THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: June 26, 2008 08:30 AM Thursday;
Millie meeting UCSF 5th cycle cetuximab Carboplatin treat IBC.
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1...Brigid will request a copy of the Chemotherapy Order from the Infusion
Meeting Examination Doctor Review Strategy Work Plan 3rd Cycle 1st T
CT Testcle 3rd Relapse IBC 5th Cycle 1st Treatment Chemotherapy Agen
1504 - ..
1505 - Summary/Objective
150601 - Follow up ref SDS D9 0000. ref SDS D2 0000.
150607 - ..
1509 - Progress
151001 - Millie went to the 5th floor Infusion Clinic at 0800 and got a blood
151002 - draw. Catherine is coming in now at 0800. Diane was also in the
151003 - clinic this morning. She related schedule changes working on Sundays
151004 - which explain why we have not seen her for a few weeks on Thursdays.
151006 - ..
151007 - Catherine said the medical team in the Breast Care Clinic on the 2nd
151008 - floor did not submit orders and vials to the Infusion Clinic on the
151009 - 5th floor for the blood draw today. She used the scope for lab
151010 - orders, ref SDS E9 439L, as set out in Millie's letter to the medical
151011 - team yesterday on 080625. ref SDS E8 IU3Y There seems to be a growing
151012 - commnication problem collaborating on this account, illustrated by
151013 - work last month on 080529. ref SDS D9 4E5J
151015 - ..
151016 - Millie met with Brigid at 0830 on the 2nd floor.
151018 - ..
151019 - Brigid introduced two trainees, Thomas and Eileen, or Patty (not
151020 - sure). Thomas called Millie a few days ago about the CT test
151021 - schedule. Brigid said this morning that Thomas is the study
151022 - coordinator today for Millie's case, because Megan is out of town.
151024 - [On 080724 Thomas leaves assignment for Study Coordinator, and
151025 - replaced by Jonathon; encountered difficulties with referral
151026 - coordination. ref SDS F5 KV4M
151028 - ..
151029 - Brigid had reviewed the letter Millie submitted to the medical team
151030 - yesterday. She did not have a copy of the letter, and so asked
151031 - Millie about the agenda for today.
151033 - ..
151034 - Millie explained the letter reminded the medical team to take the
151035 - order for the blood draw to the 5th floor clinic this morning. She
151036 - asked how the patient can support the medical team for timely
151037 - coordination with the Infusion Clinic?
151039 - ..
151040 - Thomas explained that Catherine did not have the order for Millie
151041 - blood draw this morning, because he planned to submit this with the
151042 - Chemotherapy Orders to the Infusion Clinic on the 5th floor, after
151043 - Millie meets with the medical team on the 2nd floor.
151045 - ..
151046 - Brigid was pleased that Catherine took immediate action to recover
151047 - from delay getting the order for a blood draw by doing the work based
151048 - on prior orders, so that UCSF can post critical results in time for
151049 - the meeting, which was, also, proposed in Millie's letter to UCSF
151050 - yesterday.
151052 - ..
151053 - During the meeting, results for the blood draw this morning were
151054 - displayed on Brigid's computer screen in the examination room. Brigid
151055 - noted that NEUTS 1.80 is a very favorable test result, ref SDS E9
151056 - QY6H, that enbles Millie to get treatment today with Carboplatin, by
151057 - increasing from very low NEUTS .74 in the blood test last week on
151058 - 080619. ref SDS E5 PU6K
151060 - ..
151061 - Improvement in blood counts for Millie to get chemotherapy today
151062 - supports Brigid's letter on 080620 calling for Millie to get only 1
151063 - Neupogen treatment at Kaiser, ref SDS E7 YY5H, rather than 2
151064 - treatments which was raised in Millie's letter to the medical team the
151065 - day before on 080619. ref SDS E6 YU8W
151067 - ..
151068 - Brigid said that the Chemotherapy Orders for Carboplatin issued by the
151069 - doctor today for the 5th cycle continues with 2 Neupogen treatments
151070 - starting tomorrow, as specified in the Chemotherapy Orders 4 weeks ago
151071 - starting the 4th cycle on 080529. ref SDS E0 PWSY
151073 - [...in another record today, Chemotherapy Orders for
151074 - Carboplatin show no prescription for Neuopgen. ref SDS E9 PWSY
151076 - ..
