440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700


DIARY: May 1, 2008 08:30 AM Thursday; Rod Welch

Millie meeting UCSF 17th cycle cetuximab Carboplatin treat IBC.

2...Work Plan Continue Carboplatin Full Dose Optimize Recovery Prospects
3...Neupogen Increase Blood Counts Enable Full Dose Carboplatin Treatment
4...NEUTS 1.34 Blood Counts Low Treatment Approved with Neupogen Treatments
5...Neupogen 2 Treatments Prescribed by Clinical Study Changed to 1 by UCSF
6...Cellulitis Lymphedema Research Reduce Recurrence
7...Examination Finds Substantially Reduced IBC Rash Response to Treatment
8...CT Test Findings Cancer Stable Align with Examination
9...Exercise Increases Good Tolerance Carboplatin Chemotherapy
10...Current Medications Case Management Referral Coordination with Kaiser
11...Magnesium Low Treatment Prescribed
12...CT Test Huber Needle Power Port Inject Contrast Medium
13...Power Port Huber Needle CT Test New Method Avoid Needle Punctures

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Meeting Examination Doctor Review Strategy Work Plan 3rd Cycle 1st T

1503 -
1503 -    ..
1504 - Summary/Objective
1505 -
150501 - Follow up ref SDS A4 0000. ref SDS 94 0000.
150502 -
150503 -
150504 -
150505 -
150506 -
150507 -
150508 -
150510 -  ..
1506 -
1507 -
1508 - Progress
1509 -
150901 - Agenda for the meeting today was submitted with Millie's letter to the
150902 - medical team yesterday on 080430. ref SDS D4 1H6Y
150903 -
150904 -
150905 -
150906 -
1510 -

