CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 19 0000. ref SDS 18 0000.
040502 -
040503 -
040504 - [On 091106 1000 book crediting VA for best medical quality
040505 - care, ref SDS 25 I15I, aligns with this record today
040506 - showing comprehensive, effective collaboration and
040507 - coordination among VA medical doctors and nurses enabled
040508 - through doctor/patient partnership. ref SDS 0 01F9
040509 -
040510 -
040511 -
040512 -
040514 - ..
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 12 1W5I
040910 - ..
040911 - On 091006 0843 Karen called and scheduled angiogram test on 091020 at
040912 - the VA in San Francisco. ref SDS 13 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 13 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 14 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 15 A68H
040929 - ..
040930 - 091019 1300 meeting at VA in Cardiology for blood test to prepare for
040931 - angiogram test tomorrow, ref SDS 16 X59F, per Karen's letter on 091007
040932 - 0818. ref SDS 15 A68H
040934 - ..
040935 - 091020 0700 meeting at VA in San Francisco for angiogram test delayed,
040936 - ref SDS 17 01F9, explained in the record on 091019 1300. ref SDS 16 VH6Q
040938 - ..
040939 - 091021 0716 Meeting at VA to complete angiogram test orientation
040940 - meeting, ref SDS 18 01F9, and perform test.
040942 - ..
040943 - On 091022 0700 Doctor Seng, Casey and others performed the surgery.
040944 - ref SDS 19 01F9
040946 - ..
040947 - 091030 0810 meeting Joe, Casey, Paula, Neil to order release, and plan
040948 - follow up. ref SDS 0 01F9
040949 -
040950 -
040952 - ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Met with entire surgical team, except for Doctor Tseng. Doctor Mark
041302 - Ratcliff, Chief of surgery, joined the team.
041304 - ..
041305 - Neil indicated lab work is good.
041307 - ..
041308 - Neil will prepare discharge documents.
041310 - ..
041311 - Mark advised that the CT team has been "walkng around" meeting with
041312 - others at the hospital on solving the swallowing problem. They feel
041313 - inability to swallow food slows internal healing of heart surgery.
041314 - Mark said someone from the GI Clinic will stop by later today to
041315 - present their solution using medication and dilation procedures. The
041316 - team also also asked Doctor Stewart, Chief of General Surgery, to
041317 - propose a surgical solution.
041319 - ..
041320 - [...below on 091030 0810 at 1348 meeting with Doctor Sachin
041321 - Garg from GI Department explains dilation procedures for
041322 - fixing swallowing problem. ref SDS 0 0345
041324 - ..
041325 - [...below on 091030 0810 at 1406 meeting with Doctor
041326 - Stewart, Chief General Surgery, recommends Heller Myotomy
041327 - surgery that permenantly cuts open LESV to aid swallowing,
041328 - ref SDS 0 KE3B, and would construct a flap to prevent acid
041329 - from washing back into the esophagus. ref SDS 0 OY64
041331 - ..
041332 - [On 091106 1000 book crediting VA for best medical quality
041333 - care, ref SDS 25 I15I, aligns with this record today
041334 - showing comprehensive, effective collaboration and
041335 - coordination among VA medical doctors and nurses enabled
041336 - through doctor/patient partnership. ref SDS 0 01F9
041337 -
041338 -
041340 - ..
0414 -
0415 -
0416 - 1009
0417 -
041701 - Joe arrived to get a sonogram to evaluate a new problem in the neck.
041702 -
041703 - The Cardiothoracic Surgery team found in the CT test yesterday,
041704 - performed to check for fluid in the lungs, and evaluate the achalasia
041705 - problem, a possible blood clot in the neck (called DVT, per below,
041706 - ref SDS 0 NX3N), where the Cordis catheter was placed by Doctor
041707 - Brzezinski on 091022 for the heart bypass surgery. ref SDS 19 PQWU
041708 -
041709 - [...below, sonogram test seems to show clot attached to the
041710 - vein. ref SDS 0 1N5P
041712 - ..
041713 - [...below, KC advises that DVT has been confirmed and will
041714 - require treatment with Levonox to increase INR, and with
041715 - Coumadin for 6 weeks to resolve the problem. ref SDS 0 KF5W
041717 - ..
041718 - [On 091208 1300 follow up sonogram finds no evidence of DVT nor
041719 - blood clotting of any kind in location discovered today; Doctor
041720 - Stewart orders treatments with Coumadin to end, which is needed
041721 - for surgery on 091216, but with findings today, Coumadin need
041722 - not be resumed after surgery. ref SDS 26 D24G
041724 - ..
041725 - Joe pushed the patient in a wheelchair to the Radiology Department.
041727 - ..
041728 - Joe discussed the schedule with Irene. She explained it is Friday, so
041729 - eveything is backed up with a sudden surge of patients requiring
041730 - sonogram studies to perform.
041732 - ..
041733 - Joe pulled the wheelchair to a patient waiting area. Joe advised
041734 - that he has to attend a meeting. He said that after the Radiology
041735 - test is completed, ask the nurse to call his pager at Cardiac Thoracic
041736 - Surgery. Joe will return and take the patient back to Telemetry.
041737 -
041738 -
041740 - ..
0418 -
0419 -
0420 - 1029
0421 -
042101 - After waiting about 20 minutes, a nurse came from the Radiology
042102 - Patient Waiting and Admin area. She said that Irene in Sonogram test
042103 - department told her to return patient to Telemetry, and that the
042104 - Radiology Department will come and get the patient for sonogram test
042105 - afer the backlog is resolved.
042107 - ..
042108 - Was wheeled back to Telemetry.
042109 -
042110 -
042112 - ..
0422 -
0423 -
0424 - 1228
0425 -
042501 - Nurse comes and wheels patient from Telemetry to Radiology Department for
042502 - Sonogram test.
042503 -
042505 - ..
0426 -
0427 -
0428 - 1310
0429 -
042901 - Irene did the sonogram test. She recalled doing initial sonogram to
042902 - prepare for CABG surgery a week ago on 091021 0716. ref SDS 18 04CH
042904 - ..
042905 - The test today confirmed initial findings reported this morning that a
042906 - small blood clot (called Deep Vein Thrombosis - DVT, per above,
042907 - ref SDS 0 1N6L), has formed in the right side of the neck where the
042908 - Cordis IV catheter was placed a week ago on Thursday during heart
042909 - by-pass surgery, reported on 091022 0700, ref SDS 19 PQWU, and which
042910 - was removed this past Tuesday, 091027, as a predicate to release from
042911 - ICU.
042913 - ..
042914 - [...below reported prelim results to Joe. ref SDS 0 03GF
042916 - ..
042917 - [...below, KC advises that DVT has been confirmed and will
042918 - require treatment with Levonox to increase INR, and with
042919 - Coumadin for 6 weeks to resolve the problem. ref SDS 0 KF5W
042921 - ..
042922 - [On 091208 1300 follow up sonogram finds no evidence of DVT nor
042923 - blood clotting of any kind in location discovered today; Doctor
042924 - Stewart orders treatments with Coumadin to end, which is needed
042925 - for Heller Myotomy surgery to resolve achalasia swallowing
042926 - problems, scheduled on 091216, but with findings 091208,
042927 - Coumadin need not be resumed after surgery. ref SDS 26 D24G
042928 -
042929 -
042931 - ..