151077 - [On 080721 UCSF advises that Neupogen treatment was not needed
151078 - to recover blood counts, ref SDS F3 YU7N, from the bleeding
151079 - incident today on 080718, per above, ref SDS F2 IC6F, and in
151080 - order to get chemotherapy next Thursday at UCSF.
151082 - ..
151083 - [On 080814 UCSF advises Neupogen was ordered for the Power Port
151084 - matter. ref SDS F7 4Q5O which seems conflicting with the record
151085 - on 080721. ref SDS F3 YU7N
151087 - ..
151088 - Brigid was pleased to hear that Kaiser has scheduled Millie for weekly
151089 - Neupogen treatments in the Infusion Clinic. She advised that the
151090 - doctor has prescribed 2 Neupogen treatments per weekly treatment with
151091 - Carboplatin, continuing the work plan in the Chemotherapy Order for
151092 - cycle 4 issued on 080529. ref SDS E0 PWSY
151094 - ..
151095 - Millie asked why UCSF changed the amount of Carboplatin treatment
151096 - from 250 mg to 175 mg in the Chemotehrapy Orders on 080501, and again
151097 - on 080529? There is nothing in the record on this change.
151099 - ..
151100 - Millie received the doctor's letter dated 080423 disclosing that once
151101 - the dose of Carboplatin treatment is reduced the treatment protocol
151102 - does not permit increasing the dose to improve effectiveness.
151103 - ref SDS C8 415F Patient history reviewed on 080418 shows Millie has
151104 - repsonded well to adjusting the dose up and down for chemotherapy
151105 - treatments according to blood counts. ref SDS C7 598J
151107 - ..
151108 - Millie advised UCSF later that day on 080423 that she tolerated the
151109 - full dose of Carboplatin well, and so preferred to continue with this
151110 - regimen in order to optimize recovery from IBC, and increase Neupogen
151111 - to increase blood counts rather than reduce the dose of Carboplatin.
151112 - ref SDS C8 TY6Y
151114 - ..
151115 - Millie asked about the error in the dose of Carboplatin specified by
151116 - Chemotherapy Orders for 080529? ref SDS E0 PVUQ Can UCSF correct the
151117 - mistake by increasing the dose to the higher levels requested in
151118 - Millie's letter?
151120 - ..
151121 - Brigid recalled there was confusion during the meeting on 080501,
151122 - because Doctor Rugo was out of town that day. ref SDS D2 4G7G
151123 - Starting the next cycle on 080529, Doctor Rugo was again out of town,
151124 - and Jackie, who normally does study coordination for Millie, was not
151125 - available. Brigid was also away performing annual reserve duty with
151126 - the military. ref SDS D9 4E65 Case management was hectic on 080529
151127 - with everyone new to Millie's case. ref SDS D9 NW35
151129 - ..
151130 - Today, Brigid looked through Millie's medical chart. She said the
151131 - Chemotherapy Orders on 080529 showing "error" for the dose of
151132 - Carboplatin treatments is missing from the file. Doctor Rugo was
151133 - concerned about data missing from the medical chart on 080219.
151134 - ref SDS B9 L18L Starting the prior cycle on 080529 Lynn and Megan
151135 - filled in some data that was missing from the medical chart,
151136 - ref SDS D9 L255, and discussed finding an error in the Chemotherapy
151137 - Order. ref SDS D9 NW89
151139 - ..
151140 - Millie said the Chemotherapy Orders for Carboplatin received from UCSF
151141 - for 080529, actually received on 080605 and marked Received by the
151142 - Infusion Clinic on 080602 shown an error on the dose for Carboplatin.
151144 - ..
151145 - Brigid will request a copy of the Chemotherapy Order from the Infusion
151146 - Clinic and make a review to make sense of what has happened the past
151147 - several cycles.
151149 - [...in another record after meeting on the 2nd floor, the
151150 - files for the Infusion Clinic on the 5th floor show the
151151 - Chemotherapy Order for 080529 that seems to be missing from
151152 - the medical chart used by the medical team. ref SDS E9 CD4F
151154 - ..