Work Plan Carboplatin Full Dose Optimize Recovery NEUTS 1.34 Blood C

4003 -
400401 -  ..
400402 - Work Plan Continue Carboplatin Full Dose Optimize Recovery Prospects
400403 - Neupogen Increase Blood Counts Enable Full Dose Carboplatin Treatment
400404 - NEUTS 1.34 Blood Counts Low Treatment Approved with Neupogen Treatments
400405 -
400406 - Millie had a blood draw in the Infusion Clinic this morning at 0800.
400407 - ref SDS D6 DT3M
400409 -  ..
400410 - During the meeting today in the Breast Care Clinic, Brigid introduced
400411 - Megan who is taking over for Jackie as Clinical Research Coordinator
400412 - for Millie's treatment.  Jackie is going to law school, after working
400413 - the past 15 months, as Clinical Research Coordinator for Doctor Rugo
400414 - on Millie's case.
400416 -  ..
400417 - Brigid displayed results of the blood test on the computer in the
400418 - examination room.  Brigid was disappointed that NEUTS 1.34 are still
400419 - below the safe level for chemotherapy today, ref SDS D6 QY6H, despite
400420 - not getting chemotherapy during the "bye-week" in the 4-week cycle for
400421 - Carboplatin, implementing Brigid's instructions in UCSF's letter on
400422 - 080418. ref SDS C9 MR3L
400424 -  ..
400425 - As proposed in Brigid's letter on 080418 saying to skip Neupogen
400426 - during the bye-week for Carboplatin, discussed today treatment plans
400427 - to solve problem of low blood counts that have forced Millie to skip
400428 - treatments with Carboplatin chemotherapy, most recently on 080410.
400429 - ref SDS C8 PU6K
400431 -  ..
400432 - At that time on 080418, Brigid reported the doctor would discuss today
400433 - possibly lowering the dose of Carboplatin hoping to reduce effects on
400434 - blood counts so that Millie will not have to skip treatments.
400435 - ref SDS C9 MR3L  Millie responded on 080423 with a possible treatment
400436 - plan to reduce the dose of Carboplatin for 1st or 2nd weekly
400437 - treatment, and then give the full dose for 2nd or 3rd treatment in the
400438 - cycle, since the 4th week in the cycle already skips Carboplatin under
400439 - the protocol. ref SDS D0 OY7S  Doctor Rugo said in a reply letter that
400440 - the dose for Carboplatin cannot be increased to improve care, after
400441 - once being decreased to avoid low blood counts. ref SDS D0 I49N
400443 -  ..
400444 - Today, during the meeting, Millie confirmed notice in her letter to
400445 - UCSF on 080423 that she wants to continue getting the full dose of
400446 - Carboplatin in order to increase chances of continued improvement
400447 - treating IBC, ref SDS D0 TY6Y, noted today by Brigid during
400448 - examination, per below. ref SDS 0 JJ3N  Millie wants to first try
400449 - maintaining blood counts to get the full dose of Carboplatin by adding
400450 - treatment with Neupogen.
400452 -  ..
400453 - Since Doctor Rugo is out of town today, Brigid will advise Clinical
400454 - study management that Millie wants to optimize recovery from cancer
400455 - with 1 Neupogen treatment for every week in the cycle, rather than
400456 - skip Neupogen during the bye-week, and in order to maintain blood
400457 - counts for getting the full dose of Carboplatin, since this
400458 - prescription was ordered by the doctor starting the previous cycle on
400459 - 080403, ref SDS C1 6Y9K  Getting the full dose of Carboplatin has been
400460 - very effective reducing IBC symptoms, and getting 1 Neupogen treatment
400461 - per week was very effective increasing NEUTS 6.85, about 400% above
400462 - the target level of 1.8, reported on 080410. ref SDS C7 QY6H
400464 -  ..
400465 - After meeting with the medical team on the 2nd floor, Megan did not
400466 - submit the Chemotherapy Orders and blood vials for delivery by Millie
400467 - to the nurse in the Infusion Clinic on the 5th floor.
400468 -
400469 -        [On 080529 review of Chemotherapy Orders for today, 080501,
400470 -        which were received from UCSF on 080515, ref SDS E1 E43I, and
400471 -        shown in this part of the record, ref SDS E7 MM9I, discovered
400472 -        UCSF evidently reduced the dose of Carboplatin and prescribed 2
400473 -        weekly Neupogen treatments, per below, ref SDS D6 PVUQ,
400474 -        contrary to understandings with the medical team today, 080501,
400475 -        that Millie would get full dose of Carboplatin with 1 weekly
400476 -        Neupogen tratment this cycle. ref SDS D5 CZ3N
400478 -         ..
400479 -        [On 080529 Chemotherapy Orders for Carboplatin show same dose
400480 -        175 mg as today, ref SDS E7 PVUQ, but there is a handwritten
400481 -        mark that says "error," dated 080529 with initials mg.