0430 -
0431 -
0432 - 1320
0433 -
043301 - Wheeled back to Telemetry from Radiology by a support staff person.
043302 -
043303 - Called Millie and explained plan for coming home later today.
043304 -
043305 - [...below, plans for discharge delayed until at least Monday
043306 - due to test findings DVT, per below. ref SDS 0 KF5W
043307 -
043308 -
043310 - ..
0434 -
0435 -
0436 - 1348
0437 -
043701 - Doctor Sachin Garg arrives from GI Department, scheduled earlier this
043702 - morning by Doctor Ratcliffe, per above. ref SDS 0 0Q4H
043704 - ..
043705 - Sachin submits document explaining treatments for achalasia,
043706 - previously discussed with the Chief of GI, and her team last week.
043708 - ..
043709 - Sachin apologized for delay submitting the letter he planned on
043710 - Tuesday to present the work plan proposed by the GI team for solving
043711 - achalasia. He explained that his boss wants to get more information
043712 - before submitting a proposal.
043714 - ..
043715 - Sachin said to read through the documentation to prepare for meeting
043716 - later today with GI, the General Surgeon, and the CT team for
043717 - coordinating a solution.
043718 -
043719 - [On 091104 0718 at 1613 met with Sachin again, and he
043720 - advised that the GI team has signed-off on Heller Myotomy
043721 - surger as the best solution for achalasia in this case.
043722 - ref SDS 24 044F
043723 -
043724 -
043726 - ..
0438 -
0439 -
0440 - 1406
0441 -
044101 - Doctor Lygia Stewart arrives, Chief of General Sugery, implementing
044102 - Doctor Ratcliffee's planning earlier this morning, per above.
044103 - ref SDS 0 0Q4H
044105 - ..
044106 - Doctor Stewart can be reached at...
044107 -
044108 - 415 750 6922
044110 - ..
044111 - Doctor Stewart reported review of records of the barium swallow test
044112 - on 050714, performed at the VA in Martinez, ref SDS 4 2I4S, and which
044113 - showed expanded esophagus just above the lower esophageal sphincter
044114 - (LES) valve. ref SDS 4 Q869 This condition is presented in the VA
044115 - radiology report received on 050830 1000. ref SDS 5 6G7I
044117 - ..
044118 - Today, Doctor Stewart described VA findings from the swallowing test
044119 - on 050714 as the classic symptom of achalasia, that retains food in
044120 - the esophagus, thus impacting nutrition.
044122 - ..
044123 - The doctor asked for patient history on resolving achalasia?
044125 - ..
044126 - Patient history on swallowing disorder called "achalasia" is shown in
044127 - the record meeting with Doctor Lee at the VA in Martinez on 090908
044128 - 1130. ref SDS 11 FT6M This record has been presented to 12 doctors at
044129 - the VA during the past several weeks, beginning on 091002, as shown in
044130 - the record on 091021 0716. ref SDS 18 LJ7L Referred the doctor to the
044131 - medical chart on those meetings.
044133 - ..
044134 - Doctor Stewart requested another verbal explanation, because finding
044135 - relevant patient history in the medical chart takes a lot of time
044136 - using the VA computer system.
044138 - ..
044139 - Explained the record again on 090908 1130, ref SDS 11 FT6M, reviewed
044140 - with Doctor Lee during a meeting at the VA in Martinez planning
044141 - pneumatic dilation procedure to resolve achalasia, reported on 090908
044142 - 1130, ref SDS 11 MY4N
044143 -
044144 - [On 091208 1300 Doctor Tabrizi requested patient history on
044145 - achalasia again to prepare for meeting with Doctor Stewart who
044146 - was previously briefed today. ref SDS 26 QB7H
044148 - ..
044149 - Doctor Stewart says that pneunatic (balloon) dilation has fallen out
044150 - of favor for treating Achalasia. She related recent studies showing
044151 - surgery, called a "Heller Myotomy," is safer and lasts longer than
044152 - pneumatic dilation.
044154 - ..
044155 - Requested copies of studies for the record.
044157 - ..
044158 - The doctor commented that her department has published numerous
044159 - article, and that she has been included as the author on some of them.
044161 - ..
044162 - The doctor seems like a straight shooter, who is deeply focused on her
044163 - profession providing excellent care to improve quality of life for
044164 - patients.
044166 - ..
044167 - Doctor Stewart drew several diagrams showing the surgical process of
044168 - Heller Myotomy laproscopic surgery to repair the lower esophugul
044169 - sphincter (LES) by cutting away one side of the LES, so that the valve
044170 - cannot close, as it is now, thereby resolving achalasia...
044171 -
044172 - | |
044173 - | | Throat
044174 - | |
044175 - | |
044176 - | |
044177 - |||||||| <---- Lower esophageal sphincter valve (LESV)
044178 - ||||||||
044179 - / \
044180 - / -----\
044181 - | -\
044182 - | - Stomache
044183 - | |
044184 - / /
044185 - / --------- /
044186 - | /
044187 - \ \
044188 - \ -----------
044189 - ------------------
044191 - ..
044192 - Plan view Lower Esophageal Sphincter (LES) Valve
044193 -
044194 - -------\
044195 - /-----\ \
044196 - -------> / \ \
044197 - / / \ \
044198 - | | | |
044199 - | | | |
044200 - | \ / /
044201 - | \ / /
044202 - | \-----/ /
044203 - | -------/
044204 - |
044205 - +------------------------------------------+
044206 - |
044207 - |
044208 - Heller Myotomy surgery will cut away half of LES so that the esophagus
044209 - cannot close; this allows food to pass normally into the stomach. The
044210 - doctor seemed to say that the surgical procedure bloats the stomach
044211 - temporarily with benign gas to make room for laproscopic tools to
044212 - access the LES location...
044213 -
044214 - [On 091219 0600 pain bloating after surgery resolved with
044215 - medication and hiking. ref SDS 31 7Q6P
044217 - ..
044218 - [On 100810 1530 months after Heller Myotomy surgery to
044219 - correct achalasia, swallowing problems continue; Doctor Lee
044220 - at VA in Martinez explains understanding that surgery may
044221 - not have removed half of esophageal sphincter valve,
044222 - ref SDS 33 NF76, as understood today during meeting with
044223 - Doctor Stewart. ref SDS 0 GM5I
044225 - ..
044226 - [On 110429 1230 received hand drawn diagram from Doctor Lee
044227 - entered in the discharge documentation, and noting the
044228 - swallowing stricture still occurs at LESV, and furtrher
044229 - saying after 5 pneumatic dilations, LESV has been expanded
044230 - to the size of a "ring finger." ref SDS 36 DU6J
044232 - ..
044233 - [On 150623 1300 meeting with Doctor Stewart cites VA team
044234 - care for favorable results resolving achalasia swallowing
044235 - problems combining Heller Myotomy and Dor Fundoplication
044236 - surgery on 091216, with continuing EGD dilation procedures
044237 - performed by Doctor Lee, GI Clinic at VA Medical Center in
044238 - Sacramento. ref SDS 41 2M6G
044240 - ..
