CONTACTS 

SUBJECTS
Power Port Access Failure Recovery Surgery Incision Bleeding Extrava

1703 -
1703 -    ..
1704 - Summary/Objective
1705 -
170501 - Follow up ref SDS 44 0000. ref SDS 43 0000.
170502 -
170503 - Millie was given 2 injections of Neupogen for treatment that meets
170504 - UCSF prescription of 480 mcg. ref SDS 0 SR37  Power port was accessed
170505 - with 1" Huber needle, and seems to be in good working order.
170506 - ref SDS 0 OH5H  Port was flushed according to protocol. ref SDS 0 LD7N
170507 - Surgical wound examined.  Shows slight separation from bleeding during
170508 - attempts to perform power injection for CT test yesterday; incision
170509 - wound was cleaned, and fresh surgical tape applied. ref SDS 0 LD84
170510 - Millie greatly relieved.  Everything seems in place for treatment at
170511 - UCSF on Thursday, 080724.  Hikes 5.5 miles. ref SDS 0 LD8J  Kaiser
170512 - called and left message in late morning to advise work was approved by
170513 - the doctor. ref SDS 0 PRXW
170514 -
170515 -
170516 -
170517 -
170518 -
170520 -  ..
1706 -
1707 -
1708 - Progress
1709 -
170901 - Kaiser Infusion Clinic Neupogen and Access Power Port
170902 -
170903 - Follow up ref SDS 44 9W9I, ref SDS 22 9W9I.
170904 -
170905 - Millie went to the Adult Medicine counter on the 2nd floor across the
170906 - hall from Oncology, which is closed on weekends.  She gave her Kaiser
170907 - membership card to the attendant.
170909 -  ..
170910 - The attendant found Millie is scheduled for Neupogen treatment, per
170911 - Zan's schedule received on 080711. ref SDS 40 PF4F  This conflicted
170912 - with the meeting yesterday in the Oncology Department, when Millie
170913 - cancelled treatment for yesterday and today, ref SDS 44 9W9I, based on
170914 - having high blood counts at UCSF the day before on 080717. ref SDS 43
170915 - QY6H, which resulted in Catherine saying Neupogen treatment is not
170916 - needed this week. ref SDS 43 PU6K
170918 -  ..
170919 - Walked back to the Oncology Department, and to the waiting area for
170920 - the Infusion Clinic.  In a few minutes, a nurse opened the door and
170921 - led Millie into the Infusion Clinic.
170922 -
170923 -
170924 -
170925 -
1710 -

