CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 30 0000. ref SDS 29 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Arrived at VA Medical Center in San Francisco at about 1150. Went to
040902 - Module 2, where Neurology Clinic is open on Friday.
040904 - ..
040905 - Megan was at the front desk.
040907 - ..
040908 - While waiting in line, Lana got in line to schedule a patient for
040909 - follow up in Wound Care. Said hello, and asked if she had a good trip
040910 - to Russia on vacation. She seemed enthusiastic talking about it.
040912 - ..
040913 - Finally, talked to Megan. She said Doctor Yoo is not in the office
040914 - today, and further that the Neurology Clinic will not start until
040915 - after lunch.
040916 -
040917 - [On 160722 0938 at 1348 received letter from Doctor Yoo
040918 - saying he only works at VA Medical Center in San Francisco
040919 - on days when he is assigned to the clinic, and that today
040920 - he is working at San Francisco General Hospital across
040921 - town. ref SDS 31 7E5J
040923 - ..
040924 - Went across the street to building 203, and talked to Kim in the GI
040925 - Clinic. Kim said Debbie is assisting in a procedure and so is not
040926 - available to follow up discussions last week on meeting with GI on
040927 - Doctor Stewart's suggestion during a meeting on 160705, to consider
040928 - switching to a stent that would replace continuing EGD dilations for
040929 - maintaining swallowing, ref SDS 24 EG66,
040931 - ..
040932 - Went for a walk around the campus, about a mile.
040934 - ..
040935 - Returned to Module 2 in Building 200.
040937 - ..
040938 - Megan was no longer on station at the front desk. Another schedule
040939 - clerk went into the examination area and told Doctor Massa I would
040940 - like to meet for a minute.
040942 - ..
040943 - Doctor Massa came into the patient waiting area. He was very kind to
040944 - discuss the case for about 20 minutes. Apologized for taking time
040945 - from his other patient. The doctor said that's okay, because
040946 - determining causation of stroke symptoms is important, particularly
040947 - where a medical procedure may be involved.
040948 -
040949 - [On 160727 0004 letter to Doctor Massa requests comments
040950 - with additions or corrections to this record. ref SDS 35
040951 - SZ48
040953 - ..
040954 - Doctor Massa advised that he has read the letter sent to Doctor Yoo
040955 - this morning asking about causative relation between MRI findings on
040956 - left anterior choroidal artery infundibulum and patient symptoms of
040957 - short term motor control and vision impairment (less than 2 days),
040958 - following EGD dilation on 160617, as reported in another record
040959 - earlier today on 160722 0938. ref SDS 30 MU48
040961 - ..
040962 - Thanked Doctor Massa's notice today, that he has seen all the
040963 - correspondence submitted to Doctor Yoo. This provides patient
040964 - confidence that the attending physician is fully engaged in the case
040965 - through continuing correspondence that has occurred with Doctor Yoo, a
040966 - resident, who has done excellent work attempting to keep up with all
040967 - the details in a very complicated case.
040968 -
040969 - [On 160722 0938 at 1348 received letter from Doctor Yoo
040970 - saying he only works at VA Medical Center in San Francisco
040971 - on days when he is assigned to the clinic, and that today
040972 - he is working at San Francisco General Hospital across
040973 - town. ref SDS 31 7E5J
040975 - ..
040976 - Doctor Massa then seemed to say that Neurology believes MRI finding of
040977 - "left anterior choroidal artery infundibulum" shown in the record on
040978 - 160618 1348, ref SDS 20 VN4G, and cited in the letter to the team
040979 - earlier today, shown on 160722 0938, ref SDS 30 MU48, could not have
040980 - caused short term motor control and vision impariment, because, if it
040981 - did, then the patient would have had more symptoms, given that
040982 - infundibulum occurred "down stream" from where vision and motor
040983 - control are managed in the brain. Since only vision and motor control
040984 - deficits occurred, this reduces liklihood of a causitive relationship.
040986 - ..
040987 - There was not enough time to consider today, that since disruption of
040988 - vision and motor control was minor, a broader array of less prominent
040989 - symptoms could also have occurred, but with such minor effects as to
040990 - go unnoticed, and then resolved by the time professional care made an
040991 - examination, in the same way that the 2 major symptoms of vision and
040992 - motor control, which force high awareness, disolved within a day or
040993 - so. Couldn't there in fact have actually been other symptoms, which
040994 - were missed on a routine stroke examination in the same way that some
040995 - minor glitch occurred performing the EGD dilation, but was overlooked
040996 - by expert an physician and support team.