044241 - The problem to solve is how to replace the purpose of the esophageal
044242 - sphincter valve to prevent backflow of harmful stomach acid and
044243 - contents from washing back into the esophagus and mouth.
044245 - ..
044246 - Doctor Stewart drew another graph showing that a second step in the
044247 - operation is to construct a protective "flap" by folding over existing
044248 - stomach tissue. The doctor seemed to say this "flap" prevents
044249 - backflow from the stomach into the esophagus and up to the mouth.
044251 - ..
044252 - The doctor feels confident that approving this surgery will relieve
044253 - chronic swallowing problems the past 5 years.
044254 -
044255 - [On 100928 received VA medical records on Heller Myotomy
044256 - and fundoplication performed on 091216; consent for surgery
044257 - aligns with presentation today, that fundoplication
044258 - prevents acid from washing back into the esophagus.
044259 - ref SDS 34 B04R
044261 - ..
044262 - [On 121016 1302 Doctor Stewart ordered barrium swallow test
044263 - to evaluate prospects of follow up surgery to improve
044264 - swallowing and avoid continual pneumatic dilation
044265 - procedures, ref SDS 37 FN4G, as shown in patient history
044266 - listed on 121016. ref SDS 37 XS62
044268 - ..
044269 - [On 121016 1302 Doctor Stewart explained she constructed a
044270 - "wrap" and not a "flap" to prevent backflow from the
044271 - stomach into the esophagus. ref SDS 37 LZ4N
044273 - ..
044274 - [On 121113 1100 meeting with Doctor Stewart advised that
044275 - barrium swallow test shows improved condition of esophagus
044276 - and that nothing further can be performed surgically to
044277 - resolved failed "wrap" to prevent backflow from the stomach
044278 - into the esophagus when laying on left side. ref SDS 38
044279 - EI9M
044281 - ..
044282 - [On 150319 0800 meeting with Doctor Lee indicated acid
044283 - reflux increased causing ulceration and constriction to
044284 - LESV that hampers swallowing, because fundoplication has
044285 - unraveled, ref SDS 40 N535; remedy - referral to Doctor
044286 - Stewart to assess re-fundoplication or other measures.
044287 - ref SDS 40 JQ5J
044289 - ..
044290 - [On 150623 1300 meeting with Doctor Stewart cites VA team
044291 - care for favorable results resolving achalasia swallowing
044292 - problems combining Heller Myotomy and Dor Fundoplication
044293 - surgery on 091216, with continuing EGD dilation procedures
044294 - performed by Doctor Lee, GI Clinic at VA Medical Center in
044295 - Sacramento. ref SDS 41 2M6G
044297 - ..
044298 - Since continual delays have prevented performing pneumatic dilation,
044299 - approved go ahead for Heller Myotomy surgery. Asked Doctor Stewart to
044300 - submit a date scheduling work to recover from achalasia, which has
044301 - proven ellusive the past 5 years, noted by Doctor Lee on 090908 1130.
044302 - ref SDS 11 HX4H Would like to have work scheduled before discharge to
044303 - go home planned for next Monday or Tuesday.
044304 -
044305 - [On 100305 1000 endoscopy test identifies "acid burn" evident
044306 - on only the "flap" tissue, ref SDS 32 PR6P; indicates "flap"
044307 - accomplishing design goals for Heller Myotomy surgery,
044308 - ref SDS 32 B65F; requested that the VA in Martinez notify
044309 - Doctor Stewart at the VA Medical Center in San Francisco that
044310 - the "flap" created during Heller Myotomy surger to resolve
044311 - achalasia shows "acid burn" during endoscopy test, ref SDS 32
044312 - HB4K; Doctor Lee advised that the VA relies on referral doctors
044313 - using proactive case management to discover possible problems
044314 - related to their work by reviewing the computer system.
044316 - ..
044317 - [On 1000305 1000 endoscopy test findings do not list "acid
044318 - burn," ref SDS 32 Y65V, and photographs cited as evidence are
044319 - not included in the record. ref SDS 32 XI5O
044321 - ..
044322 - [On 100305 1000 VA Progress Notes report findings from
044323 - ednoscopy describing "Fundalplication; Esophagitis"; research
044324 - indicates this scope was accomplished with "flap" surgically
044325 - constructed during Heller Myotomy procedure. ref SDS 32 Y65V
044327 - ..
044328 - [On 101210 0930 photographs taken during 3rd EGD continue to
044329 - indicate esophabus, including flap constructed during Heller
044330 - Myotomy surgery appear health without signs of disease.
044331 - ref SDS 35 BF6M
044333 - ..
044334 - Doctor Stewart will talk to Doctor Tseng about the earliest date the
044335 - next surgery can be performed after recovering from CABG. She cited a
044336 - good relationship that will expedite communicaiton toward a mutually
044337 - agreeable solution. Sounded like this can be done in late December.
044339 - ..
044340 - Doctor Stewart seemed to discuss scheduling a meeting next week or the
044341 - week after for follow up review and to schedule surgery.
044342 -
044343 - [On 091102 0642 Paula advises that CT surgery team is working
044344 - to provide, at the time of discharge from the hospital for the
044345 - current CABG surgery, a date scheduling Heller Myotomy surgery
044346 - to recover from achalasia. ref SDS 22 RD8O
044348 - ..
044349 - [On 091103 0347 at 1439 Paula reported that Doctor Stewart has
044350 - scheduled meeting on 091208 for pre-surgery consultation, and
044351 - that Heller Myotomy surgery is schedule the following week on
044352 - 091217. ref SDS 23 PS60
044354 - ..
044355 - [On 091216 Heller Myotomy surgery performed to recover from
044356 - achalasia. ref SDS 28 KE9U
044358 - ..
044359 - [On 091217 0600 report surgery successful for recovering from
044360 - achalasia; there was a slight complication of a small tear in
044361 - the esophagus, which was repaired during the surgery procedure;
044362 - so patient is NPO, can have nothing by mouth to eat or drink.
044363 - The repair will be tested the next day on 091218, ref SDS 29
044364 - 0042; Doctor Stewart indicates that if the test is favorable
044365 - can begin eating and go home. ref SDS 29 027A
044367 - ..
044368 - [On 091218 0541 xray study performed, ref SDS 30 PQ5Q; results
044369 - seem to show repair was effective, indicating successful Heller
044370 - Myotomy surgery to recover from achalasia. ref SDS 30 ES5H
044372 - ..
044373 - Doctor Stewart asked about history of endoscopy and manometry tests to
044374 - rule out throat cancer, and to verify criteria for achalasia
044375 - diagnosis. This follows up discussions with the CT surgery team
044376 - yesterday on 091029. ref SDS 20 CR6G
044378 - ..
044379 - Reviewed discussions yesterday citing prior tests at VA in Martinez on
044380 - 051209. ref SDS 6 B150 Another endoscopy was performed on 060330,
044381 - ref SDS 7 VX4G; and at that time a manometry test was also performed.