SUBJECTS
Power Port Access Failure Recovery Surgery Incision Bleeding Extrava

2703 -
270401 -  ..
270402 - Surprise Millie Doing Well 7 Years Stage IV Cancer Treatments
270403 - Chemotherapy Clinic Familiar Faces Build Confidence Recover CT Problems
270404 -
270405 - Sharee and Julie recognized Millie from providing care in 2002 - 2006.
270406 - They were surprised Millie is still alive, and very gracious welcoming
270407 - Millie back to the Chemotherapy Clinic for Neupogen treatments,
270408 - similar to the surgeon's surprise meeting Millie last month on 080606
270409 - to plan surgery for the Power Port. ref SDS 32 0T6I
270411 -  ..
270412 - Millie laughed, and said Kaiser has taken good care of her.  She was
270413 - apologetic coming in today for treatment due to exigent circumstances
270414 - to recover from problems with the CT test yesterday.
270415 -
270416 -        [On 080811 Sheree called for Paula to schedule Millie's next CT
270417 -        test this time at Kaiser in Oakland where there is experience
270418 -        using the Power Port. ref SDS 51 L45M
270420 -         ..
270421 -        [On 090213 case study patient advised to get affairs in
270422 -        order for life ending in months. ref SDS 53 L19H
270424 -  ..
270425 - Sharee has treated Millie on several occassions, e.g., on 021204,
270426 - ref SDS 3 LY3G, and previously on 020318. ref SDS 2 0R3X  Sharee
270427 - worked with Millie again, assisting Diana providing chemotherapy on
270428 - 040615.  At that time, Sharee submitted a lab report showing Millie's
270429 - blood counts increased, ref SDS 7 MY9K, so Kaiser increased
270430 - chemotherapy to a full dose. ref SDS 7 4N5M  There was some confusion
270431 - that day taking vitals. ref SDS 7 053H
270432 -
270433 -
270435 -  ..
270436 - Cancelled Treatment Reinstated Due to Exigent Circumstances
270437 -
270438 - Sharee asked about the scope of work today?  What needs to be done?
270440 -  ..
270441 - She checked the medical chart and noted Millie was scheduled for
270442 - Neupogen treatment today, but the chart is marked "cancelled."
270444 -  ..
270445 - Julie asked who prescribed Neupogen, and why was treatment cancelled?
270447 -  ..
270448 - Millie cited her letter to Kaiser and the medical team early this
270449 - morning, reported in the record yesterday, ref SDS 44 I46Q, and Didi's
270450 - letter through the Kaiser Hot Line system requesting treatment today.
270451 - ref SDS 44 4545
270453 -  ..
270454 - Sharee said there is nothing in Millie's medical chart showing these
270455 - communications.  The medical chart indicates Millie has not been
270456 - treated in the Infusion Clinic at Kaiser for a long time.
270458 -  ..
270459 - Millie explained treatment on referral from Kaiser in a clinical study
270460 - at UCSF the past 18 months.  Kaiser retains responsibility for tests
270461 - and medications.
270463 -  ..
270464 - UCSF prescribes Neupogen in Chemotherapy Orders for each 4-week cycle.
270465 - Millie's primary care physician at Kaiser ordered treatments in the
270466 - Infusion Clinic here at Kaiser, which were scheduled on 080609 by Zan
270467 - in the Oncology Pharmacy. ref SDS 33 IL6I  Actual treatments depend on
270468 - blood counts reported in labs at UCSF each week on Thursday.  This
270469 - past Thursday, 080717, blood counts were very high, and Millie was
270470 - treated only with cetuximab, because the 4th treatment in the cycle is
270471 - a bye week for Carboplatin.  Since, Millie did not get Carboplatin
270472 - chemotherapy, the nurse at UCSF said Neupogen treatment is not needed
270473 - this week. ref SDS 43 V46L
270475 -  ..
270476 - Yesterday, on 080718 Millie went to the Oncology counter at 1030, and
270477 - notified Kaiser she did not need the port accessed for the CT test,
270478 - ref SDS 44 2U4S, which Bella had scheduled on 080617 for 1030, because
270479 - the CT Department called on Wednesday and said they had made other
270480 - arrangements for this to be performed in the CT Department during the
270481 - test.  They said they cancelled the meeting in the Infusion Clinic for
270482 - port access, ref SDS 42 AN5I, but since sometimes communications get
270483 - mixed up, Millie notified the Infusion Clinic as a courtesy, as well.
270485 -  ..
270486 - At that same time, 080718 1030, Millie, further, notified the Oncology
270487 - counter attendant that Neupogen treatments are not needed this week,
270488 - i.e., for yesterday and today, on advice of UCSF, because her blood
270489 - counts are already very high, and yesterday was a bye week in her
270490 - treatment that omits Carboplatin chemotherapy. ref SDS 44 9W9I,
270492 -  ..
270493 - After cancelling Neupogen treatments for this week, Millie went to the
270494 - Radiology Department located in the basement for a CT test at 1100.
270495 - At that time on 080718, the CT test failed using the Power Port,
270496 - causing bleeding from the wound for Power Port surgery, ref SDS 44
270497 - A26Y, performed a week earlier on 080708.  Swelling in the right
270498 - chest, shoulder, and arm from contrast medium overflowing the Power
270499 - Port during power injection, ref SDS 44 NN5P, prevented flushing the
270500 - port after the procedure, as required by manufacturer's Instructions
270501 - for Use on Power Injection Procedures, step 11. ref SDS 44 YX8N
270502 -
270503 -            [On 080811 Paula investigating solutions to support CT
270504 -            Department for Millie's next test OA 080912; issue has been
270505 -            elevated, but no progress from management reported at this
270506 -            time, ref SDS 51 LD3H; there seems to be at least three (3)
270507 -            solutions. ref SDS 51 CW3O  Paula coordinating with primary
270508 -            care physician about contacting Kaiser Oakland to perform
270509 -            Millie's next CT test. ref SDS 51 DE79
270511 -  ..
270512 - Yesterday, after the CT test episode, Millie called Kaiser about
270513 - getting Neupogen treatment today as a precaution to maintain blood
270514 - counts in order to get chemotherapy treatment to start cycle 6 at UCSF
270515 - on Thursday, 080724. ref SDS 44 CE5O  Kaiser was called using an
270516 - after-hours hot line.  As noted, Didi suggested Millie get a blood
270517 - draw today to see if a Neupogen treatment is needed.  She sent a
270518 - message to Millie's doctor asked about ordering the labs, Neupogen
270519 - treatment, and to access Millie's port if possible, and to maintain
270520 - the port, which could not be done at Kaiesr yesteday. ref SDS 44 4535
270522 -  ..
270523 - Didi said that Kaiser would respond by 0900 this morning. ref SDS 44
270524 - 4545  By 1030 Kaiser had not responded, so Millie came to the Infusion
270525 - Clinic for assistance.
270526 -
270527 -            [...below, when Millie returned from Kaiser, there was a
270528 -            telephone message from Kaiser telling Millie to get
270529 -            treatment at the Infusion Clinic. ref SDS 0 PRXW
270531 -             ..
270532 -            [On 080724 labs at UCSF for treatment show NEUTS 2.74 (ANC
270533 -            2740 at Kaiser), declined from the week before despite
270534 -            bye-week for Carboplatin chemotherapy; indicates getting
270535 -            Neupogen treatment at Kaiser was helpful proactive case
270536 -            management. ref SDS 48 PU6K
270537 -
270539 -  ..
270540 - Swelling Overflow CT Contrast Medium Substantially Reduced
270541 - Communication Delay Orders Recover from CT Test Problems Not Received
270542 - Experienced Nurse Adjusted to Context Applied Judgement Expedites Work
270543 -
270544 - Today, swelling on the right chest, shoulder, and arm has gone down
270545 - considerably, from conditions yesterday that prevented port access
270546 - during the CT test. ref SDS 44 A26Y
270548 -  ..
270549 - Sharee said this sounds very complex.  Nobody has notified the
270550 - Infusion Clinic to treat Millie this morning.  She explained that the
270551 - Clinic cannot give treatments without doctor's order.
270553 -  ..
270554 - Millie recalled again that Zan has scheduled Neupogen treatment for
270555 - today ordered by the primary care physician on 080609. ref SDS 33 IL6I
270557 -  ..
270558 - Sharee checked Millie's medical chart again.  She found Zan's order on
270559 - 080609 for weekly Neupogen treatments of 480 mcg. ref SDS 33 L16I  She
270560 - decided to approve treatment today, and to access the port for
270561 - maintenance, if possible.  Sharee said Millie does not need labs for
270562 - the CBC, proposed yesterday by Didi, until Thursday, when UCSF will
270563 - draw labs to evaluate Millie's treatment.
270565 -  ..
270566 - She asked Millie to sit in a chemotherapy chair, beginning to make
270567 - progress.
270568 -
270569 -
270570 -
270571 -
2706 -

