.
043302 -
043303 - She brought a schedule chart for selecting another date for the test.
043305 - ..
043306 - We considered standing down and doing the test tomorrow, or coming
043307 - back at a future date.
043309 - ..
043310 - Karen advised that she wants to try and get the test done today,
043311 - rather than schedule another visit. She seemed to indicate patient
043312 - history suggests that the angiogram test may only take 20 minutes to
043313 - establish that no additional procedures are needed, per Kurts'
043314 - explanation yesterday, on 091019 1300. ref SDS 7 TH3O
043316 - ..
043317 - The test could be delayed until 1600 or so, and could take up to 4
043318 - hours if extensive repair is required. If repair stents are needed,
043319 - then recovery remaining stationary on the gurney will take another 4
043320 - hours.
043322 - ..
043323 - Karen said she talked to the GI staff at the VA in Martinez about this
043324 - case. They feel there is a strong possibility that chest pains may be
043325 - due to achalasia, as discussed with Doctor Lee on 090908 1130,
043326 - ref SDS 2 MY4N, so the test today will find no problems, and so only
043327 - take 20 minutes. Karen therefore recommended not standing down, but
043328 - continuing to stand by to get the test done today.
043330 - ..
043331 - Agreed to this work plan.
043332 -
043333 - [On 091021 angiogram test positive; heart bypass surgery
043334 - scheduled for 091022. ref SDS 8 7L43
043335 -
043336 - [On 091022 0700 quadruple heart bypass surgery performed by
043337 - Doctor Tseng, and her team; took about 8 hours. ref SDS 10 01F9
043339 - ..
043340 - Karen ordered fluid injection with the IV, since nothing has been
043341 - eaten and no liquids since about 2000 yesterday.
043343 - ..
043344 - Asked Karen about durability of stents. Related experience this
043345 - morning overhearing nurses welcoming patients back, and Mariela's
043346 - explanation that many patients require rework on stents fairly
043347 - regularly, per above, ref SDS 0 U59M, which seems to align with Doctor
043348 - Hoffman's inquiries about patient's history of prior procedures,
043349 - reported on 091019 1300. ref SDS 7 CW6G
043351 - ..
043352 - Karen seemed to indicate that stent technology and procedures are
043353 - improving, but reliability depends a lot on patient health and
043354 - lifestyle. She indicated active patients do better, but some
043355 - patients are unable to be active, and so in many cases can be helped
043356 - with mutliple procedures to implant additional stents, and replace
043357 - prior ones.
043358 -
043359 - [...below on 091020 0700 at 1324 Doctor Quinn also asked
043360 - patient about prior angiogram/stent procedures. ref SDS 0
043361 - C46L
043363 - ..
043364 - [On 091021 0716 meeting with Doctor Shunk during angiogram
043365 - procedure in Cath Lab - doctor recommended heart bypass
043366 - surgery (CABG) to repair 3 blood flow blockages,
043367 - ref SDS 9 G15L; approved CABG as more reliable, safer
043368 - procedure in this case. ref SDS 8 H87F
043369 -
043370 -
043371 -
043372 -
043374 - ..
0434 -
0435 -
0436 - 1416
0437 -
043701 - Still standing by.
043702 -
043703 - Renee connects fluids to IV ordered by Karen, per above. ref SDS 0
043704 - PQSR
043706 - ..
043707 - No other patients are in the holding area. Seems like the team has
043708 - processed 6 or 8 patients today.
043709 -
043711 - ..
0438 -
0439 -
0440 - 1553
0441 -
044101 - Rene says the medical team is now ready for this case. They are
044102 - coming to get the patient.
044103 -
044105 - ..
0442 -
0443 -
0444 - 1609
0445 -
044501 - Jacqueline St Paul arrives. She is the charge nurse for the
044502 - angiogram test department.
044504 - ..
044505 - Jacki has good news and bad news.
044507 - ..
044508 - The test can be performed immediately. However, if any problems are
044509 - discovered that require repair, e.g., stents, then this work will
044510 - require coming back tomorrow. In that case, the patient will be a
044511 - "floater" again, and may get bumped several more times, as occurred
044512 - today.
044514 - ..
044515 - Alternatively, Jacki has arranged for the patient to be the first
044516 - procedure in the morning, which starts at 0930 on Wednesdays. Both
044517 - the test and any repair will be performed all at once. If no repair
044518 - is needed, then the work will only take 20 minutes or so. If repair
044519 - is needed, then it will be performed immediately.
044521 - ..
044522 - Decided to do all of the work tomorrow.
044524 - ..
044525 - Rene called and found that the Hoptel is booked for tonight.
044526 -
044527 - [On 091021 angiogram test positive; heart bypass surgery
044528 - scheduled for 091022. ref SDS 8 7L43
044529 -
044530 - [On 091022 0700 quadruple heart bypass surgery performed by
044531 - Doctor Tseng, and her team; took about 8 hours. ref SDS 10 01F9
044533 - ..
044534 - Jacki called Evelyn in the Post-op ASU to arrange for a room in the
044535 - hospital. This makes the case an "inpatient" matter, and so will have
044536 - priority for care tomorrow.
044538 - ..
044539 - Patient will not come back to the Pre-op ASU waiting area tomorrow
044540 - morning, but will be wheeled on the gurney from the hospital room
044541 - directly to the treatment area for immediate care.
044543 - ..
044544 - While Rene and Jacki arranged to implement the new work plan,
044545 - Pastaveia St John stopped by, ending her day, per above. ref SDS 0
044546 - XU5F
044548 - ..
044549 - She asked about computer c16 being used to report on events today, and
044550 - to plan tomorrow. Explained the HP HDX 18t, purhcased on 090623 1648.
