THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: March 30, 2006 07:12 AM Thursday; Rod Welch

Manometry test VA Mather AFB Sacramento to treat achalasia.

1...Summary/Objective
2...Administration Check-in Submitted VA Card
3...Patient Initial Setup to Prepare for Testing Procedure
4...Work Delayed Patient Idle Waiting for Doctor's Schedule to Clear
5...Work Begins Final Patient Preparation Meeting with Doctor
....1...Endocsopy and Xray??
....2...Manometry test
6...Planning Follow Up Schedule Pneumatic Dilation Treat Achalasia


..............
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CONTACTS 

SUBJECTS
Manometry Test for Esophageal Sphincter Valve Predicate to Balloon D

1603 -
1603 -    ..
1604 - Summary/Objective
1605 -
160501 - Follow up ref SDS 48 QG7M, ref SDS 46 0000.
160502 -
160503 - Two or possibly three tests were performed today.  Excellent work by
160504 - the entire GI Clinic team, including administration, ref SDS 0 446F,
160505 - and Susan and colleagues who performed initial patient setup.
160506 - ref SDS 0 LD98  There was an hour or so of idle time waiting in the
160507 - queue, which can be used for intelligence support. ref SDS 0 424L  The
160508 - doctor clarified key issues to strengthen doctor and patient
160509 - partnership. ref SDS 0 PM7M  The first part of the work was performing
160510 - evidently two tests - xray and endoscopy under general anesthetic.  Vi
160511 - and her team were terriffic assisting the doctor. ref SDS 0 VX4G  The
160512 - manometry test went smoothly with Vi performing the technical details
160513 - and the doctor observing diagnostics needed to finalize diagnosis and
160514 - treatment plan. ref SDS 0 MC7P  The doctor will submit a report on the
160515 - work.  He expects to schedule treatment for achalasia based on
160516 - findings today. ref SDS 0 MD4N
160517 -
160518 -     [On 060331 follow up call on patient care residual effects from
160519 -     work today, ref SDS 49 0001, submitted letter of appreciation for
160520 -     excellent work. ref SDS 49 NO5V
160522 -      ..
160523 -     [On 060505 delays were encountered receiving diagnostic data from
160524 -     manometry test today; doctor following up to obtain data, and
160525 -     plans to submit the data during the week of 060508 along with a
160526 -     schedule to treat achalasia. ref SDS 51 PU4N
160528 -      ..
160529 -     [On 060614 GI clinic has experienced increased work load,
160530 -     which requires prioritizing; patient advocate, Rubin Soto,
160531 -     will coordinate with the GI Clinic notifying the customer
160532 -     of the schedule based on current priorities. ref SDS 52
160533 -     J86N
160534 -
160535 -
160536 -
160537 -
160538 -
160539 -
160541 -  ..
1606 -
1607 -
1608 - Progress
1609 -
160901 - Administration Check-in Submitted VA Card
160902 -
160903 - Follow up ref SDS 48 FT6M, ref SDS 46 5K5F.
160904 -
160905 - On 060317 Vi scheduled this transaction for today. ref SDS 48 QG7M
160907 -  ..
160908 - Made good time driving from Concord using instructions from Vi
160909 - received on 060125. ref SDS 43 EG36
160911 -  ..
160912 - Talked to Jimmy Ward.  He still had not worked down his email to the
160913 - letter submitted on 060209 commending work in the GI clinic.
160914 - ref SDS 45 4W44
160916 -  ..
160917 - Jimmy said the manufacturing company for the manometry equipment tried
160918 - to get the VA to buy a $40K new equiment for a $300 repair.  He saved
160919 - taxpayers a lot of money by opting for repairs.
160921 -  ..
160922 - James took the VA card to prepare registration documents.  He was
160923 - helpful this morning expediting treatment ahead of schedule.
160924 -
160925 -
160927 -  ..
1610 -
1611 -
1612 - 0733
1613 -
161301 - Received VA card from James.  He verified address is current.  James
161302 - needs Millie to sign a document as the designated driver.
161304 -  ..
161305 - This was accomplished when Mil returned from the coffee shop.
161306 -
161307 -
161308 -
161309 -
1614 -