SUBJECTS
Neupogen Quality Care Requires Prescribed Dose Given in 2 Injections

5003 -
500401 -  ..
500402 - Neupogen Quality Care Requires Prescribed Dose Given in 2 Injections
500403 -
500404 - Julie McLugage gave Millie Neupogen treatment, implementing Didi's
500405 - instructions yesterday on 080718. ref SDS 44 4535 [responding to
500406 - Millie's concern about low blood counts caused by bleeding incident
500407 - from extravasation during CT test on 080718 that failed using the
500408 - Power Port, ref SDS 44 A370].  Her work was terrific.  Millie was
500409 - relieved everything went smoothly.
500410 -
500411 -        [On 080721 Millie suffers bone pain and fatigue from Neupogen
500412 -        treatment today. ref SDS 47 9W9I
500414 -         ..
500415 -        [On 080721 UCSF reports Neupogen treatment not needed on
500416 -        080719, because blood counts in this case are not affected by
500417 -        bleeding incident, ref SDS 46 YU7N, that occurred during the CT
500418 -        test at Kaiser on 089718. ref SDS 44 A370
500420 -         ..
500421 -        [On 080814 UCSF says Neupogen was ordered on the Power Port
500422 -        issue today, ref SDS 52 4Q5O; but Nuepogen not needed with labs
500423 -        showing blood counts NEUTS 1.37 below safe level for
500424 -        chemotherapy treatment because the medical team expects the
500425 -        body will replace needed blood in time for treatment the
500426 -        following week on 080821. ref SDS 52 UK3K
500428 -  ..
500429 - Julie explained Kaiser quality care requires 2 Neupogen injections for
500430 - UCSF Chemotherapy Orders that specify 480 mcg, submitted to Kaiser on
500431 - 080609. ref SDS 33 L16I  Making 2 injections of 240 mcg each
500432 - implements protocol presented by Laura on 080628. ref SDS 36 Q74G
500433 -
500434 -        [On 080726 Bonnie applied Kaiser protocol for 2 injections of
500435 -        Neupogen. ref SDS 49 983L
500437 -         ..
500438 -        [On 080801 Florida disclosed that Kaiser Infusion Clinic has
500439 -        standardized the protocol for Neupogen treatments using 2
500440 -        injections for 480 mcg. ref SDS 50 9W9I
500441 -
500442 -
500443 -
500444 -
5005 -