400482 -        ref SDS E7 F55F
400484 -         ..
400485 -        [On 080625 Millie asks medical team about error in Chemotherapy
400486 -        Orders discovered on 080605. ref SDS F4 PQWV
400488 -         ..
400489 -        [On 080716 Millie letter to Kaiser asks about meeting to
400490 -        discuss CA 15-3 141 and progression of disease before
400491 -        scheduled meeting on 080829. ref SDS F6 VG7L
400493 -  ..
400494 - Later, Megan visited Millie and the nurse in the Infusion Clinic on
400495 - the 5th floor. ref SDS D6 4E9N  She confirmed that the Clinical Study
400496 - people approved Millie to get Carboplatin chemotherapy today despite
400497 - NEUTS 1.34, below the 1.50 standard that signals safe treatment.  She,
400498 - also, submitted Chemotherapy Orders today for both cetuximab,
400499 - ref SDS D6 MM6N, and Carboplatin. ref SDS D6 I66I  This is the first
400500 - time in patient history, since starting the 2nd Arm of the clinical
400501 - study on 080313 that UCSF has submitted Chemotherapy Orders for both
400502 - drugs. ref SDS D6 4E9N
400503 -
400505 -  ..
400506 - Neupogen 2 Treatments Prescribed by Clinical Study Changed to 1 by UCSF
400507 -
400508 - Megan submitted the Chemotherapy Orders for today to the nurse showing
400509 - the clinical study management recommended 2 treatments with Neupogen
400510 - this cycle for each weekly treatment with Carboplatin. ref SDS D6 PWSY
400511 - Megan explained that increasing Neupogen from 1 to 2 treatments per
400512 - week this cycle will increase and maintain blood counts at or above a
400513 - level showing the immune system is strong enough for safe treatment
400514 - with the full dose of Carboplatin chemotherapy, discussed during the
400515 - meeting with Brigid this morning, per above. ref SDS 0 CZ3N
400517 -  ..
400518 - Millie did not receive the Chemotherapy Orders today.  Understandings
400519 - were based on conversations with Megan and the nurse. ref SDS D6 4E9N
400521 -  ..
400522 - Before getting information about the 2 treatments with Neupogen a
400523 - letter to UCSF and with a copy to Kaiser confirmed understandings in
400524 - the meeting with the medical team that Millie will continue getting a
400525 - full dose of Carboplatin to provide the best chance of recovery from
400526 - IBC, and this will supplemented with 1 treatment per week of Neupogen
400527 - that maintains the immune system with blood counts at a safe level for
400528 - chemotherapy treatments.
400529 -
400530 -        [ another record, after the meeting Millie sent a letter
400531 -        to the medical team confirming understandings the doctor
400532 -        ordered a full dose of Carboplatin chemotherapy, and ordered 1
400533 -        treatment of Neupogen to maintain blood counts. ref SDS D7 MG3P
400535 -  ..
400536 - Subsequently, Brigid wrote a letter to Millie explaining that review
400537 - of patient history shows Millie's blood counts increased dramatically
400538 - from 1.34 to over 6.00, reported 080410, ref SDS C7 QY6H, with just 1
400539 - Neupogen treatment prescribed on 080403. ref SDS C1 6Y9K  As a result,
400540 - UCSF changed the prescription from 2 to just 1 Neupogen treatment per
400541 - week for this new cycle starting today, which, it turned out,
400542 - conformed with the letter sent to UCSF shortly after the meeting.
400543 - ref SDS D7 MG3P  Brigid does not relate in her letter that UCSF
400544 - considered unusual contextual effects of Millie suffering Cellulitis
400545 - recurrence during the week when blood counts increased, and the
400546 - possibility that much of the rise was due to that factor, as related
400547 - in Millie's letter to UCSF on 080410. ref SDS C6 F85X
400548 -
400549 -        [On 080502 health care cost containment saves patient $500 by
400550 -        checking the record to discover only 1 Neupogen treatment
400551 -        needed. ref SDS D9 OV8J
400553 -         ..
400554 -        [On 080529 blood counts improve, ref SDS E6 4F38, medical team
400555 -        prescribes 1 treatment with Neupogen starting the 4th cycle.
400556 -        ref SDS E6 4F42; during treatment in the Infusion Clinic after
400557 -        meeting with medical team, nurse confirms guidance for 1
400558 -        treatment with Neupogen. ref SDS E7 TE6N
400560 -         ..
400561 -        [On 080609 Kaiser prescribed Neupogen treatment in Infusion
400562 -        Clinic for quality care that avoids confusion and mistakes.
400563 -        ref SDS F1 IL6I
400565 -  ..
400566 - In any case, starting with 1 Neupogen treatment might work, and
400567 - reduces wear and tear, including emotional capital on the patient.
400568 -
400569 -
400570 -
4006 -