044382 - ref SDS 7 MC7P
044383 -
044384 - [On 091208 1300 Doctor Stewart could not recall discussions on
044385 - 091030 reporting patient history of pre-op testing with
044386 - endoscopy and manometry establish diagnosis of achalasia; the
044387 - surgery team could not find records of testing on the VA
044388 - computer system; Doctor Stewart approved Heller Myotomy surgery
044389 - to resolve achalasia, ref SDS 26 BJ3H, which aligns with Doctor
044390 - Ratcliffee's findings today. ref SDS 0 V16J
044392 - ..
044393 - Complete patient history of tests and plans for recovering from
044394 - achalasia is listed in the record on 090908 1130. ref SDS 11 FT6M
044395 - This has been considered 10 or so times the past few months, reported
044396 - in the meeting with Doctor Tseng on 091021 0716. ref SDS 18 LJ7L
044398 - ..
044399 - Doctor Stewart will review the VA's records on prior tests to develop
044400 - local patient history for performing Heller Myotomy surgery to correct
044401 - achalasia problem.
044402 -
044403 -
044404 -
044405 -
044407 - ..
0445 -
0446 -
0447 - 1430
0448 -
044801 - Reviewed paper on treating achalasia which was delivered by Sachin
044802 - earlier this afternoon, per above. ref SDS 0 0345
044804 - ..
044805 - The paper has same content submitted previously in 2006 by Doctor Lee
044806 - with the GI Department in Martinez.
044807 -
044808 - 1. Pill placed under the tongue, and 20 minutes later patient can
044809 - eat a normal meal and the lower esophugus sphincter valve will
044810 - have relaxed enough for normal swallowing to occur.
044811 - Only risk is that this method does not remain effective for
044812 - very long, i.e., maybe 6 months, or less in some cases.
044814 - ..
044815 - 2. Penumatic dilation.
044816 -
044817 - Least invasive, and most direct and long lasting solution,
044818 - generally preferred for most patients.
044820 - ..
044821 - 3. Heller myotomy surgery effective, but has risks of invasive
044822 - surgery.
044824 - ..
044825 - 4. Botox injection to the LES, similar short term solution as the
044826 - pill, per above. ref SDS 0 495I
044827 -
044828 -
044829 -
044831 - ..
0449 -
0450 -
0451 - 1440
0452 -
045201 - Meeting with Mark Ratcliffee, MD, Chief of Surgery, and with Neil, KC,
045202 - and Paula, doctors on the cardio thoracic (CT) surgery team at the VA
045203 - in San Francisco. This follows up the meeting yesterday on 091029
045204 - 0700. ref SDS 20 RE6J
045206 - ..
045207 - Paula asked if the sonogram ordered for the neck has been done?
045209 - ..
045210 - Advised that Irene in the Radiology Department did the test late this
045211 - morning, and found a small blood clot (DVT), where the cordis catheter
045212 - was placed in the neck for heart surgery on 091022, per above.
045213 - ref SDS 0 1N5P
045215 - ..
045216 - Paula will look at results of the sonogram and consult with colleagues
045217 - on next steps needed.
045218 -
045219 - [...below, KC advises that DVT has been confirmed and will
045220 - require treatment with Levonox to increase INR, and with
045221 - Coumadin for 6 weeks to resolve the problem. ref SDS 0 KF5W
045223 - ..
045224 - Doctor Ratcliffe reported continuing discussions with Doctor Stewart
045225 - in General Surgery on resolving achalasia as soon as possible, so that
045226 - patient nutrition will support recovery from heart surgery performed
045227 - on 091022.
045229 - ..
045230 - Advised of having met about an hour ago, first with Sachin, briefly,
045231 - to get documentation from the GI Department, per above, ref SDS 0
045232 - 0345, and then with Doctor Stewart about 20 minutes later who
045233 - explained surgical procedure called a Heller Myotomy for treating
045234 - achalasia. ref SDS 0 P69G Showed the team the diagram that Doctor
045235 - Stewart prepared illustrating the scope of Heller Myotomy, per above.
045236 - ref SDS 0 GM5I
045238 - ..
045239 - Doctor Ratcliffe asked if Doctor Stewart discussed scope of pre-op
045240 - testing? He feels Doctor Stewart wants to first perform endoscopy and
045241 - manometry tests because nobody can find records on these tests in VA
045242 - computers.
045244 - ..
045245 - Explained discussions with Doctor Stewart relating background on
045246 - endoscopy and manometry tests already performed by the VA per above.
045247 - ref SDS 0 6H9J Doctor Stewart plans to search VA records again to
045248 - find patient history on these tests, as discussed with Doctor
045249 - Ratcliffee and the CT surgery team yesterday on 091029 0700.
045250 - ref SDS 20 CR6G
045252 - ..
045253 - Further noted patient history shows manometry testing is very
045254 - difficult to tolerate, reported on 060330 0712. ref SDS 7 MC6K As a
045255 - result, the patient should not suffer this onerous test again, since
045256 - the record is clear the test was performed and results support
045257 - diagnosis of achalalasia, noted by Doctor Lee at that time on 060330
045258 - 0712. ref SDS 7 MD4N
045260 - ..
045261 - Doctor Ratcliffe then advised the CT surgery team that he is now
045262 - satisfied patient records fully demonstrate pre-op endoscopy and
045263 - manometry tests have been performed, so that these pre-op requirements
045264 - need not be done again as a condition for resolving achalasia with
045265 - surgery.
045266 -
045267 - [On 091208 1300 Doctor Stewart could not recall discussions on
045268 - 091030 reporting patient history of pre-op testing with
045269 - endoscopy and manometry establish diagnosis of achalasia; the
045270 - surgery team could not find records of testing on the VA
045271 - computer system; Doctor Stewart approved Heller Myotomy surgery
045272 - to resolve achalasia, ref SDS 26 BJ3H, which aligns with Doctor
045273 - Ratcliffee's findings today. ref SDS 0 V16J
045275 - ..
045276 - [On 091214 1100 during a meeting at the VA for pre-op on Heller
045277 - Myotomy surgery to resolve achalasia, Isagani found Doctor
045278 - Lee's report on 090908 confirming diagnosis of achalasia based
045279 - on observing manometry test on 060330. ref SDS 27 TF58
045281 - ..
045282 - Relying on the record of patient history helps demonstrate benefits of
045283 - doctor patient partnership writing things down that complement
045284 - constant discussions, as reviewed yesterday with the team on 091029
045285 - 0700. ref SDS 20 RE81
045287 - ..
045288 - Doctor Ratcliffe is very ademant again this afternoon that the patient
045289 - in this case should use a feeding tube for the next several months to
045290 - increase nutrition for heart surgery to succeed, and for patient
045291 - health until the next surgery can be performed to correct achalasia in
045292 - December, January, or February, continuing the discussion yesterday,
045293 - reported on 091029 0700. ref SDS 20 RE6J
045295 - ..
045296 - The team discussed discharging the patient to a VA medical holding
045297 - facility in the Concord area, and which has skilled staff for using
045298 - the feeding tube to deliver nutrients. The staff can monitor
045299 - nutrition levels with daily or weekly labs, and adjust the diet to
045300 - meet requirements.
045302 - ..
045303 - KC explained that poor nutrition can cause dehiscence, which presents
045304 - risk of the heart surgery wound failing to heal properly, and in fact
045305 - opening up.
045307 - ..