040997 -
040998 - [On 160726 1117 public reporting by CNBC that Olympic
040999 - gastrointestinal scopes have caused illness and deaths due
041000 - to design flaw that spreads infection, should be considered
041001 - for cause of infection in this case resulting in large area
041002 - of inflammation above the brain, possibly caused by VA
041003 - using Olympic gastrointestinal scopes. ref SDS 34 FH6N
041005 - ..
041006 - For example, A week or so after the EGD dilation procedure on 160617,
041007 - Kathy and I were driving somewhere. I wanted to lean my head back and
041008 - close my eyes to rest during an extended drive. The head rest was not
041009 - comfortable, so Kathy produced a neck support she got a year or so ago
041010 - for a 96 year old former colleague at Sutter General, whom she takes
041011 - on short drives from time to time. This was not comfortable, so Kathy
041012 - next produced a rolled up hospital blanket. This didn't work either,
041013 - so we forgot about it, but I asked if the blanket was left over from
041014 - Kathy's work as a maternity nurse at Sutter hospital in Sacramento,
041015 - where she retired last year? Kathy said no.
041016 -
041017 - [On 160727 0004 letter to medical team presents list of
041018 - stroke symptoms showing more than simply vision and motor
041019 - control were affected. ref SDS 36 S154
041021 - ..
041022 - [On 160907 1420 letter notifies medical team that
041023 - Triamcinolone may have caused stroke symptoms on 160617,
041024 - because dose over 3 month period accumulated to
041025 - significantly more than commonly given in this case.
041026 - ref SDS 37 BI60
041028 - ..
041029 - Kathy advised that I had walked out of the hospital the week before on
041030 - 160617, with the blanket wrapped around my shoulders, gotten into the
041031 - car and driven home still with the blanket wrapped around my
041032 - shoulders.
041034 - ..
041035 - This event is a complete blank, and so supplements the record of
041036 - stroke symptoms reported in the record on 160617 1637. ref SDS 19 5F6F
041038 - ..
041039 - Loss of memory on 160617, seems similar to being knocked out with a
041040 - knee to the head during football practice 55 years ago, rushing up
041041 - from a DB position to tackle a runner coming through the line. An
041042 - hour or so later after recovery, a friend, who happened to be at the
041043 - track training for the decathelon, explained what happend, and that I
041044 - was walking along the sidelines afterwards with seemingly normal motor
041045 - control but saying over and over - "I know my name, I know my name..."
041046 - In other words, I appeared functional, but without memory for a block
041047 - of time.
041049 - ..
041050 - Similarly, recollections on 160617, are in part a complete blank.
041052 - ..
041053 - I recall waiting for Doctor Lee in a small admin office off the main
041054 - work area for the GI Clinic. Feeling chilled, which has never
041055 - occurred previously, I asked the nurse for a blanket. After a few
041056 - minutes Doctor Lee came and we had the usual post procedure meeting to
041057 - review findings and plan the next phase. I recall him saying he found
041058 - increased ulceration on LESV, and that LESV again contracted back to
041059 - 10 mm, the worst condition in patient history. We discussed remedies.
041060 - I requested reducing the next procedure from 4 months, back to 3
041061 - months, which worked in 2011 to eventually expand LESV up 18 mm. The
041062 - doctor concurred, and also proposed increasing Omeprazole back to 20
041063 - mg every day. I was worried this would again cause dehydration that
041064 - prevents hiking required to maintain HDL > 60, which prevent
041065 - atherosclerosis. I remember nothing else from that meeting. So, I
041066 - may or may not have voiced this objection to increasing Omeprazole.
041068 - ..
041069 - Later I was aware of difficulty fastening and unfastening the seat
041070 - belt, which Kathy finally accomplished.
041072 - ..
041073 - This record seems to suggest a rising array of minor symptoms, yet
041074 - only slight vision weakness and motor control are reported by the
041075 - neurology medical team, simply because they are prominent and lasted
041076 - longer.
041078 - ..
041079 - These minor cognitive deficits could have been related to conscious
041080 - sedation, but had never occurred previously. The patient has always
041081 - been fully alert and engaged in post procedure meetings.
041083 - ..