044551 - ref SDS 1 294M
044553 - ..
044554 - Pastaveia is an MBA student. We discussed POIMS, concepts for working
044555 - intelligently, ref OF 3 6221, including Communication Metrtics.
044556 - ref OF 6 685K
044558 - ..
044559 - Pastaveia looked up welchco.com on the Internet and sent an email to
044560 - provide contact for follow up...
044564 - ..
044565 - Thanked Pastaveia for supporting the angiogram test. Will try to
044566 - follow up tomorrow after returning home following the test.
044567 -
044568 - [On 091130 2007 follow up delayed due to complications of
044569 - quadruple heart bypass surgery on 091022. ref SDS 11 PB5I
044571 - ..
044572 - Rene disconnected the IV. The needle will remain overnight so it
044573 - does not have to be done again.
044574 -
044575 - [On 091021 angiogram test positive; heart bypass surgery
044576 - scheduled for 091022. ref SDS 8 7L43
044577 -
044578 - [On 091022 0700 quadruple heart bypass surgery performed by
044579 - Doctor Tseng, and her team; took about 8 hours. ref SDS 10 01F9
044581 - ..
044582 - Rene and Jacki assembled belongings, including the computer, and
044583 - wheeled the gurney from Pre-op ASU into Post-op ASU to wait for a room
044584 - to stay the night.
044586 - ..
044587 - Rene met with Carol and explained the work plan for Welch to stay
044588 - overnight in the hospital.
044589 -
044590 -
044592 - ..
0446 -
0447 -
0448 - 1644
0449 -
044901 - Carol introduced herself.
044902 -
044903 - She will call Evelyn on progress arranging for a room in the
044904 - hospital.
044905 -
044907 - ..
0450 -
0451 -
0452 - 1652
0453 -
045301 - Carol asked about ordering dinner. She thinks it might be another
045302 - hour before a room is available, and then it could take another hour
045303 - after that to get a meal. She suggests ordering dinner now.
045305 - ..
045306 - She does not know the menu.
045307 -
045309 - ..
0454 -
0455 -
0456 - 1705
0457 -
045701 - Millie called. Filled her in on the work plan.
045702 -
045704 - ..
0458 -
0459 -
0460 - 1729
0461 -
046101 - Carol reports a room has been assigned. There is more administrative
046102 - work to file reports required for getting into the room. Carol is
046103 - having problems explaining there is no medical record in this case,
046104 - because no work was actually done today.
046106 - ..
046107 - Carol asked for the color of the IV needle. Looks like pink.
046108 -
046110 - ..
0462 -
0463 -
0464 - 1748
0465 -
046501 - Michale and Carol moved patient from Post-op ASU into a hospital
046502 - room.
046504 - ..
046505 - Dinner showed up in the Pre-op ASU. Carol took the dinner tray, and
046506 - Michael wheeled the patient in a wheelchair.
046508 - ..
046509 - Met Ed the orderly, and the nurse.
046511 - ..
046512 - Got the computer set up.
046514 - ..
046515 - Vitals were taken for record purposes only since the patient has no
046516 - actual treatable condition at this time.
046517 -
046518 -
046520 - ..
0466 -
0467 -
0468 - 1835
0469 -
046901 - Nurse brought another dinner tray. Same menu, ravioli.
046902 -
046904 - ..
0470 -
0471 -
0472 - 2310
0473 -
047301 - Doctor Gene R. Quinn, MD MS, visited.
047302 -
047303 - He is a doctor in training with UCSF and working at the VA.
047305 - ..
047306 - Reviewed medical history of current problem, reported on 091002 0900.
047307 - ref SDS 3 1W5I, citing the record meeting with Doctor Lee at the VA in
047308 - Martinez on scheduling a procedure to resolve achalasia, reported on
047309 - 090908 1130, ref SDS 2 MY4N, and further and cited in the letter to
047310 - Karen on 091007 0021. ref SDS 5 VM4V
047312 - ..
047313 - The doctor asked about prior stent procedures, and was told that this
047314 - will be the first one, if necessary, per discussion with Doctor
047315 - Hoffman, last night, shown on 091019 1300. ref SDS 7 CW6G
047317 - ..
047318 - This question on prior angiogram/stent procedures, aligns with
047319 - experience this morning overhearing nurses welcoming back prior
047320 - patients for follow up work, per above. ref SDS 0 U59M
047322 - ..
047323 - Gene has not worked with Doctor Rugo, but seemed to indicate having
047324 - worked with Doctor Hsu in Radiation Oncology at UCSF.
047326 - ..
047327 - Reviewed advantages of a well ordered record, explained in POIMS,
047328 - ref OF 3 ZC6N, and in NWO. ref OF 12 Q07K
047329 -
047330 -
047332 - ..
0474 -
0475 -
0476 - 0026
0477 -
047701 - Julie Ishida, MD visited and made another review, exactly as performed
047702 - by Doctor Quinn. ref SDS 0 PS5U
047704 - ..
047705 - Julie explained that she supervises Gene's work, and so she will work
047706 - with him on writing up the record on these meetings. She advised
047707 - there will be only one report for the two separate consultations.
047709 - ..
047710 - Explained medical history again for current problem, reported to
047711 - Doctor Egan at the Va in Martinez, on 091002 0900. ref SDS 3 1W5I,
047712 - citing the record meeting with Doctor Lee at the VA in Martinez on
047713 - scheduling a procedure to resolve achalasia, reported on 090908 1130,
047714 - ref SDS 2 MY4N, and further and cited in the letter to Karen on 091007
047715 - 0021. ref SDS 5 VM4V
047716 -
047717 -
047718 -
047719 -
047720 -
047721 -
047722 -
0478 -
Distribution. . . . See "CONTACTS"