151155 - [On 080724 medical team has not had time to review the
151156 - error in the Chemotherapy Order on 080529, ref SDS F5 PW6G,
151157 - the new Chemotherapy Order for 080724 shows same dose
151158 - marked "error" in the work on 080529. ref SDS F6 PVVR
151160 - ..
151161 - Planning to upgrade the port catheter to a Power Port reported by
151162 - Kaiser on 080523, ref SDS D7 MG6F, was not discussed during the
151163 - meeting today, because Lynn did not get the letter on this issue
151164 - submitted to UCSF yesterday, ref SDS D8 IJ6W, as related above.
151165 - ref SDS D9 4E69
151167 - ..
151168 - Brigid asked Millie if she received a printed report from the staff at
151169 - the front desk showing her current medications, based on the meeting
151170 - last month when Lynn discussed this with Millie, reported on 080529?
151171 - ref SDS D9 8A9G
151173 - ..
151174 - Millie handed Brigid the list received from the front desk clerk, and
151175 - explained that Kaiser submitted a complete list of patient medications
151176 - prescribed for her care, shown in the record meeting with Kaiser on
151177 - 080502, ref SDS D3 E43I, and including comments on frequency of use.
151178 - ref SDS D3 N84O This supplements the list Brigid prepared at UCSF on
151179 - 080501? ref SDS D2 QK4G
151181 - ..
151182 - Millie advised today that there have been no changes to Kaiser's
151183 - list of current medications since 080502, and seems considerably
151184 - longer than the list UCSF has on file.
151186 - ..
151187 - Brigid made an examination.
151189 - ..
151190 - There were no findings of adenopathy on the left axilla and left
151191 - supraclavicular, and no indications from palpation of lumps in the
151192 - right axillary. Brigid noted intensity of IBC disease has subsided
151193 - from the prior examination Brigid made on 080501. ref SDS D2 JJ3N
151195 - [On 080627 primary care physician at Kaiser examination finds
151196 - improving and stable IBC disease. ref SDS F0 NH4N
151198 - ..
151199 - Brigid advised that the doctor wants to advance the date of the next
151200 - CT test scheduled for 080718 by Kaiser on 080617, ref SDS E4 DF55, and
151201 - implementing plans presented at UCSF on 080529. ref SDS D9 3F9O She
151202 - explained that CT tests should be performed according to the original
151203 - 8 week schedule, beginning from the start of the 2nd arm of Millie's
151204 - care in the cetuximab Carboplatin clinical study. Previously, on
151205 - 080619 Thomas had called for Doctor Rugo and proposed advancing the
151206 - CT test on the same grounds of switching back from 12 to 8 weeks
151207 - between tests. ref SDS E6 YV5W
151209 - [On 080821 UCSF does not discuss results of CT test which were
151210 - subject of considerable discussion to expedite, ref SDS F8
151211 - MF9K; only review of findings reported in patient record on
151212 - 080723. ref SDS F4 4K5H
151214 - ..
151215 - Millie related the follow up call yesterday from Thomas again asking
151216 - about advancing the date of the CT test, and cited in Millie's letter
151217 - to Kaiser yesterday on 080625. ref SDS E8 IU5X
151219 - [On 080627 referral coordination with primary care physician at
151220 - Kaiser indicates that surgery on 080708 to implant a Power
151221 - Power controls the next CT test scheduled for 080718.
151222 - ref SDS F0 NF62
151224 - ..
151225 - [On 080708 CA 15-3 141 cancer marker for labs at Kaiser to
151226 - support surgery seem conflicting with clinical examination
151227 - findings today; raise major concern of advancing disease; tests
151228 - may have been compromised, so CT test and follow up labs at
151229 - UCSF will guide assessment. ref SDS F1 L74K
151231 - ..
151232 - Brigid received Millie's letter, and said that patient support
151233 - advancing the date of the CT test, ref SDS E8 IU6U, will help align
151234 - testing at Kaiser with clinical study protocol at UCSF.
151236 - [On 080627 primary care physician at Kaiser reported that
151237 - surgery upgrade port catheter to Power Port controls date of CT
151238 - test in order to use the Power Port for the CT test to prevent
151239 - further injury to Millie's arm.
