CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 13 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040507 -
040509 - ..
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 6 1W5I
040910 - ..
040911 - On 091006 0843 Karen called and scheduled angiogram test on 091020 at
040912 - the VA in San Francisco. ref SDS 7 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 7 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 8 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 9 A68H
040929 - ..
040930 - 091019 1300 meeting at VA in Cardiology for blood test to prepare for
040931 - angiogram test tomorrow, ref SDS 10 X59F, per Karen's letter on 091007
040932 - 0818. ref SDS 9 A68H
040934 - ..
040935 - 091020 0700 meeting at VA in San Francisco for angiogram test delayed,
040936 - ref SDS 11 01F9, explained in the record on 091019 1300. ref SDS 10 VH6Q
040938 - ..
040939 - 091021 0716 Meeting at VA to complete angiogram test orientation
040940 - meeting, ref SDS 12 01F9, and perform test.
040942 - ..
040943 - On 091022 0700 Doctor Seng, KC and others performed the surgery.
040944 - ref SDS 13 01F9
040946 - ..
040947 - On 091029 0700 meetings with team to develop solutions to achalasia
040948 - swallowing problem which impacts recovery from heart surgery.
040949 - ref SDS 0 RE4O
040950 -
040951 -
040953 - ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Have been hiking 10 laps 3 - 6 times per day, and at all hours, e.g.,
041302 - 2300, 0200, 0500, 1100, 1500, and fitted between meals, meetings,
041303 - calls, tests, and rest throughout the day.
041305 - ..
041306 - Ten (10) laps around the perimeter of the TCU ward is about a mile.
041307 - Calculated the distance from counting 400 steps per lap, and assume
041308 - about 1.5 feet per step.
041309 -
041310 - 1.5 x 400 x 10 = 6000 and a mile is 5,280 feet
041312 - ..
041313 - There is actually variability in the number of steps, since hiking
041314 - fast and slow yield different lengths per step. Depending on level of
041315 - activity, may do less than 10 laps, say 3, 5, 8, and can loose count
041316 - of the number of laps, so level of activity is only an estimate.
041318 - ..
041319 - Generally averaging 3 - 4 miles per day, and this has been increasing.
041320 - Hope to reach 6 miles per day.
041322 - ..
041323 - Hiking is prescribed therapy to strengthen the heart and circulatory
041324 - system to recover from cardiothoracic surgery on 091022. It also
041325 - helps dissipate pain and ill feeling from surgery that occurs
041326 - throughout the day, reducing reliance on medications.
041327 -
041328 - [On 091219 0600 doctors prescribed hiking to recover from
041329 - Heller Myotomy surgery resolving achalasia. ref SDS 18 7Q6P
041331 - ..
041332 - Was tired of eating Ensure today. This has become nauseating since
041333 - implementing Helen's recommendations proposed in the Nutrition
041334 - Department 2 days ago on Tuesday, 091027. When Helen calculated 7
041335 - cans of Ensure per day will provide equal or better nutrition than
041336 - using a feeding tube procedure, seemed like that would be an easy
041337 - solution. Now just the thought of Ensure makes me gag.
041339 - ..
041340 - So skipped it, since planning to get released today or tomorrow and
041341 - can eat normal food again.
041342 -
041343 -
041345 - ..
0414 -
0415 -
0416 - 1116
0417 -
041701 - Met with the primary surgical team, except for Doctor Tseng.
041702 -
041703 - Doctor Ratcliffe explained concern about sending patient home with
041704 - eating disorder caused by achalasia. Neil said the labs indicate
041705 - anemia, especially albumin and pre-albumin are improving.
041707 - ..
041708 - Joe indicated the numbers on nutrition from the blood test today have
041709 - improved since yesterday, but not enough for the CT team to feel
041710 - confident that the patient will get enough nurishment for the heart
041711 - surgery to heal, and allow the achalasia problem to be corrected some
041712 - weeks in the future.
041713 -
041714 - [On 091030 0810 medical team proposes feeding tube to solve
041715 - dilemma of low nutrition preventing recovery from heart surgery
041716 - due to achalasia problem. ref SDS 14 8J5J
041718 - ..