041084 - During pre-procedure on 160617, the nurses were asked about allowing
041085 - the patient to sleep another hour before being awakened from recovery.
041086 - Doctor Lee and everyone agreed, because there was a low patient flow
041087 - that day.
041089 - ..
041090 - Conceivably, the dose required to induce conscious sedation might have
041091 - been increased slightly to accomodate patient request for a longer
041092 - recovery period. The record may or may not show this. Busy nurses
041093 - and doctors sometimes write down what is typically done or occurs with
041094 - a patient, rather than the actual situation.
041096 - ..
041097 - Thus, symptoms commonly associated with mere grogginess from conscious
041098 - sedation, might in fact have been mild symptoms adding to loss of
041099 - vision and motor control that reconciles MRI report of...
041100 -
041101 - "left anterior choroidal artery infundibulum"
041103 - ..
041104 - Doctor Massa restated the theory in Doctor Yoo's Progress Notes that
041105 - patient symptoms were caused by a lesion that blocked blood flow
041106 - further up stream nearer to where vision and motor control are managed
041107 - in the brain, originally presented by Doctor Yoo during the meeting
041108 - also held here in Patient Waiting area of Module #2, on 160623 0830.
041109 - ref SDS 23 P78F
041111 - ..
041112 - Doctor Massa further agreed with Doctor Yoo's explanation that there
041113 - is no evidence of any lesions nor blood clots, in all the testing
041114 - performed on the patient, that supports this Neurology theory,
041115 - originally presented during the meeting with Doctor Yoo on 160623
041116 - 0830. ref SDS 23 8I6O Thus, the Neurology theory of the case
041117 - hypothesizes a blood flow blockage without any lingering trace of
041118 - evidence, and ignores the evidence that is prominent in the MRI scan.
041120 - ..
041121 - Did not discuss why atherosclerosis plaque would form at only 2
041122 - specific spots entirely by chance, and just happen to be at the right
041123 - place to cause vision and motor control impairment, and then just
041124 - miracuously disappear the next day before the MRI test was performed?
041125 - If atherosclerotic plaque and lesions are forming wouldn't it be
041126 - expected to find other instances, even very minor instances?
041128 - ..
041129 - Assuming there was no atherosclerotic plaque that caused a blood clot
041130 - to form a temproary blockage, then presumably any such blockage would
041131 - have to be caused by an extra large blood clot that encourntered a
041132 - narrowing blood vessel channel.
041134 - ..
041135 - What can cause out of the blue a large enough blood clot to form that
041136 - has not occurred the past 7 years in a patient who has hiked nearly
041137 - 12,000 miles the past 5 years to raise HDL from 30 to HDL 73? Can a
041138 - heart that hikes 11 - 15 miles per day produce one blood clot without
041139 - some specific stimulous?
041141 - ..
041142 - Why would a clot form after an EGD dilation with conscious sedation
041143 - and not at any other time before nor since? Out of 250 million times
041144 - the heart pumped since 091022, the day of CABG x4, what was special
041145 - about a heart pump on 160617, that could have caused an oversized
041146 - blood clot, when none had been produced prevously nor since?
041148 - ..
041149 - Doctor Msassa explained the team hopes doing another Zio XT 2-week
041150 - heart monitoring test will shed light on this issue. He asked if
041151 - Cardiology has notified the patient to come in to begin this
041152 - additional test?
041154 - ..
041155 - Advised of discussions with Doctor Simpson on this matter.
041156 -
041157 - [On 160722 1710 telephone message from Doctor Simpson said
041158 - he has ordered Zio XT test. ref SDS 33 509K
041160 - ..
041161 - Asked Doctor Massa what review has occured of EGD Dilation on 160617
041162 - that preceeded stroke symptoms in this case?
041164 - ..
041165 - The doctor seemed to say none, because nobody on the Neurology team
041166 - can think of anything that is done during EGD dilation that can cause
041167 - a stroke.
041169 - ..
041170 - Asked how many cases Doctor Massa has managed where stroke symptoms
041171 - occured after an EGD dilation?
041173 - ..
041174 - Doctor Massa said none.
041176 - ..
041177 - Asked if Doctor Massa has consulted the GI Clinic next door in
041178 - building 203 on the 2nd floor, to see if anyone has ever performed an
041179 - EGD dilation procedure with conscious sedation that resulted in
041180 - stroke symptoms?