SUBJECTS
Patient Initial Setup Vitals Orientation IV Connected Excellent Work

2103 -
210401 -  ..
210402 - Patient Initial Setup to Prepare for Testing Procedure
210403 -
210404 - Susan took vitals and verified patient ID.  She configured a wrist
210405 - band with ID and specification for the procedure to avoid mixups.
210407 -  ..
210408 - Vitals.....
210409 -
210410 -    1.  Temperature................  96.8
210411 -    2.  Weight..................... 188
210412 -    3.  Pulse......................  79
210413 -    4.  Blood pressure............. 97/63
210415 -  ..
210416 - Actual weight is therefore about 182, which is a welcome trend
210417 - dropping 20 pounds in the past few months, and six (6) pounds from the
210418 - meeting two weeks ago on 060317. ref SDS 48 L45N
210420 -  ..
210421 - After dressing in hospital gown, Susan performed initial patient
210422 - setup for the work today.
210424 -  ..
210425 - Susan was excellent configuring the IV, which occassionally can
210426 - devolve into a problematic project, causing severe side effects, as
210427 - reported at Kaiser on 031205. ref SDS 13 CO3G  She noted today that
210428 - viens in the hands where the IV was installed with a needle are
210429 - "little." Normally these viens are prominent.  Susan explained that
210430 - requirements for a clear liquid diet over 48 hours, and nothing to
210431 - dring past midnight, submitted by Vi on 060125, ref SDS 43 HE53, can
210432 - cause dehydration that shrinks viens.  This presents a common delimma
210433 - of taking some measure essential for primary treatment that reduces
210434 - ability to perform other steps to prepare for treatment, in this case
210435 - setting up an IV.  While Susan attended a few administrative matters a
210436 - few exercises were done to pump up the muscles in both arms and hands
210437 - that cause viens to dilate.
210439 -  ..
210440 - Susan decided to select from viens above the right hand.  She
210441 - requested a fist to make the viens stand out.  She waited about 2
210442 - minutes, and patted the top of the hand several times to further cause
210443 - the viens to expand.  With this preparation, she installed the IV
210444 - without incident.  There was no discomfort and the task was
210445 - accomplished on the first try.
210447 -  ..
210448 - Another nurse, Dan, assisted with patient setup.  He, too, was highly
210449 - skilled providing a thorough explanation of procedures, so the patient
210450 - was prepared for each step.  Dan's 25 years experience were evident in
210451 - making things go smoothly like clockwork.
210453 -  ..
210454 - Susan submitted several documents for signature, following prior
210455 - practice on 051209. ref SDS 35 455N
210457 -         ..
210458 -        Discharge papers signed.
210460 -         ..
210461 -        Consent for procedure signed.
210463 -  ..
210464 - Susan used a stethescope to listen to heart, lungs, and stomach; she
210465 - said these diagnostics seem normal.
210467 -  ..
210468 - Overall, the GI Clinic presented a strong team with everyone
210469 - coordinated and doing their part efficiently with high degree of skill
210470 - and assurance.  This level of competence greatly reassures the
210471 - patient.
210472 -
210473 -
210474 -
210475 -
2105 -

SUBJECTS
Work Delayed Patient Idle Waiting for Doctor's Schedule to Clear Cap

2303 -
230401 -  ..
230402 - Work Delayed Patient Idle Waiting for Doctor's Schedule to Clear
230403 -
230404 - Susan initially indicated that Welch would be the doctor's first
230405 - patient.  There was express comment that, while the schedule called
230406 - for work to begin OA 0800, this task was started OA 0730 in order to
230407 - be the first patient treated, because another patient had not shown
230408 - up.
230410 -  ..
230411 - There was some minor mixup between the published schedule prepared by
230412 - James the day before, and the list Susan was using which showed a
230413 - different listing.  James noted that the list is published at the end
230414 - of his shift, but that additions can occur later.  This mixup was
230415 - resolved by placing the Welch project 2nd rather than 1st, as
230416 - initially indicated.
230418 -  ..
230419 - Susan recommended that Millie take the computer, and explained that
230420 - she could not remain in patient setup while waiting for the doctor to
230421 - complete treatment of the first patient.
230423 -  ..
230424 - There was inquiry about how long the wait would be for treatment to
230425 - begin.  Dan estimated about an hour or so.  This provided time to
230426 - report the record of organizational memory, as explained in POIMS,
230427 - ref OF 5 2300
230429 -  ..
230430 - Susan proposed that rather than visit with Millie and use the computer
230431 - to report the record, as occurred in the GI Clinic VA Martinez on
230432 - 051209, ref SDS 35 V47H, that the patient should be idle worrying
230433 - about what was to come.  Estimates of delay varied from 40 minutes to
230434 - several hours.  Susan suggested that Millie go shopping.  Mil asked if
230435 - there is a shopping mall near by.  One of the nurses suggested Sunrise
230436 - Mall.
230438 -  ..
230439 - There was discussion that patient idle time increases the burden to
230440 - play catch up hours, even days, later after recollection of events has
230441 - faded.  This significantly weakens accuracy of communications.
230443 -  ..
230444 - Susan asked how organizational memory on health care is accomplished
230445 - to support the doctor/patient partnership?
230447 -  ..
230448 - We discussed briefly the eight (8) steps of Communication Metrics set
230449 - out in POIMS. ref OF 6 685K  Further discussed practice in the GI
230450 - Clinic at VA Martinez.  On 051209 there was approximately 30 minutes
230451 - delay following patient setup.  At that time, Theresa supported
230452 - doctor/patient communications without objection to patient reporting
230453 - progress while waiting for the doctor's schedule to clear for
230454 - treatment. ref SDS 35 V47H
230456 -  ..
230457 - To maintain good working relations with the GI team, decided to forgoe
230458 - using the idle time productively.  This will require putting in a lot
230459 - of extra time later, trying remember critical details, and reconstruct
230460 - a coherent record of the work.
230461 -
230462 -
230463 -
230464 -
2305 -
2306 -
230601 -
2307 -