045308 - Thanked the team for continued focus on quality care.
045310 - ..
045311 - Reviewed Sachi's documenation from GI Department an hour ago, listing
045312 - 2 short-term solutions, per above. ref SDS 0 495I
045314 - ..
045315 - Neil said the pill is a "beta breaker" which won't last very long.
045317 - ..
045318 - We reviewed Doctor Ratcliffee's requirements for a short-term solution,
045319 - until the Heller Myotomy surgical procedure can be performed after the
045320 - CT team signs off on the heart surgery recovery, as related by Doctor
045321 - Stewart during the meeting earlier today, per above. ref SDS 0 KE3B
045323 - ..
045324 - Neil said that the pill "beta blocker" would not be effective because
045325 - the patient has suffered from achalasia for a proloned period of 4 - 5
045326 - years.
045328 - ..
045329 - Yesterday, Doctor Ratcliffee noted that doctors use conversation to
045330 - make patient care fast and easy. At that time, the team also
045331 - considered reliance on the record to improve accuracy that reduces
045332 - medical mistakes, reported on 091029 0700. ref SDS 20 RE81 Can the
045333 - team find a better balance between incessant conversation that
045334 - devolves talent and hard work into continual bumbling, by instead
045335 - placing greater reliance on written records that convert information
045336 - into the power of knowledge that drives productivity?
045338 - ..
045339 - Handed Neil the document describing solutions for achalasia, and which
045340 - was submitted earlier today by Sachin, per above. ref SDS 0 0345
045342 - ..
045343 - Asked Neil to show the team in the VA's documentation on achalasia
045344 - where there is a limitation of effectiveness for a few weeks or
045345 - months, based on duration of condition? The team needs a short-term
045346 - solution, and the literature says the pill is a short-term remedy.
045348 - ..
045349 - Neil could not find any limitation in the documentation for either the
045350 - pill nor the Botox injection based on patient having suffered
045351 - achalasia for any length of time, per above. ref SDS 0 495I
045353 - ..
045354 - Doctor Ratcliffee objected to doing an experiment for 20 minutes to
045355 - see if the pill and/or Botox solutions would be as good or better than
045356 - the feeding tube, per above. ref SDS 0 T76G None of the CT team spoke
045357 - up to help reach a decision based on best evidence.
045359 - ..
045360 - Joe's report this morning that albumin blood count shows nutrition has
045361 - improved implementing Helen's recommendations proposed in the
045362 - Nutrition Department on Tuesday, 091027. At that time, Helen
045363 - calculated that drinking 7 cans of Ensure per day will provide equal
045364 - or better nutrition than using a feeding tube procedure. The lab
045365 - today, supports her calculations.
045366 -
045367 - [On 161117 1430 Jannel said Nutrition Department at VA
045368 - Medical Center in Sacramento only prescribes Ensure for
045369 - dietary supplement to help patients gain weight.
045370 - ref SDS 42 JW9H She explained VA Sacramento does not order
045371 - Ensure for liquid diet to to help recover from Achalasia,
045372 - as done previously at VA in San Francisco. ref SDS 42 VK4F
045374 - ..
045375 - Reviewed patient history that nutrition evaluated with blood counts
045376 - suffered at time of admittance to the VA on 091019, because eating was
045377 - stopped the day before in order to avoid vomitting during the
045378 - angiogram procedure, which requires laying flat on the surgery table.
045380 - ..
045381 - Subsequently, nutrition diagnostics further declined, because the VA
045382 - delayed the test a day due to emergency care for another patient on
045383 - 091020. ref SDS 17 XV54 Nutrition dropped again the next few days,
045384 - because the angiogram test on 091021, led to performing heart bypass
045385 - surgery on 091022, and the patient was not awake until the morning of
045386 - 091023. After surgery, could not eat regular food, until Hellen came
045387 - up with the Ensure solution on 091027. Typically, not eating for 4 or
045388 - 5 days drops nutrition blood counts.
045389 -
045390 - [...below, on 091030 0810 at 1621 see diagnostics on
045391 - pre-albumin and albumin showing steady decline in nutrition
045392 - from not eating in order to avoid interrupting medical
045393 - precedures, and until 091027, when Ensure was adopted to
045394 - restore nutrition, which then increased 500%. ref SDS 0
045395 - PRWU
045397 - ..
045398 - Since 091027 consuming Ensure, as prescribed by Hellen, the
045399 - nutritionist, should have increased nutrition, per above. ref SDS 0
045400 - 1O58
045402 - ..
045403 - Doctor Ratcliffee proposed checking blood counts tomorrow, to see if
045404 - albumin has recovered as Joe expected. He feels that if the blood
045405 - counts are still too low, the patient should get the feeding tube
045406 - solution to reach standard of care before leaving the hospital.
045408 - ..
045409 - Agreed to consider feeding tube, as a solution along with the pill,
045410 - botox, and drinking Ensure, if the lab for tomorrow does not show
045411 - improvement in Albumin, and pre-Albumin, as a result of taking Ensure
045412 - for dinner this evening.
045413 -
045414 - [...below CT team wants to proceed with feeding tube today
045415 - based on lab counts on nutrition for earlier this morning,
045416 - which were known to the team at the time of proposing doing
045417 - another blood test tomorrow to evaluate trends. ref SDS 0 PRTX
045419 - ..
045420 - [On 091214 1100 lab shows albumin 4.2, increased well above 3.6
045421 - nutrition target criteria set by CT Surgery Team on 091030,
045422 - ref SDS 0 MU5N, and was achieved with 6 cans of Ensure per day,
045423 - and minimal normal food digestion, pending resolution of
045424 - achalasia. ref SDS 27 GI65
045426 - ..
045427 - Team left.
045429 - ..
045430 - The knowledge management dilemma is balancing quality of life against
045431 - avoiding every conceviable malady, which is impossible.
045432 -
045434 - ..
0455 -
0456 -
0457 - 1510
0458 -
045801 - Xray technician came to get progress on the lungs.
045802 -
045803 -
045805 - ..
0459 -
0460 -
0461 - 1522
0462 -
046201 - KC came in and said that Doctor Ratcliffee feels blood counts for
046202 - albumin in the test today are too low. He wants KC to install a
046203 - feeding tube discussed since Monday, and without waiting for testing
046204 - tomorrow to see if Ensure, and/or the pill will work, per planning in
046205 - the meeting earlier today, above. ref SDS 0 T84K
046207 - ..
046208 - During this discussion, KC replaced the wrap on the right leg that
046209 - "protects" the long surgical incision for heart surgery on 091022.
046210 - ref SDS 19 LO3G
046211 -
046212 - [On 091101 0910 Neil removed the ace bandage on the right
046213 - leg surgical incision. ref SDS 21 H37S
046215 - ..
046216 - [On 100928 0706 KC was 1st Assist on CT surgery team.
046217 - ref SDS 34 UPQP
046219 - ..
046220 - Neil came in during the meeting and confirmed that the team supports
046221 - Doctor Ratcliffee's analysis on what is needed to protect patient
046222 - health, despite evident conflict with the evidence.
046224 - ..
046225 - Advised of understanding this would be based on another blood draw
046226 - tomorrow, which has not yet been performed, per above. ref SDS 0 1O64
046228 - ..