Cellulitis Lymphedema Research Reduce Recurrence UCSF No Ideas Advic

6003 -
600401 -  ..
600402 - Cellulitis Lymphedema Research Reduce Recurrence
600403 -
600404 - Millie asked for advice and referral to UCSF for research on
600405 - Cellulitis and lymphedema which increase health care costs and take a
600406 - lot of time for providers and the patient to recover?  Case study on
600407 - patient history in the record for 061203 shows Millie has suffered
600408 - recurrence some 41 times since 2003, ref SDS 47 YT4M, most recently on
600409 - 080409. ref SDS C5 0001  Causes of Cellulitis and lymphedema are shown
600410 - in case study on 070130. ref SDS 60 VX6F  Affects of exercise causing
600411 - recurrence of Cellulitis and lymphedema are tracked in a third study
600412 - on 070218. ref SDS 66 K55K
600414 -  ..
600415 - Brigid seemed to indicate today that UCSF has no advice nor remedies
600416 - to reduce risks of Cellulitis and lymphedema on Millie's left arm.
600417 -
600418 -        [On 080606 surgeon advises that when lymph nodes are removed,
600419 -        remaining lymphatic system eventually grows more robust and
600420 -        reduces recurrence of lymphedema and Cellulitis from increased
600421 -        exercise. ref SDS E8 4P6L
600422 -
600423 -
600424 -
6005 -