041182 - ..
041183 - Doctor Massa said nobody has consulted the GI Clinic about experience
041184 - performing EGD dilations with conscious sedation that resulted in
041185 - stroke symptoms.
041187 - ..
041188 - Doctor Massa did offer that Neurology seperates consideration of EGD
041189 - dilation from the conscious sedation procedure. He seemed to feel
041190 - conscious sedation in his experience could cause stroke symptoms.
041192 - ..
041193 - Why then is there no discusson in Neurology Progress Notes of what
041194 - happened with conscious sedation in this case, that could have caused
041195 - stroke symptoms?
041197 - ..
041198 - Doctor Massa advised that he has a patient waiting, and that Doctor
041199 - Yoo is off site today on another assignment. He is not familiar with
041200 - progress reviewing what role conscious sedation might have played in
041201 - stroke symptoms that occurred after the EGD dilation procedure on
041202 - 160617.
041204 - ..
041205 - Explained concern that repeat EGD dilation with conscious sedation is
041206 - scheduled on 160909, and that I have to decide on having this
041207 - procedure based on evidence showing adverse results will not be
041208 - repeated.
041210 - ..
041211 - Doctor Massa asked how swallowing is going?
041213 - ..
041214 - Explained seems like increased vomiting has already begun, indicating
041215 - narrowing of LESV has resumed. This suggests timliness completing a
041216 - reliable review process is critical now only 1.5 months before the
041217 - next EGE dilation and conscous sedation on 160909.
041219 - ..
041220 - For the past several years, swallowing has remained favorable through
041221 - the EGD dilation treatment cycle. Possibly recent addition of aspirin
041222 - has shortened this, discussed previously with Doctor Yoo on 160715
041223 - 1630. ref SDS 26 NM8K
041225 - ..
041226 - Asked Doctor Massa if he approved Doctor Yoo's letter to Doctor Lee
041227 - last Friday, on 160715, saying Neurology has cleared the patient to
041228 - have the EGD dilation with conscous sedation scheduled on 160909?
041230 - ..
041231 - Doctor Massa said yes.
041233 - ..
041234 - Asked how Neurology can clear a patient to repeat a procedure that
041235 - resulted in severe stroke symptoms (loss of vision and motor control -
041236 - fortunately with only mild intensity this time - without ever talking
041237 - to the doctor who did the work, nor any of the support team, to
041238 - determine what could have happened, in order to avoid repeating stroke
041239 - symptoms with worse consequences the next time?
041241 - ..
041242 - Shouldn't Neurology review Progress Notes for the event; talk to
041243 - participants, check on volume and rates of administring drugs for
041244 - conscousl sedation?
041246 - ..
041247 - Shouldn't Neurology consider the report resulting from the
041248 - "independent review" Doctor Lee ordered on 160714, ref SDS 25 SG67,
041249 - before giving the go ahead to repeat a procedure still under review
041250 - for possibly causing stroke symptoms?
041252 - ..
041253 - Is there a published standard of care for investigating the cause of
041254 - stroke symptoms that occur after a medical procedure?
041256 - ..
041257 - Doctor Massa pointed out again that he has many patients. It is
041258 - difficult to keep all the details of one case in mind.
041260 - ..
041261 - Thanked Doctor Massa for providing care as attending physician.
041262 - Patients at the VA Medical Center in San Francisco are blessed to have
041263 - the highest caliber doctors and nurses in the world. Limited time
041264 - leads to rushing past critical details "hidden in plain sight." The
041265 - doctor patient partnership leverages medical exertise to facilitate
041266 - thorough, timely review that prevents small problems from escalating
041267 - into error, confusion, chaos and calamity.
041269 - ..
041270 - Explained going next door to GI Clinic asking if meeting has been
041271 - scheduled to consider stent option for resolving achalasia in lieu of
041272 - doing another EGD dilation in Sacramento, while
041274 - ..
041275 - Doctor Massa asked how the right knee problem is going, that was
041276 - injured last Friday, before meeting with Doctor Yoo?
041278 - ..
041279 - Thanked him for concern, and said just today, it seems to be healing.
041280 - Was able to do a lap around the campus here on site, so Half Dome is
041281 - still in play, scheduled on 160914.
041282 -
041283 -
041284 -
041285 -
041286 -
041287 -
041288 -
041289 -
041290 -
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041294 -