046229 - KC said that Doctor Ratcliffee wants to rely on the blood test this
046230 - morning, before this issue was presented, rather than evaluate patient
046231 - nutrition trends based on another lab tomorrow, as discussed earlier
046232 - today. ref SDS 0 1O64 Obviously, everyone knew results for the lab
046233 - this morning at the time this issue was reviewed in the afternoon, per
046234 - above. ref SDS 0 1O64 Why the rush to judgement, since nutrition is a
046235 - long term issue?
046237 - ..
046238 - Asked what the lab this morning shows?
046240 - ..
046241 - KC related that there are 2 albumin elements of the blood test.
046242 -
046243 -
046244 - Lab Ref Range CT Team Range
046245 -
046246 - 1. Pre-albumin 18 45 20 45
046247 - 2. Albumin 3.3 5.2 3.6 5.2
046248 -
046250 - ..
046251 - KC advised that the lab on 091024 2 days after surgery shows
046252 - pre-albumin 11, which is well below the Lab Ref Range. This dropped
046253 - to pre-albumin 8 a few days later on 091026, and the next day on
046254 - 091027, pre-albumin dropped to 3. This record aligns with patient
046255 - history discussed earlier today with Doctor Ratcliffee, and the CT team,
046256 - explaining that eating was interrupted from 091019 to 091027, per
046257 - above. ref SDS 0 CV6O
046259 - ..
046260 - Today, pre-albumin 15, has increased 500%, since the test a few days
046261 - ago, and reflecting Hellen's work plan to use Ensure, reported on
046262 - 091027, per above. ref SDS 0 1O58
046264 - ..
046265 - KC said the CT team feels that a 500% increase in pre-albumin
046266 - nutrition diagnostic after just 3 days on Hellen's Ensure plan
046267 - demonstrates the patient will recover nutrition in another day or so.
046269 - ..
046270 - KC advised that the second nutrition test today shows albumin 3,2.
046271 - The team wants to see 3.6.
046272 -
046273 - [On 091214 1100 lab shows albumin 4.2, increased well above
046274 - 3.6 nutrition target criteria set by CT Surgery Team on
046275 - 091030, ref SDS 0 MU5N, and was achieved with 6 cans of
046276 - Ensure per day, and minimal normal food digestion, pending
046277 - resolution of achalasia. ref SDS 27 GI65
046279 - ..
046280 - There was discussion that these numbers show albumin is rising without
046281 - a feeding tube, and in the next day or so will meet requirements.
046283 - ..
046284 - KC and Neil explained that Doctor Ratcliffee wants the patient to be
046285 - released only after reaching nutrition standard of care for heart
046286 - surgery patients, and since those specific numbers have not yet been
046287 - reached, he wants to take immediate action to perform corrections,
046288 - interpretted as a feeding tube procedure, rather than allow time for
046289 - Hellen's Ensure plan to reach full effect in the next day or so.
046291 - ..
046292 - Neil said the patient can refuse to approve the procedure, which
046293 - aligns with "Patient Bill of Rights" listed on the wall about 20 feet
046294 - down the hall.
046296 - ..
046297 - Neil further said, the patient can remove the feeding tube at any
046298 - time, if the situation becomes intolerable.
046300 - ..
046301 - KC said that adding the feeding tube will extend time in the hospital
046302 - until at least Monday.
046304 - ..
046305 - KC and Neil explained that Doctor Ratcliffee really wants to use the
046306 - feeding tube, rather than test the other solutions, as discussed and
046307 - agreed during the meeting earlier today, per above. ref SDS 0 G49H
046308 -
046309 - [On 091101 0800 feeding tube ordered removed by Doctor
046310 - Nguyen. ref SDS 21 EX5C
046312 - ..
046313 - [On 091102 0642 Joe reports that Doctor Tseng is
046314 - disappointed about order to remove the feeding tube, and
046315 - she prescribes replacing the feeding tube again as a
046316 - condition for discharging the patient. ref SDS 22 WC77
046318 - ..
046319 - [On 091103 0347 Neil advised CT Surgery Team discussed
046320 - replacing feeding tube; this is patient's call based on
046321 - history since 2005 adapting to achalasia and maintaining
046322 - sufficient nutrition for lifestyle of vigorous exercise.
046323 - ref SDS 23 U66G
046325 - ..
046326 - [On 091214 1100 lab shows albumin 4.2, increased well above
046327 - 3.6 nutrition target criteria set by CT Surgery Team on
046328 - 091030, ref SDS 0 MU5N, and was achieved with 6 cans of
046329 - Ensure per day, and minimal normal food digestion, pending
046330 - resolution of achalasia. ref SDS 27 GI65
046332 - ..
046333 - Agreed to proceed with feeding tube in order to accomodate personal
046334 - feelings, despite lack of evidence. This will maintain good relations
046335 - with everyone on the team.
046337 - ..
046338 - We will monitor albumin. If Albumin shows continued improvement to
046339 - levels for standard of care, per above, ref SDS 0 7U52, then the
046340 - patient will remove the tube on Monday, subject to comments from the
046341 - team.
046343 - ..
046344 - KC explained that she can start the procedure immediately here in the
046345 - patient's room. She forces a tube through the nostrile to
046346 - approximately half way down the esophagus. The patient is then
046347 - wheeled on the gurney (and so need not get out of bed) to the Internal
046348 - Radiology (IR) Department on the 3rd floor. The medical team in IR
046349 - then extends the feeding tube through the lower esophogeal sphincter
046350 - valve into the stomach, and lower intestine, using internal cameras
046351 - that guide location.
046352 -
046354 - ..
0464 -
0465 -
0466 - 1613
0467 -
046701 - KC performed the initial procedure pushing a feeding tube through the
046702 - right nostril, down the throat into the esophugus. This was somewhat
046703 - uncomfortable, but went quickly, and was tolateted well, thanks to
046704 - KC's expertise.
046705 -
046710 -
046711 -
046713 - ..
0468 -
0469 -
0470 - 1638
0471 -
047101 - Attendant arrives for pushing the patient on the gurney to Nuclear
047102 - Medicine.
047104 - ..
047105 - KC says she will do this herself.
047107 - ..
047108 - KC then pushed the gurney down the hall to the elevator. Took
047109 - elevator to ground floor. She pushed the gurney down the hall to
047110 - Nuclear Medicine Department.
047111 -
047112 -
047114 - ..
0472 -
0473 -
0474 - 1643
0475 -
047501 - Meet Doctor Michale Olinger while on gurney waiting in the hallway.
047502 - KC placed her hand on my shoulder while the doctor provides initial
047503 - explanation of the procedure, which aligns with KC's orientation
047504 - earlier, per above. ref SDS 0 1P34
047506 - ..
047507 - Wheeled into the IR treatment room.
047509 - ..
047510 - Meet Don and Linda who move the patient from the gurney to the
047511 - operating table, and perform setup, like Dennis did for the angiogram
047512 - test on 091021 0716. ref SDS 18 025B
047514 - ..
047515 - Meet Doctor Rajar Sawhney, who led the team performing the work.
047517 - ..
047518 - This occurs without anesthetic.
047520 - ..