Examination IBC Stable to Improved Condition Full Dose Carboplatin C

7603 -
760401 -  ..
760402 - Examination Finds Substantially Reduced IBC Rash Response to Treatment
760403 -
760404 - Follow up ref SDS C1 S55F. ref SDS B7 NW3N.
760406 -  ..
760407 - Brigid made an examination.  She received Millie's letter on 080423
760408 - asking for UCSF opinion on evident good response to treatment with
760409 - reduced IBC rash after starting 2nd arm of clinical study that added
760410 - treatment with Carboplatin chemotherapy. ref SDS D0 TY7X
760412 -  ..
760413 - Brigid reported today IBC disease shows favorable response to
760414 - treatment improving findings on 080403. ref SDS C1 SA5J  There is now
760415 - substantially less IBC rash with Millie getting full dose of
760416 - Carboplatin (230 mg) prescribed for each treatment, beginning with
760417 - cycle 1 on 080313. ref SDS B9 2N4N  Brigid indicated this is good
760418 - recovery from cancer relapse diagnosed by the doctor on 080219,
760419 - ref SDS B5 QY5I, and despite Millie getting only 50% of Carboplatin
760420 - chemotherapy treatments.  Low blood counts required skipping
760421 - treatments on 080320, ref SDS C0 SE5R, and again most recently on
760422 - 080417. ref SDS C8 PU6K
760424 -         ..
760425 -        [On 080502 examination by primary care physician at Kaiser
760426 -        finds favorable response to treatment, ref SDS D8 NH4N, despite
760427 -        getting only 50% of prescribed Carboplatin chemotherapy,
760428 -        ref SDS D8 NH4N, which Millie has tolerated well shown by
760429 -        significantly increased exercise. ref SDS D8 ZD9O
760431 -         ..
760432 -        [On 080520 Millie reported in a letter to the Medical team
760433 -        again further increased energy and exercise showing
760434 -        continued tolerance of chemotherapy Carboplatin treatments
760435 -        at UCSF. ref SDS E2 TV6U
760436 -
760437 -
760438 -
7605 -

CT Test 080425 Findings Cancer Stable Align with Examination Reverse

A203 -
A20401 -  ..
A20402 - CT Test Findings Cancer Stable Align with Examination
A20403 -
A20404 - Brigid seemed to indicate findings from the CT test on 080425 show
A20405 - response to treatment increased on 080313 adding Carboplatin to
A20406 - cetuximab.  Rising adenopathy reported in the prior test on 080212,
A20407 - and reviewed on 080215 seems to have ended based on the recent CT
A20408 - test.  This aligns with review on 080428, ref SDS D2 EO8F, and further
A20409 - reflects examination today showing IBC disease subsiding. ref SDS 0
A20410 - NW3N
A20411 -
A20412 -
A20413 -
A205 -