SUBJECTS
Work Begins Final Patient Preparation Meeting with Doctor

2503 -
2504 - 0940
250501 -  ..
250502 - Work Begins Final Patient Preparation Meeting with Doctor
250503 -
250504 - Vi said the doctor was ready for this project.  She wheeled the gurney
250505 - from patient setup into the hall and down to a room where an endoscopy
250506 - was performed, repeating the prior work on 051209. ref SDS 35 CY5M
250508 -  ..
250509 - The doctor joined the team at this time.
250511 -  ..
250512 - Issues for discussion...
250513 -
250514 -    1.  Did the doctor receive the letter on 060221 notifying of
250515 -        indefinite delay in manometry testing, ref SDS 46 7U8H,
250516 -
250517 -        Wound up not addressing this issue, but mentioned that Kim
250518 -        Gentle has transferred to the doctor's team, and that she was
250519 -        very effective facilitating communications the past year with
250520 -        the primary care physician, cited in the letter to the VA on
250521 -        060314. ref SDS 47 2M7I
250523 -         ..
250524 -        The doctor today did not object to facilitating communications
250525 -        through Kim, based on prior practice and her excellent work
250526 -        with the primary care physician reported on 060317, ref SDS 48
250527 -        KS7G
250529 -         ..
250530 -    2.  Dental support per review on 060317. ref SDS 48 YR4J
250531 -
250532 -        We discussed briefly requirements for dental support to
250533 -        complement work today, and planned to complete treatment of
250534 -        digestion issues caused by achalasia.  Treatment for achalasia
250535 -        to permit digestion will not be effective, because functioning
250536 -        of esophageal sphincter valve depends on mastication, as
250537 -        reported on 060317 reviewing need for dental treatment.
250538 -        ref SDS 48 M56G
250539 -
250540 -            [On 060403 received call from Connie saying the primary
250541 -            care physician needs input on eligibility for dental work
250542 -            to avoid compounding digestion problem being treated for
250543 -            achalasia. ref SDS 50 YY51
250544 -
250545 -
250546 -
250547 -
250548 -
2506 -

SUBJECTS
Endoscopy Xray Camera Probe Pushed through Patient Nose Esophageus S
Work Begins Final Patient Preparation Meeting with Doctor

2704 -
270501 -  ..
270502 - This was a two (2) step process.
270503 -
270504 -    1.  Endocsopy and Xray??
270505 -
270506 -        There was discussion of the doctor performing another
270507 -        endoscopy.  This required general anesthetic, where the patient
270508 -        is not conscious.
270510 -         ..
270511 -        Vi did the primary patient setup, with assistance of Remy.
270513 -         ..
270514 -        Patient sits up on a table.  Vi sprayed the right nostrile of
270515 -        nose with an agent, perhaps a local anesthetic.  The patient
270516 -        sniffs the agent into the air passage, perhaps also as a
270517 -        lubricant.  Vi then fed a tube through the nose and down the
270518 -        throat, as was done for the prior endoscopy on 051209, except
270519 -        on that occassion, this work was performed after the general
270520 -        anesthetic took effect. ref SDS 35 B150
270522 -         ..
270523 -        This is not a pleasant experience.  Vi reported progress
270524 -        feeding the probe into the esophagus, and on into the stomach.
270525 -        She was reporting progress of the probe based on observing a
270526 -        monitor receiving signals from a camera at the end of the
270527 -        probe.  This step may have taken 5 minutes or so, with the
270528 -        nurse gradually forcing the probe deeper.  This rate of
270529 -        progress reduces discomfort and trauma to the patient relative
270530 -        to simply forcing the probe in a matter of seconds.
270532 -         ..
270533 -        The patient is positioned on the left side, and a large
270534 -        equipment unit is positioned above the right side to accomplish
270535 -        an xray of some kind.
270537 -         ..
270538 -        General anesthetic was administered with Remy's assistance.
270540 -         ..
270541 -        Evidently another endoscopy was performed during this period.
270542 -
270543 -
270544 -
270545 -
2706 -