047521 - There was discussion the opration may take 20 minutes to 1.5 hours.
047523 - ..
047524 - Patient's goal was for the operation to fail in order to demonstrate
047525 - willingness to coperate with Doctor Ratcliffe's ideas in the matter.
047527 - ..
047528 - Doctor Sawhney explains a camera is run into the throat in order for
047529 - the doctor to see the precise location of the opening in the lower
047530 - esophugal sphincter valve where the feeder tube can pass into the
047531 - stomach.
047532 -
047534 - ..
047535 - Throat Cancer No Findings from Inspection During Procedure
047536 - Stomach Cancer No Findings from Inspection During Procedure
047537 -
047538 - The doctor indicated this camera can assist him to assess cancer,
047539 - which could have formed in the throat (esophagus), after many years
047540 - having achalasia, beginning about 2004.
047542 - ..
047543 - KC has moved to the control room where she observes the procedure
047544 - through glass windows.
047546 - ..
047547 - After the procedure was started, Doctor Sawhney advised there is no
047548 - evidence of throat cancer. He reported success moving the feeder
047549 - tube through the lower esophagul sphincter valve and into the stomach.
047550 - The doctor further commented finding no evidence of stomach cancer.
047551 - This supplements findings from Doctor Lee's examination at the VA in
047552 - Martinez on 051209, ref SDS 6 PRRT, when four (4) photographs were
047553 - taken and show no evidence of cancer. ref SDS 6 CZ6M
047555 - ..
047556 - Doctor Sawhney comments there seem to be some snags getting the feeder
047557 - tube from the stomach into the lower bowel. He discusses with doctor
047558 - Ohlinger possible work arounds.
047560 - ..
047561 - I offer a comment that failure will be welcome, as a joke.
047563 - ..
047564 - After about 20 mintues, Doctor Sawhney reports success positioning the
047565 - feeder tube. He further reports no findings of throat or stomach
047566 - cancer were evident from inspection during the procedure.
047567 -
047568 -
047569 -
047571 - ..
0476 -
0477 -
0478 - 1719
0479 -
047901 - KC pushed the gurney back to Telemetry.
047902 -
047903 - KC notices the Kitchen Department did not leave a meal.
047905 - ..
047906 - KC leaves to place order for intravenous feeding.
047908 - ..
047909 - Elizabeth leaves to the get the equipment.
047910 -
047912 - ..
0480 -
0481 -
0482 - 1723
0483 -
048301 - Elizabeth returns with intravenous feeding drip bag equipment ordered
048302 - by KC.
048304 - ..
048305 - Elizabeth says she configures intravenous feeding equipment a lot and
048306 - it is pretty tricky.
048308 - ..
048309 - There are several false starts configuring the feeding tube system.
048311 - ..
048312 - Elizabeth leaves.
048313 -
048315 - ..
0484 -
0485 -
0486 - 1722
0487 -
048701 - Intravenous feeding equipment begins beeping.
048702 -
048703 - Pat arrives and changes dials to get beeping to stop.
048704 -
048706 - ..
0488 -
0489 -
0490 - 1819
0491 -
049101 - KC returns.
049102 -
049103 - She has been reading Welchco.com on the Internet, and feels she has
049104 - been "twice around the world" opening links...
049106 - ..
049107 - http://www.welchco.com/
049109 - ..
049110 - KC seems to grasp objectives and practices for Communication Metrics,
049111 - as presented in POIMS and NWO. She feels the core idea using computer
049112 - technology to write down a greater share of daily work fits practices
049113 - at the VA and UCSF for doctors to write notes that explain their work,
049114 - including discussions with colleagues and customers (patients). The
049115 - Welch method adding links to original sources helps make analyis and
049116 - verification fast and easy to reduce mistakes, explained in the record
049117 - on 950721. ref SDS 1 1740 KC noted that merely having a lot of notes
049118 - can become a burden, especially if there isn't enough time to read
049119 - through everything in complex cases. When time is short, people miss
049120 - important details buried in a lot of text. Links enable people to
049121 - create trails in the record so that cause and effect are instantly
049122 - clear.
049124 - ..
049125 - Vannevar Bush explained this idea in his famous article "As We May
049126 - Think," published by Atlantic Monthly in July 1945, reported on 960304
049127 - 1904. ref SDS 2 L47F Bush forecast at the close of WWII, that
049128 - computers would one day enable people to construct trails of
049129 - associations in the record of daily work, and to cope more quickly and
049130 - accurately with rising complexity in the modern world. ref SDS 2 HE6L
049132 - ..
049133 - KC related that her husband is CEO and founder of a new software
049134 - development company. However, he is not working on using computers to
049135 - lift the capacity to think, remember, and communcate, called out in
049136 - NWO. She will ask him about these ideas.
049138 - ..
049139 - Explained how to read a well conected record without "traveling twice
049140 - around the world," explained in POIMS. ref OF 3 ZC6N
049142 - ..
049143 - KC feels more comfortable now about the various meetings with the
049144 - medical team the past few days that avoided mistakes by revealing gaps
049145 - in understanding from aligning communications with patient history,
049146 - illustrated by work earlier today on the feeding tube issue, per
049147 - above. ref SDS 0 03GF KC, also, recalled discussions with the team
049148 - yesterday when Doctor Ratcliffee asked if writing in SDS replaces
049149 - talking to customers and colleagues in the hallway, reported on 091029
049150 - 0700. ref SDS 20 RE81
049152 - ..
049153 - KC is leaving the VA/UCSF Cardiothoracic Surgery team today. She
049154 - starts a new assignment next week at a hospital in Oakland. KC will
049155 - try discussing her experience working with Welch using Communciation
049156 - Metrics to support the CT team, and will further try to send an email
049157 - on her assessment for advancing case management.
049158 -
049160 - ..
0492 -
0493 -
0494 - 1922
0495 -
049501 - KC left to perform assignment on call tonight for the Cardiothoracic
049502 - Surgery team.
049503 -
049505 - ..
0496 -
0497 -
0498 - 1941
0499 -
049901 - DVT - Deep Vein Thrombosis Blood Clot in Neck Due to Cordis Catheter
049902 -
049903 - KC returns.
049904 -
049905 - Reports the medical team has confirmed new problem in the Welch case,
049906 - initially indicated in the CT test yesterday, per discussion with Joe
049907 - this morning, ref SDS 0 1N6L, and confirmed by sonogram testing this
049908 - afternoon, per above. ref SDS 0 1N5P
049910 - ..
049911 - A blood clot has formed in right internal jugular vein caused by the
049912 - Cordis catheter placed by the team on 091022 0700. ref SDS 19 PQWU
049913 - The clot seems firmly attached, rather than free floating, which
049914 - presents the most dangerous condition that causes pulmonary embolism.
049916 - ..
049917 - KC explained blood clot problem discovered today is not PE, but rather
049918 - is called a DVT - deep vein thrombosis.
049920 - ..
049921 - Adding DVT (see explanation below, ref SDS 0 NX3N) to achalasia
049922 - compounds complexity and challenges recovering from heart surgery.