Exercise Fitness Increase Good Tolerance Carboplatin Chemotherapy Hi

AS03 -
AS0401 -  ..
AS0402 - Exercise Increases Good Tolerance Carboplatin Chemotherapy
AS0403 -
AS0404 - Brigid noted Millie's letter on 080409 citing very good tolerance of
AS0405 - Carboplatin chemotherapy added to cetuximab for the 2nd arm of the
AS0406 - study. ref SDS C4 W14X  Millie reported today significantly increased
AS0407 - exercise in the gym and hiking at Lafayette Reservoir adding distance
AS0408 - and increasing the pace of workouts.  Increases quality of life,
AS0409 - vigor, interest and ability to get things done.
AS0411 -  ..
AS0412 - Previously, exercise was cited on 030606 at Kaiser for helping
AS0413 - patients maintain fitness for aggressive chemotherapy to recover from
AS0414 - cancer. ref SDS 5 NE57
AS0415 -
AS0416 -        [On 080502 examination by primary care physician at Kaiser
AS0417 -        finds favorable response to treatment, ref SDS D8 NH4N,
AS0418 -        despite getting only 50% of prescribed Carboplatin
AS0419 -        chemotherapy, ref SDS D8 NH4N, which Millie has tolerated
AS0420 -        well shown by significantly increased exercise. ref SDS D8
AS0421 -        ZD9O
AS0423 -         ..
AS0424 -        [On 080520 Millie reported in a letter to the Medical team
AS0425 -        again further increased energy and exercise showing
AS0426 -        continued tolerance of chemotherapy Carboplatin treatments
AS0427 -        at UCSF. ref SDS E2 TV6U
AS0429 -         ..
AS0430 -        [On 080528 Millie sent another letter to the medical team
AS0431 -        reporting rising energy and exercise. ref SDS E5 XY9J
AS0433 -  ..
AS0434 - On 050609 article reports study found exercise repairs some of the
AS0435 - cumulative damage chemotherapy causes to the immune system; this
AS0436 - prolings effectiveness of chemotherapy treatment to aid recovery from
AS0437 - breast cancer, ref SDS 21 F88M; quality of life from strength and
AS0438 - range of motion are obvious benefits of exercise. ref SDS 21 F93X
AS0439 -
AS0440 -
AS0441 -
AS05 -

Current Medications New UCSF Case Management System Relies Patient P

BB03 -
BB0401 -  ..
BB0402 - Current Medications Case Management Referral Coordination with Kaiser
BB0403 -
BB0404 - Follow up ref SDS B6 7Y6F.
BB0405 -
BB0406 - Brigid took down a list of current medications, which is a new quality
BB0407 - control procedure being tried at UCSF.  Maintaining a list of current
BB0408 - medications is listed in referral coordination planning proposed on
BB0409 - 070222. ref SDS 67 V16F  On 080307 Millie notified Kaiser Coagulation
BB0410 - Control Department, and the Oncology Department to update list of
BB0411 - current medications, ref SDS B8 RW3T, based on Kaiser's medical chart
BB0412 - for Millie from meeting with the primary care physician on 080305,
BB0413 - ref SDS B6 7Y6F, including discussion of Prosac and Keflex at that
BB0414 - time on 080305. ref SDS B6 IE6M  Today, UCSF did not have the list,
BB0415 - and so asked Millie to construct another list from personal memory.
BB0417 -  ..
BB0418 - Brigid seemed to present a future procedure of UCSF using the list
BB0419 - prepared by hand writing today to construct a printed report which the
BB0420 - patient will examin on subsequent meetings, and continually update,
BB0421 - including sign to authenticate accuracy of the report, so that UCSF
BB0422 - can maintain a list of current medications.
BB0423 -
BB0424 -     [On 080529 Lynn asked Millie if the UCSF front desk staff in the
BB0425 -     breast care clinic submitted the printed list of current
BB0426 -     medications for review, update, and signature; this was not done
BB0427 -     for the meeting on 080529. ref SDS E6 8A9G
BB0428 -
BB0429 -
BB0430 -
BB05 -

Magnesium Low Blood Counts 1.6 Below 1.8 Requirement Labs UCSF Magne

C203 -
C20401 -  ..
C20402 - Magnesium Low Treatment Prescribed
C20403 -
C20404 - Magnesium 1.6 was low again today, so Brigid prescribed treatment with
C20405 - magnesium during infusion treatment today, as was done previously on
C20406 - 080404, ref SDS C3 O059, for the blood test the day before on 080403.
C20407 - ref SDS C2 CP6J
C20409 -  ..
C20410 - Sodium is also low in the blood test today.  Brigid noted this is only
C20411 - very slightly low, as is carbon, and so these conditions do not
C20412 - require treatment.
C20413 -
C20414 -
C20415 -
C205 -