151241 - ..
151242 - [On 080718 CT test at Kaiser tried using Power Port; problems
151243 - prevented completing the test, ref SDS F2 LK3R, the test was
151244 - performed with conventional IV. ref SDS F2 A363
151246 - ..
151247 - [On 080723 report on CT test shows no evidence progression of
151248 - disease. ref SDS F4 4K5H
151250 - ..
151251 - Millie reviewed work at UCSF, Kaiser and by the patient over many
151252 - months to schedule the CT test in accordance with examination by the
151253 - primary care physician at Kaiser on 080502 finding damage to the right
151254 - arm from needle punctures for injecting CT test contrast medium.
151255 - ref SDS D3 WX6I Brigid seemed aware that the doctor made a referral
151256 - at that time on 080502 prescribing surgery to implant a Power Port
151257 - that avoids further damage from needle punctures for injecting CT test
151258 - contrast medium, ref SDS D3 VG5J, as set out in Millie's letter to
151259 - UCSF on 080502. ref SDS D4 GN8P Brigid recalled presenting the Power
151260 - Port solution to Millie during a meeting at UCSF the day before on
151261 - 080501. ref SDS D2 766K
151263 - ..
151264 - Brigid feels the UCSF medical chart for the meeting on 080529 should
151265 - show the patient disclosed planning for the CT test after surgery to
151266 - implant the Power Port, ref SDS D9 4F47, as proposed by UCSF on
151267 - 080501, and since this was submitted in a letter to UCSF on 080528.
151268 - ref SDS D8 IJ6W
151270 - ..
151271 - Brigid noted that the doctor appreciates Millie's efforts on 080617 to
151272 - coordinate complex scheduling that accomodates conflicting conditions
151273 - across multiple departments, ref SDS E4 MG5I, and offer to undergoe CT
151274 - testing prior to surgery for the Power Port, even though this will
151275 - cause damage to her arm, noted by Kaiser's examination on 080502, and
151276 - in order to accomplish UCSF requirements for timely CT testing, citing
151277 - again Millie's letter yesterday. ref SDS E8 IU5V
151279 - ..
151280 - Millie cited concern that many hours coordinating to schedule CT
151281 - testing this cycle to follow Power Port surgery that prevents further
151282 - damage to the patient at the level caused by previous CT tests
151283 - reported on 080425, ref SDS C9 FP6F, has been presented at UCSF as an
151284 - unnecessary convenience for avoiding patient "discomfort," rather than
151285 - a requirement determined by the doctor on 080502 for avoding further
151286 - damage to the patient? ref SDS D3 WX6I
151288 - [On 080627 referral coordination with primary care physician at
151289 - Kaiser indicates that surgery on 080708 to implant a Power
151290 - Power controls the next CT test scheduled for 080718.
151291 - ref SDS F0 NF62
151293 - ..
151294 - Brigid explained that limited time makes understanding controlling
151295 - forces very difficult on complex work. Health care professionals have
151296 - many responsibilities that reduce the time for careful review to grasp
151297 - correlations, implications, and nuance in this case.
151299 - ..
151300 - Millie asked why UCSF request for a specific date on the CT test was
151301 - not presented in time for effective coordination to schedule surgery
151302 - that controls the date of the CT test at Kaiser? Last minute calls
151303 - requesting changes to work that are hard to schedule create emotional
151304 - trauma, stress, and anxiety among patients and health care providers.
151305 - On 080403 Doctor Rugo explained challenges coordination presents for
151306 - professional people. ref SDS C3 S26I At that time, the doctor asked
151307 - for support through the doctor/patient partnership. ref SDS C3 4U9O
151308 - As with the Neupogen issue on 080403, Millie has coordinated CT
151309 - testing and surgery for orderly performance of the work.
151311 - ..
151312 - Brigid noted that referral coordination is complex, difficult work
151313 - that nobody likes to do. She explained that Thomas will coordinate
151314 - changes to CT testing and Millie's surgery.
151316 - [On 080627 referral coordination with primary care physician at
151317 - Kaiser indicates that surgery on 080708 to implant a Power
151318 - Power controls the next CT test scheduled for 080718.
151319 - ref SDS F0 NF62