THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: July 19, 2008 11:00 AM Saturday;
Millie gets Neupogen treatment and Power Port examined at Kaiser.
2...Kaiser Infusion Clinic Neupogen and Access Power Port
3...Surprise Millie Doing Well 7 Years Stage IV Cancer Treatments
4...Chemotherapy Clinic Familiar Faces Build Confidence Recover CT Problems
5...Cancelled Treatment Reinstated Due to Exigent Circumstances
6...Swelling Overflow CT Contrast Medium Substantially Reduced
7...Communication Delay Orders Recover from CT Test Problems Not Received
8...Experienced Nurse Adjusted to Context Applied Judgement Expedites Work
9...Neupogen Quality Care Requires Prescribed Dose Given in 2 Injections
10...Power Port Accessed and Maintained Working Beautifully 1" Needle
11...Incision Wound Power Port Surgery Slight Gap Cleaned Tape Replaced
12...Kaiser Report for Review at UCSF Available from PCP
13...Referral Coordination Effective Kaiser Infusion Clinic and UCSF
14...Exercise Hiking 5.5 Miles Moderate Pace
15...Kaiser Hot Line Response Approves Post Op Recovery at Infusion Clinic
Click here to comment!
Power Port Access Failure Recovery Surgery Incision Bleeding Extrava
1703 - ..
1704 - Summary/Objective
170501 - Follow up ref SDS 44 0000. ref SDS 43 0000.
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
170520 - ..
1708 - Progress
170901 - Kaiser Infusion Clinic Neupogen and Access Power Port
170903 - Follow up ref SDS 44 9W9I, ref SDS 22 9W9I.
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.
Power Port Access Failure Recovery Surgery Incision Bleeding Extrava
270401 - ..
270402 - Surprise Millie Doing Well 7 Years Stage IV Cancer Treatments
270403 - Chemotherapy Clinic Familiar Faces Build Confidence Recover CT Problems
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.
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
270435 - ..
270436 - Cancelled Treatment Reinstated Due to Exigent Circumstances
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
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.
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
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
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.
Neupogen Quality Care Requires Prescribed Dose Given in 2 Injections
500401 - ..
500402 - Neupogen Quality Care Requires Prescribed Dose Given in 2 Injections
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.
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
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
Power Port Bard Access Huber Needle Maintain Saline Flush Heprin
710401 - ..
710402 - Power Port Accessed and Maintained Working Beautifully 1" Needle
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,
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
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
Incision Wound Power Port Surgery Slight Gap Bleeding Cleaned Surgic
880401 - ..
880402 - Incision Wound Power Port Surgery Slight Gap Cleaned Tape Replaced
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
Power Port Bard Access Huber Needle Maintain Saline Flush Heprin
A90401 - ..
A90402 - Kaiser Report for Review at UCSF Available from PCP
A90403 - Referral Coordination Effective Kaiser Infusion Clinic and UCSF
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
A90427 - ..
Hike 5.5 Miles Time 95 Minutes Pace Moderate Lafayette Reservoir Aft
AH04 - 1141
AH0501 - ..
AH0502 - Exercise Hiking 5.5 Miles Moderate Pace
AH0504 - Millie went hiking at Lafayette Reservoir - 2 laps, about 5.5 miles.
AH0506 - ..
AH0507 - Did not go fast today, time about 95 minutes.
AH0509 - [On 080721 Millie suffers side effects Neupogen bone pain,
AH0510 - fatigue, compounded by increased exercise. ref SDS 47 9W9I
Power Port Access Failure Recovery Kaiser Hot Line Response Approves
AZ04 - 1411
AZ0501 - ..
AZ0502 - Kaiser Hot Line Response Approves Post Op Recovery at Infusion Clinic
AZ0504 - Followed up ref SDS 44 A46R.
AZ0506 - Arrived home.
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.