Power Port Huber Needle Solution UCSF Mistakes CT Test Injury 4 Need

CM03 -
CM0401 -  ..
CM0402 - CT Test Huber Needle Power Port Inject Contrast Medium
CM0403 - Power Port Huber Needle CT Test New Method Avoid Needle Punctures
CM0404 -
CM0405 - Brigid noted during the meeting today that she received Millie's
CM0406 - letter submitted yesterday on 080430 requesting UCSF comment on
CM0407 - Kaiser's letter the day before on 080429, ref SDS D4 W64T, which
CM0408 - advised that Millie's primary care physician is investigating the use
CM0409 - of a "Huber" needle with Millie's current port catheter for CT tests.
CM0410 - ref SDS D3 1H6Y  Using a port avoids injury, pain, and suffering which
CM0411 - have escalated with recent CT tests using conventional IV needle
CM0412 - punctures into Millie's right arm to inject test contrast medium,
CM0413 - reported last week on 080425. ref SDS D1 FP6F
CM0415 -  ..
CM0416 - Brigid advised that last June in 2007, UCSF adopted a policy of
CM0417 - implanting only Power Port catheters for IV transfusions and drawing
CM0418 - blood.  She explained that UCSF experienced problems using standard
CM0419 - port catheters for injecting CT test contrast medium.  These
CM0420 - injections create greater pressures on the port mechanism than occurs
CM0421 - from blood draws and IV injections of chemotherapy treatment drugs,
CM0422 - e.g., Taxotere, Bevacizumab, Carboplatin, and this can cause the port
CM0423 - to fail, with significant problems for patients.  Brigid said the new
CM0424 - Power Port catheters are designed to withstand the higher pressures
CM0425 - that occur with CT test injections.  This solves problems of patient
CM0426 - safety that occurred with the earlier technology for port catheters.
CM0427 - Brigid was unaware of any patient safety issues using the new Power
CM0428 - Ports for injecting CT test contrast medium.
CM0430 -  ..
CM0431 - Millie asked how the Power Port can be used in her case?
CM0433 -  ..
CM0434 - Brigid feels the Power Port has to be implanted through another
CM0435 - surgery at the same location as the current port.  She said the port
CM0436 - should not be installed on the left side where IBC disease has been
CM0437 - active.  This aligns with procedures explained at Kaiser on 040318.
CM0438 - ref SDS 10 OF7H  Nor can the port be installed on a leg, or below the
CM0439 - chest area.  Brigid seemed to say the only way Millie can use a Power
CM0440 - Port catheter is to remove and replace the existing port.
CM0442 -  ..
CM0443 - Surgery to upgrade Millie's port catheter to a Power Port is needed in
CM0444 - time for the next CT test.  The recent test on 080425 was on the 12
CM0445 - week schedule the doctor implemented on 071009, ref SDS B2 985H; the
CM0446 - previous test on 080212 was expedited by the doctor on 080207 to
CM0447 - evaluate progression of disease. ref SDS B4 GH5M  The 12 week schedule
CM0448 - calculates to 080718 for the next CT test.
CM0449 -
CM0450 -     [On 080502 Millie met with the primary care physician at Kaiser;
CM0451 -     the doctor made findings of injury to Millie's right arm caused by
CM0452 -     needle punctures to inject contrast medium; ref SDS D8 WX6I; he
CM0453 -     considered UCSF experience using Power Ports to inject CT test
CM0454 -     contrast medium which avoids trauma from conventional IV needle
CM0455 -     punctures, ref SDS D8 J13G; during the meeting, the doctor sent a
CM0456 -     referral letter to the surgeon to replace the port catheter with a
CM0457 -     Power Port for injecting contrast medium on future CT tests.
CM0458 -     ref SDS D8 VG5J
CM0460 -      ..
CM0461 -     [On 080502 Millie sent a letter coordinating the medical team on
CM0462 -     work at Kaiser to implant a Power Port in time for doing the next
CM0463 -     CT test with a Power Port. ref SDS D9 GN8P
CM0465 -      ..
CM0466 -     [On 080508 Millie asks primary care physician about progress
CM0467 -     scheduling surgery to upgrade the port catheter to a Power Port
CM0468 -     for injecting contrast medium in time for the next CT test.
CM0469 -     ref SDS E0 GO8G
CM0471 -      ..
CM0472 -     [On 080520 Kaiser did not respond; Millie sent followed up letter
CM0473 -     asking Kaiser to coordinate with the Surgery department on
CM0474 -     expediting Power Port surgery, ref SDS E2 GS8K, in time for next
CM0475 -     CT test expected in 4 weeks. ref SDS E2 TV4S
CM0477 -      ..
CM0478 -     [On 080523 Millie received a letter from Kaiser advising
CM0479 -     that the surgeon reports Kaiser can upgrade Millie's port
CM0480 -     catheter to a Power Port, and he made a referral for this
CM0481 -     work to be performed, ref SDS E3 MG6F; this will solve the
CM0482 -     problems reported on 080425 injecting contrast medium for CT
CM0483 -     tests. ref SDS D1 FP6F
CM0485 -      ..
CM0486 -     [On 080528 Millie's letter to the medical team coordinated
CM0487 -     planning required for surgery to implant a Power Port,
CM0488 -     ref SDS E5 IJ6W, and for CT test department to use the Power
CM0489 -     Port for Millie's next test. ref SDS E5 IK4Q
CM0491 -      ..
CM0492 -     [On 080606 Millie met with the surgeon at Kaiser on planning to
CM0493 -     upgrade port catheter to Power Port implements direction from UCSF
CM0494 -     to do the work on the right side opposite from the primary
CM0495 -     location of Millie's cancer on the left side. ref SDS E8 IT77
CM0497 -      ..
CM0498 -     [On 080608 Millie sent a letter to the surgeon using Kaiser's
CM0499 -     internal email system, because the doctor is not included in
CM0500 -     distribution for referral coordination with the medical team at
CM0501 -     Kaiser and UCSF; and notifying the surgeon of requirements to
CM0502 -     coordinate surgery to implant the Power Port and to access the new
CM0503 -     port with a Huber needle to enable CT testing within the next few