SUBJECTS
Manometry Test Established Diagnosis Achalasia

2903 -
2904 - 1030
290501 -  ..
290502 - Patient awakens from general anesthetic from step 1. ref SDS 0 VX4G
290503 -
290504 -    2.  Manometry test
290505 -
290506 -        Vi said the doctor wanted to wait for another 30 minutes until
290507 -        the patient was fully awake.
290508 -
290510 -  ..
2906 -
2907 -
2908 - 1105
2909 -
290901 -        The doctor stopped by and talked for a few minutes to test
290902 -        patient alertness for the manometry test.
290904 -         ..
290905 -        About 10 minutes later, he was satisfied the patient was ready
290906 -        for the test, having recovered sufficiently from the general
290907 -        anesthetic for the prior procedure. ref SDS 0 VX4G
290909 -         ..
290910 -        Vi performed the manometry test with the doctor observing a
290911 -        monitor showing readings of resistance to moving the probe.  Vi
290912 -        manipulated the probe and adjusted dials on the equipment based
290913 -        on readings in realtime.  The patient senses movement of the
290914 -        probe; there is a feeling of the probe being twisted.  This
290915 -        soon becomes very unpleasant.  Someone had indicated that the
290916 -        test takes about 10 minutes.  This test may have taken 30 to 40
290917 -        minutes, and seemed like several hours.  There is a strong
290918 -        feeling of wanting to simply order the test stopped in order to
290919 -        relieve trauma of the experience.
290921 -         ..
290922 -        During this test, there was ongoing discussion between Vi and
290923 -        the doctor on readings.  Each commented at times that readings
290924 -        were good.  At other times there was concern that no readings
290925 -        were occurring.
290927 -         ..
290928 -        When the test concluded, Vi removed the probe swiftly.  There
290929 -        was strong relief with this ending.
290930 -
290931 -
290932 -
2910 -

SUBJECTS
Planning Follow Up Schedule Pneumatic Dilation Treat Achalasia

3103 -
3104 - 1236
310501 -  ..
310502 - Planning Follow Up Schedule Pneumatic Dilation Treat Achalasia
310503 -
310504 - Doctor Lee reported that findings from the manometry test today, per
310505 - above, ref SDS 0 MC6K, are consistent with diagnosis of achalasia.
310507 -  ..
310508 - The doctor further advised that the endoscopy test today, per above,
310509 - ref SDS 0 VX4G, did not find evidence of cancer, confirming results of
310510 - the first test on 051209. ref SDS 35 5B5K
310512 -  ..
310513 - The next step is to perform pneumatic (balloon) dilation, described
310514 - during the meeting on 051202. ref SDS 33 NZ4G  The doctor said that
310515 - his GI clinic at the VA Martinez has ordered the balloons for
310516 - performing this work.  He will submit a letter on the findings today,
310517 - including the readings from the test, and schedule the work to treat
310518 - achalasia.  An impression was conveyed this could occur within 3 - 6
310519 - weeks, depending on his schedule.  This addresses questions presented
310520 - in the letter to the doctor on 060321. ref SDS 46 PQ6P
310521 -
310522 -     [On 060505 delays were encountered receiving diagnostic data from
310523 -     manometry test today; doctor following up to obtain data, and
310524 -     plans to submit the data during the week of 060508 along with a
310525 -     schedule to treat achalasia. ref SDS 51 PU4N
310527 -      ..
310528 -     [On 060614 GI clinic has experienced increased work load, which
310529 -     requires prioritizing; patient advocate, Rubin Soto, will
310530 -     coordinate with the GI Clinic notifying the customer of the
310531 -     schedule based on current priorities. ref SDS 52 J86N
310533 -  ..
310534 - Thanked the doctor for good work today.
310535 -
310536 -
310538 -  ..
3106 -
3107 -
3108 - 1306
3109 -
310901 - Thanked Vi, Susan and everyone for excellent work.
310902 -
310903 - Did not feel like visiting.  Throat was sore from the work today, so
310904 - talking was a chore.  Decided to go home, rather than follow up with
310905 - visits previously planned.
310906 -
310907 -
310908 -
310909 -
310910 -
310911 -
310912 -
310913 -
310914 -
310915 -
310916 -
310917 -
3110 -