041719 - Doctor Ratcliffe reported discussions with the GI Department, and with
041720 - Doctor Stewart, Chief of General Surgery on resolving achalasia so
041721 - normal eating and digestion can occur. He emphasized that nutrution
041722 - is critical for patients to recover from heart surgery. Doctor
041723 - Ratcliffe asked if anyone has discussed the date and method for
041724 - solving achalasia? The doctor is concerned that without a date
041725 - certain for treating achalasia, the patient will turn anemic and this
041726 - will prevent proper healing of heart bypass surgery that was performed
041727 - a week ago on 091022 0700, ref SDS 13 PQWU, and moreover delays
041728 - recoverying from heart surgery will further delay surgery to fix
041729 - achalasia. This is a negative debilitating loop.
041731 - ..
041732 - Presents classic knowledge management dilemma.
041733 -
041734 - [On 091208 1300 everything lined up for Heller Myotomy surgery
041735 - on 091216 to recover from achalasia, and transform negative
041736 - synergy to make nutrition a postive factor recovery from heart
041737 - surgery. ref SDS 16 C65G
041739 - ..
041740 - Cited meetings with the GI Department in ICU this past Monday or
041741 - Tuesday. At that time, Sachin planned to submit a letter presenting
041742 - updated work plan for solving achalasia with pneumatic dilation.
041743 -
041744 - [On 091030 0810 at 1340 Sachin delivered documentation
041745 - published by the VA GI Department on procedures to treat
041746 - achalasia. ref SDS 14 0345
041748 - ..
041749 - [On 091030 0810 at 1406 meeting with Doctor Stewart on surgical
041750 - solution for achalasia. ref SDS 14 KE3B
041752 - ..
041753 - Doctor Ratcliffe noted that the CT surgery team favors a surgical
041754 - solution for achalasia, rather than pneumatic dilation performed by
041755 - the GI Depratment. The doctor explained that surgery to fix achalasia
041756 - cannot be done for 2 - 3 months after heart surgery, perhaps in late
041757 - December, January, or February depending on scheduling and rate of
041758 - patient recovery from heart surgery on 091022.
041759 -
041760 - [On 091103 Paula reports that the VA has scheduled surgery to
041761 - correct achalasia on 091217. ref SDS 15 PS60
041763 - ..
041764 - Asked to see the record on discussions between Cardio Thoricic Surgery
041765 - team, and the GI people, and with the General Surgery team, led by
041766 - Doctor Stewart?
041768 - ..
041769 - Doctor Ratcliffe said nothing has been written, because talking is
041770 - faster and easier than writing. He asked if writing things down is
041771 - better than conversation?
041773 - ..
041774 - Explained that writing and talking are complementary.
041776 - ..
041777 - Understanding and accuracy increase when discussion is written down,
041778 - and linked back to original sources, showing chronology of cause and
041779 - effect, explained in POIMS. ref OF 4 IE6L Maintaining a well ordered
041780 - record improves the quality and productivity of conversation,
041781 - explained in NWO, ref OF 9 0846, and further reviewed in POIMS.
041782 - ref OF 7 HW3O See as well explanation that "speech is a dominate
041783 - cultureal force. ref OF 7 5106 No one proposes replacing talking with
041784 - writing. Talking seems fast and easy, but causes endless mistakes.
041785 - Checking the record improves accuracy and enables comprehensive care,
041786 - and necessarily requires writing things down so there is something to
041787 - check.
041788 -
041789 - [On 091030 0810 cardiothoracic surgery team encounters example
041790 - demonstrating reliance on conversation can be complemented with
041791 - the doctor patient partnership to write things down in order to
041792 - improve accuracy understanding patient history that reduces
041793 - mistakes performing health care. ref SDS 14 V23J
041795 - ..
041796 - [On 091030 0810 cardiothoracic surgery team encounters example
041797 - of bumbling from reliance on conversation leading good people
041798 - down the wrong path, compared to "working intelligently" that
041799 - drives productivity with the power of knowledge. ref SDS 14
041800 - 0U7N
041802 - ..
041803 - [On 091219 0600 discuss joint study project funded by federal
041804 - grant to evaluate saving lives, time, and money with timely,
041805 - accurate communications. ref SDS 18 OD4L
041807 - ..