CM0504 -     days after surgery. ref SDS E9 XS4S
CM0506 -      ..
CM0507 -     [On 080609 Kaiser Surgery Department notified the patient that
CM0508 -     requirements for coordination of Power Port surgery in time for
CM0509 -     the next CT test were presented to the Schedule Department.
CM0510 -     ref SDS F0 MG5I
CM0512 -      ..
CM0513 -     [On 080617 Power Port surgery scheduled on 080708. ref SDS F2
CM0514 -     3C7N; CT test using Power Port scheduled 10 days later on 080718
CM0515 -     1100. ref SDS F2 DF55
CM0517 -      ..
CM0518 -     [On 080619 Millie notified medical team at Kaiser and UCSF that CT
CM0519 -     test is scheduled to use the Power Port on 080718, ref SDS F3
CM0520 -     YU6X; cites requirements to resolve protocol and certification
CM0521 -     issues over next 4 weeks. ref SDS F3 YV4R
CM0523 -      ..
CM0524 -     [On 080625 Millie's letter to medical team at Kaiser and UCSF
CM0525 -     confirms planning for CT test at Kaiser to use the Power Port for
CM0526 -     saving time and money that meets requirements cost containment.
CM0527 -     ref SDS F4 IU7R
CM0529 -      ..
CM0530 -     [On 080702 Millie's letter to medical team confirms that on 080627
CM0531 -     the primary care physician coordinated support by the Infusion
CM0532 -     Clinic to access the Power Port on 080718 in time for CT test at
CM0533 -     1100; and further initiated planning that, if no one else is
CM0534 -     assigned, the primary care physician will personally press the
CM0535 -     button for the CT test using the Power Port on 080718. ref SDS F5
CM0536 -     EQ3T
CM0538 -  ..
CM0539 - Brigid further indicated that surgery to remove and replace the
CM0540 - existing port with a Power Port presents high risks of surgery.  She
CM0541 - commented that risks Millie faces from trauma to her arm, experienced
CM0542 - recently on 080425, ref SDS D1 9W9I, are likely less than risks from
CM0543 - surgery to upgrade the port that will avoid trauma to the arm from
CM0544 - future CT test injections.
CM0545 -
CM0546 -     [On 080606 Kaiser surgeon schedules work to upgrade port catheter
CM0547 -     to a Power Port; reports experience shows this work can be done
CM0548 -     with risks comparable to the original surgery classified as
CM0549 -     minimal. ref SDS E8 IT6M
CM0551 -  ..
CM0552 - UCSF analysis today seems conflicting with Rosalie's explanation at
CM0553 - Kaiser on 040402 that outpatient minor surgery to implant port
CM0554 - catheter equipment is a common solution to avoid injury from continued
CM0555 - needle penetrations. ref SDS 11 V750  At that time, Kaiser did not
CM0556 - present risks of surgery as criteria for avoiding this solution, and
CM0557 - in fact scheduled the surgery.  The work was performed on 04019.
CM0558 - Kaiser post operation report described successful surgery, the whole
CM0559 - thing took about 20 minutes, ref SDS 13 PPSW
CM0561 -  ..
CM0562 - Kaiser's post-operation report has proven accurate, since the port
CM0563 - catheter has been effective for the past 4 years eliminating needle
CM0564 - punctures except for injecting CT test contrast medium.  Since this
CM0565 - latter issue CT test injectins has now become extremely problematic it
CM0566 - is unclear why upgrading the port should present greater risks than
CM0567 - existed originally, and which Kaiser has demonstrated ability to
CM0568 - manage successfully.
CM0570 -  ..
CM0571 - Brigid further explained that UCSF approves using a standard port
CM0572 - catheter, like Millie now has, to inject CT contrast medium for
CM0573 - patients who have severe injury from needle penetrations, as Millie
CM0574 - suffered on 080425. ref SDS D1 FP6F  Brigid indicated this procedure
CM0575 - requires slowing the rate of injecting CT contrast medium in order to
CM0576 - avoid damaging the port catheter, and so involves risks of failure.
CM0578 -  ..
CM0579 - This seems to suggest a strategy of trying Millie's current port on
CM0580 - the next CT test, and if it is damaged, then schedule replacement for
CM0581 - the test after that.  Brigid indicated that some CT test professionals
CM0582 - avoid accessing a port catheter for injecting contrast medium.  Millie
CM0583 - recalled asking the CT test technician at Kaiser on 080425 about using
CM0584 - her port catheter, and he was adament Kaiser would not approve this
CM0585 - procedure. ref SDS D1 2I4F
CM0587 -  ..
CM0588 - Since Kaiser policy prevents using a port catheter, Millie needs
CM0589 - surgery to upgrade to a Power Port as explained by Brigid today, per
CM0590 - above. ref SDS 0 TQ6F  Surgery should occur befor the next CT test.
CM0591 - The recent test on 080425 was 12 weeks after the prior test on 080212.
CM0592 - This allows 2 - 3 months for the surgery in time for the next CT test
CM0593 - in mid-July.
CM0594 -
CM0595 -        [On 080502 primary care physician sent a letter to surgeon at
CM0596 -        Kaiser investigating follow up surgery to upgrade Millie's port
CM0597 -        catheter implanted on 040419 to a "Power Port" for injecting CT
CM0598 -        test contrast medium in order to avoid further injury, pain,
CM0599 -        and suffering, ref SDS B3 VG5J; there is also consideration of
CM0600 -        using the existing port catheter by slowing the rate of
CM0601 -        injecting contrast medium for CT tests (point 2), if that is
CM0602 -        possible, which reduces risk of damaging the port from high
CM0603 -        pressure that occurs from CT test injections. ref SDS B3 847I
CM0605 -         ..
CM0606 -        [On 080508 Millie asks primary care physician about
CM0607 -        progress scheduling surgery to upgrade the port catheter
CM0608 -        to a Power Port for injecting contrast medium in time
CM0609 -        for the next CT test. ref SDS D1 GO8G
CM0610 -
CM0611 -
CM0612 -
CM0613 -
CM0614 -
CM0615 -
CM0616 -
CM07 -