SUBJECTS
Power Port Bard Access Huber Needle Maintain Saline Flush Heprin

7103 -
710401 -  ..
710402 - Power Port Accessed and Maintained Working Beautifully 1" Needle
710403 -
710404 - Julie accessed the port, and flushed with saline and Heperin, per
710405 - protocol in manufacturer's Instructions for Use, received on 080708.
710406 - ref SDS 37 XJ6S, and since this step could not be done yesterday on
710407 - 080718 due to excessive swelling when the CT test failed. ref SDS 44
710408 - 4S5M
710410 -  ..
710411 - Julie commented that the Power Port seems to be floating slighty in
710412 - the CT test contrast medium that overflowed yesterday, but she can
710413 - find the edges of the port with her hand enough to access the port
710414 - with a Huber needle.  Swelling has subsided substantially from
710415 - conditions Kathi enountered during the 2nd attempt to perform the CT
710416 - test using the Power Port in the CT Department yesterday on 080718.
710417 - ref SDS 44 A26Y
710419 -  ..
710420 - Julie decided to use a longer, perhaps 1", needle in order to achieve
710421 - sufficient penetration.  She stepped away from Millie's chair, and
710422 - left the area for a few minutes; then returned with a longer Huber
710423 - needle.  This might have been an issue that caused complications in
710424 - the work yesterday, despite taking great care expending 5 minutes or
710425 - so to insert the needle, ref SDS 44 LK41, when contrast medium seemed
710426 - to overflow the port, and the needle seemed to pop loose during the CT
710427 - test, ref SDS 44 4S5L,
710428 -
710429 -        [On 080724 UCSF disclosed that Huber needles injecting contrast
710430 -        medium under high pressure for CT tests have a higher standard
710431 -        of construction and safety than Huber needles used for low
710432 -        pressure blood draws and chemotherapy in the Oncology Infusion
710433 -        Clinic, ref SDS 48 OK63, this could mean that, if Millie's port
710434 -        was accessed in the Kaiser Oncology Infusion Clinic, and if it
710435 -        was not the needle that supports high pressures, cited in
710436 -        manufacturer's Instructions for Use on Power Injection
710437 -        Procedures, reported 080708, ref SDS 37 JE7N, then problems
710438 -        doing the CT test on 080718 may not have been avoided simply by
710439 -        accessing the port in the Infusion Clinic. as scheduled on
710440 -        080617 by Cal in the CT Department. ref SDS 34 DF6Y
710442 -  ..
710443 - Today, Julie accomplished port access in about 1 minute, similar to
710444 - work at the UCSF Infusion Clinic, illustrated by the record on 080717.
710445 - ref SDS 43 TZ8I  She reported that blood flows "beautifully," so the
710446 - port seems to be fully operable.  This is a big relief after problems
710447 - yesterday that caused the CT test to fail using the Power Port.
710448 - ref SDS 44 LK3R
710450 -  ..
710451 - Julie performed manufacturer's requirements on Instructions for Use to
710452 - flush the Power Port, set out in steps 11 - 14 for Power Injection
710453 - Procedures listed on 080708. ref SDS 37 XJ6S
710454 -
710455 -        [On 080811 Paula investigating solutions to support CT
710456 -        Department for Millie's next test OA 080912; issue has been
710457 -        elevated, but no progress from management reported at this
710458 -        time, ref SDS 51 LD3H; there seems to be at least three (3)
710459 -        solutions. ref SDS 51 CW3O  Paula coordinating with primary
710460 -        care physician about contacting Kaiser Oakland to perform
710461 -        Millie's next CT test. ref SDS 51 DE79
710462 -
710463 -
710464 -
710465 -
7105 -