041808 - The team considered ramifications of low nutrition delaying recovery
041809 - from heart surgery.
041811 - ..
041812 - Doctor Ratcliffe was ademant that a partial solution is essential for
041813 - releasing the patient to go home, and while waiting to perform a
041814 - procedure to fix the achalasia problem, so that normal eating can
041815 - resume to maintain nutrition levels.
041817 - ..
041818 - Doctor Ratcliffe proposed again relying on a feeding tube for interim
041819 - solution that ensures sufficient nutrition for recovery from heart
041820 - surgery, which is a predicate to treating achalasia that will then
041821 - permit normal eating to maintain nutrition. Feeding tube was
041822 - initially considered on Tuesday, 091027. At that time, Hellen the
041823 - Chief of the Nutrition Department calculated that 7 cans of Ensure per
041824 - day is equivalent to nutrition from feeding tube procedures.
041825 -
041826 - [On 091030 0810 medical team proposes feeding tube to solve
041827 - dilemma of low nutrition preventing recovery from heart surgery
041828 - due to achalasia problem. ref SDS 14 8J5J
041830 - ..
041831 - [On 091214 1100 lab shows albumin 4.2, increased well above 3.6
041832 - nutrition target criteria set by CT Surgery Team on 091030,
041833 - ref SDS 14 MU5N, and was achieved without reliance on feeding
041834 - tube, and by drinking 6 cans of Ensure per day, and minimal
041835 - normal food digestion, pending resolution of achalasia.
041836 - ref SDS 17 GI65
041838 - ..
041839 - Doctor Ratcliffe recalled discussion with Doctor Stewart in Genearl
041840 - Surgery presented questions about patient history getting a manometry
041841 - test to establish criteria for surgery to resolve achalasia.
041843 - ..
041844 - Explained patient history on 060330 showing the VA in Sacramento
041845 - performed a manometry test that found criteria for diagnosis of
041846 - achalasia. The test was ordered and performed by Doctor Lee from VA
041847 - Clinic in Martinez, ref SDS 3 MC7P At that same time on 060330, the
041848 - doctor also performed an endoscopy test that found no evidence of
041849 - cancer, ref SDS 3 VX4G This result confirmed initial endoscopy test
041850 - performed by Doctor Lee at the VA in Martinez, reported on 051209
041851 - 1130. ref SDS 2 B150
041853 - ..
041854 - Doctor Ratcliffe advised that the CT surgery team and Doctor Stewart
041855 - in the General Surgery Department cannot find records in the VA
041856 - computer system of prior manometry testing to establish achalasia. He
041857 - seemed to indicate this would require another manometry test, which
041858 - takes time and increases costs, and is a great discomfort to the
041859 - patient. "Why pay for the same real estate twice?"
041861 - ..
041862 - There was discussion of contacting Doctor Lee in the GI Clinic at the
041863 - VA facility in Martinez, for confirmation that manometry test he
041864 - performed on 060330 at the VA Medical Center in Sacramento verified
041865 - diagnosis of achalasia.
041867 - ..
041868 - Doctor Ratcliffe noted patient records showing manometry test on
041869 - 060330, 060330 0712, ref SDS 3 MC7P, appear comprehensive. He noted
041870 - that simply because the VA somehow misplaced the medical record, is
041871 - not sufficient to cause the patient significant discomfort undergoing
041872 - another test, when there is a clear record the test occurred and
041873 - diagnosed achalasia. The team will collaborate further with Doctor
041874 - Stewart on scheduling surgical solution to achalasia, and in order to
041875 - ensure nutrition needed to recovery from heart surgery.
041876 -
041877 - [On 091030 0810 Doctor Ratcliffe asked again about the record
041878 - on pre-op endoscopy and manometry testing as a condition to
041879 - treating achalasia. ref SDS 14 TZ4N
041881 - ..
041882 - [On 091030 0810 at 1406 meeting with Doctor Stewart on surgical
041883 - solution for achalasia. ref SDS 14 KE3B
041884 -
041885 -
041886 -
041887 -
041888 -
041889 -
041890 -
041891 -
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0419 -