049923 -
049924 - [On 091102 0642 at 1559 Welch case further complicated by
049925 - diagnosis of asperation pneumonia based on CT test showing
049926 - evident fluid in the lungs, though patient has no symptoms of
049927 - pneumonia; team determines new diagnosis requires treatment
049928 - with antibiotics, and restoring feeding tube to prevent further
049929 - aspiration into the lungs; patient status changed to NPO
049930 - (nothing by mouth), which requires using feeding tube.
049931 - ref SDS 22 PB6Y
049933 - ..
049934 - [On 091208 1300 follow up sonogram finds no evidence of DVT nor
049935 - blood clotting of any kind in location discovered today; Doctor
049936 - Stewart orders treatments with Coumadin to end, which is needed
049937 - for surgery on 091216, but with findings today, Coumadin need
049938 - not be resumed after surgery. ref SDS 26 D24G
049940 - ..
049941 - PE was reviewed previously in Millie's case on 060722, ref SDS 8
049942 - BP7M, and further analyzed difficult problems doctors face
049943 - distinguishing death-threatening symptoms of PE from other less
049944 - serious maladies. ref SDS 8 346F
049946 - ..
049947 - The severity of this condition is considered to be mild, since the
049948 - clot is still attached to the inside wall of the vein.
049950 - ..
049951 - KC advised that this problem occurs with many patients, who get Cordis
049952 - catheters, including for heart procedures. Most DVTs are never
049953 - discovered, and disolve themselves in due course.
049955 - ..
049956 - Since this new malady was discovered inadvertently with the CT test
049957 - yesterday to evaluate severity and solutions for achalasia, the team
049958 - prescribes affirmative treatment for 6 weeks with Coumadin, as a
049959 - precaution to prevent PE.
049961 - ..
049962 - Initial treatment is with Lovenox (Enoxaparin) low molecular weight
049963 - Heperin, which is simply larger than the Heparin being given now.
049965 - ..
049966 - This raises a question of patient tolerance of daily treatments.
049967 -
049968 - [On 091104 0718 team confirms blood clot treatment is 6 weeks
049969 - of Coumadin with follow up at Coagulation Control Clinic at VA
049970 - in Martinez. ref SDS 24 F55I
049971 -
049972 - [On 091208 1300 follow up sonogram finds no evidence of DVT nor
049973 - blood clotting of any kind in location discovered today; Doctor
049974 - Stewart orders treatments with Coumadin to end, which is needed
049975 - for surgery on 091216, but with findings today, Coumadin need
049976 - not be resumed after surgery. ref SDS 26 D24G
049978 - ..
049979 - How long will Coumadin treatment occur?
049981 - ..
049982 - Treatments Levonox and Coumadin will be twice a day until INR reaches
049983 - between 2 - 3, expected to be less than two weeks, and then continue
049984 - to complete the 6 week protocol, ending OA 091212.
049985 -
049986 - [On 091103 1547 INR 2.5 reaches target level, so Levonox ends,
049987 - will not have to give self-administered shots. ref SDS 23 A239
049989 - ..
049990 - Will be self-administered.
049992 - ..
049993 - Can it be delivered by means other than direct injection in the event
049994 - of tolerance problems or difficulty doing self-injection?
049995 -
049997 - ..
0500 -
0501 -
0502 - 2005
0503 -
050301 - Will try experiment to test self-injection of Levonex to see how the
050302 - larger dose of Heprin can be tolerated.
050304 - ..
050305 - KC indicated that Lovenox is not a higher dose of Heprin.
050307 - ..
0504 -
0505 -
0506 - 2015
0507 -
050701 - KC went to order a meal to test eating through the mouth and throat,
050702 - concurrently with getting feeding tube nurishment.
050703 -
050704 -
050706 - ..
0508 -
0509 -
0510 - 2015
0511 -
051101 - Elizabeth has been replaced by the night nurse Pat.
051102 -
051103 - Pat says the medical team has ordered IV treatment with potassium,
051104 - because the lab this morning indicates low potassium.
051106 - ..
051107 - Pat starts potassium IV.
051109 - ..
051110 - This immediately causes pain, and the pain keeps getting worse.
051112 - ..
051113 - Pat explains that sometimes potassium given through an IV causes
051114 - severe pain.
051116 - ..
051117 - She decides to give the potassium through the feeder tube.
051119 - ..
051120 - Pat left to find KC for clarification of treatment.
051121 -
051122 -
051124 - ..
0512 -
0513 -
0514 - 2028
0515 -
051501 - KC returns.
051502 -
051503 - She explains that Levonex is a bigger dose of Heprin.
051505 - ..
051506 - Consider doing a test for the patient to self-inject Levenox (higher
051507 - dose of Heprin).
051509 - ..
051510 - KC explains that VA has a team that teaches self-injection. She is
051511 - not sure about the procedure.
051513 - ..
051514 - KC advises that the kitchen has closed. When dinner was delivered,
051515 - the patient was at the Neuclear Medicine (IR), Department getting the
051516 - feeding tube in position, so delivery did not leave a tray.
051518 - ..
051519 - KC leaves to order a meal, or maybe a tuna fish sandwich brought up to
051520 - test eating with the feeding tube configuration.
051521 -
051522 -
051524 - ..
0516 -
0517 -
0518 - 2031
0519 -
051901 - Feeding tube system is beeping.
051902 -
051903 - KC leaves to find nurse for solving the feeding tube system signals.
051905 - ..
051906 - Pat returns and enters magical numbers adjusting switches and levers,
051907 - which resolves feeding tube problem.
051908 -
051910 - ..
0520 -
0521 -
0522 - 2112
0523 -
052301 - Self-injection with Lovenox was effective. There was no pain
052302 - performing needle penetration, and the injection of treatment was
052303 - well tolerated.
052304 -
052306 - ..
0524 -
0525 -
0526 - 2142
0527 -
052701 - KC suggests trying a test to eat the tuna sandwich provided by the
052702 - Kitchen.
052704 - ..
052705 - This seemed to go well for about 5 minutes. At least there is no
052706 - pain nor discomfort with eating while the feeding tube is in place,
052707 - and which necessarily conjests the throat.
052709 - ..
052710 - However, soon began to feel need to vomit. Brought up some salivary
052711 - excess, and some food. Could not expressly identify the tuna fish and
052712 - bread, so it may have dropped to the bottom of the esophugus.
052713 -
052715 - ..
0528 -
0529 -
0530 - 2213
0531 -
053101 - KC gets a call for assistance in her role as the on-call doctor
053102 - tonight in the ICU.
053104 - ..
053105 - Thank KC for extra support today, including investing time to learn
053106 - about Communication Metrics for better health care, per above.
053107 - ref SDS 0 O25X
053109 - ..
053110 - She feels this was memorable day. She starts her new assignment next
053111 - week.
053113 - ..
053114 - Offered best wishes for an interesting and productive career.
053116 - ..
053117 - KC left.
053119 - ..
053120 - Continued preparing the record for the day's events.
053121 -
053123 - ..
0532 -
0533 -
0534 - 2357
0535 -
053501 - Pat arrives and gives Temazepam for sleep.
053502 -
053503 - Get saline wash to ease eyes.
053505 - ..
053506 - Hiked 3 laps.
053508 - ..
053509 - Sleep.
053510 -
053511 -
053512 -
053513 -
053514 -
0536 -