SUBJECTS
Incision Wound Power Port Surgery Slight Gap Bleeding Cleaned Surgic

8803 -
880401 -  ..
880402 - Incision Wound Power Port Surgery Slight Gap Cleaned Tape Replaced
880403 -
880404 - Julie inspected the wound from surgery for the Power Port on 080708.
880405 - ref SDS 37 WD9J
880407 -  ..
880408 - She removed the surgical tape and noted a slight gap in the incision
880409 - with coloration, evidence of bleeding that occurred during the CT test
880410 - yesterday on 080718. ref SDS 44 A26Y  Julie cleaned the wound and
880411 - applied fresh surgical tape.  Catherine can inspect this on Thursday,
880412 - per planning at UCSF on 080717. ref SDS 43 IL3L
880413 -
880414 -
880415 -
8805 -

SUBJECTS
Power Port Bard Access Huber Needle Maintain Saline Flush Heprin

A903 -
A90401 -  ..
A90402 - Kaiser Report for Review at UCSF Available from PCP
A90403 - Referral Coordination Effective Kaiser Infusion Clinic and UCSF
A90404 -
A90405 - Julie will prepare a report on work performed today and findings on
A90406 - condition of the port and the surgical wound.  Millie can get a copy
A90407 - of the report for review at UCSF by contacting the primary care
A90408 - physician.
A90410 -  ..
A90411 - Timely documentation supports referral coordination between Kaiser and
A90412 - care at UCSF to verify for the Infusion Clinic that Millie can safely
A90413 - receive treatment with the Power Port, per communication objectives
A90414 - listed on 070222. ref SDS 8 6K3H
A90416 -  ..
A90417 - Millie thanked Julie and Sharee for taking immediate action adjusting
A90418 - to exigent circumstances.  She was greatly relieved that everything
A90419 - seems okay today at Kaiser for getting treatment at UCSF on Thursday,
A90420 - 080724.  This demonstrates effective referral collaboration within the
A90421 - Kaiser Oncology Infusion Clinic.  Helps relieve emotional trauma,
A90422 - stress, and anxiety from events yesterday, ref SDS 44 A54W, that
A90423 - drives patients to give up, rather than press forward with treatment.
A90424 - ref SDS 44 Y38M
A90425 -
A90427 -  ..
A90428 -
A905 -

SUBJECTS
Hike 5.5 Miles Time 95 Minutes Pace Moderate Lafayette Reservoir Aft

AH03 -
AH04 - 1141
AH0501 -  ..
AH0502 - Exercise Hiking 5.5 Miles Moderate Pace
AH0503 -
AH0504 - Millie went hiking at Lafayette Reservoir - 2 laps, about 5.5 miles.
AH0506 -  ..
AH0507 - Did not go fast today, time about 95 minutes.
AH0508 -
AH0509 -        [On 080721 Millie suffers side effects Neupogen bone pain,
AH0510 -        fatigue, compounded by increased exercise. ref SDS 47 9W9I
AH0511 -
AH0512 -
AH0513 -
AH0514 -
AH0515 -
AH0516 -
AH06 -

SUBJECTS
Power Port Access Failure Recovery Kaiser Hot Line Response Approves

AZ03 -
AZ04 - 1411
AZ0501 -  ..
AZ0502 - Kaiser Hot Line Response Approves Post Op Recovery at Infusion Clinic
AZ0503 -
AZ0504 - Followed up ref SDS 44 A46R.
AZ0505 -
AZ0506 - Arrived home.
AZ0507 -
AZ0508 - There was a message from Kaiser received at 1115.  The message said
AZ0509 - that labs requested in Didi's message yesterday on 080718, ref SDS 44
AZ0510 - HZ6G, were approved.  Nothing was said about Neupogen treatment, nor
AZ0511 - accessing the port.
AZ0513 -  ..
AZ0514 - The person did not leave a name, phone number, nor say who approved
AZ0515 - this work.
AZ0517 -  ..
AZ0518 - Millie decided that enough has been done on this issue, and so did
AZ0519 - not go back to Kaiser for the CBC labs.
AZ0520 -
AZ0521 -
AZ0522 -
AZ0523 -
AZ0524 -
AZ0525 -
AZ0526 -
AZ06 -