THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
S U M M A R Y
DIARY: November 7, 2008 04:00 PM Friday;
Millie core biopsy test status change Doctor Kahn at Kaiser Head Neck.
2...Core Biopsy Test Status Change Completed Minimizes Risk
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Default Null Subject Account for Blank Record
0403 - ..
0404 - Summary/Objective
040501 - Follow up ref SDS 14 0000, ref SDS 13 0000.
040506 - [On 081119 Kaiser submitted a summary of results taken from
040507 - the final pathology report for the biopsy on 081107, and it
040508 - appears that status is unchanged, still triple negative.
040509 - ref SDS 20 5O76
040511 - ..
040512 - [On 081202 1456 Kaiser submitted results of pathology for
040513 - biopsy on 081107 showing HER2 neu FISH test = 1.1,
040514 - ref SDS 21 FG5G, well below criteria for positive 2.0, and
040515 - below change in criteria to 1.6 reported under
040516 - consideration on 071007. ref SDS 1 S68T
040520 - ..
0408 - Progress
040901 - Doctor Kahn explained he was asked by Doctor Daamen to perform the
040902 - core biopsy today. This implements instructions from the primary care
040903 - physician in a letter to the medical team on 081103 saying that Kaiser
040904 - would perform the biopsy procedure, rather than use an FNA biopsy
040905 - procedure at UCSF. ref SDS 11 2M64
040907 - ..
040908 - During the meeting today, Doctor Kahn apologized for changing Millie's
040909 - schedule 5 times the past few weeks, and said that everybody in the
040910 - department has experienced a hectic schedule because Kaiesr has opened
040911 - up a new hospital in Antioch, and some of the staff are working
040912 - between Walnut Creek and Antioch during start up operations at
040913 - Antioch.
040915 - ..
040916 - Millie described surprise and appreciation getting Doctor Daamen's
040917 - call yesterday advancing the biopsy work today 2 weeks from 081117.
040918 - ref SDS 13 5F5H Doctor Kahn explained he had a last mintue
040919 - cancellation, and everybody knew Millie's work had been delayed, so he
040920 - welcomed the opportunity to expedite Millie's medical care today,
040921 - since treatment for cancer requires timely response.
040923 - ..
040924 - The doctor palpated the left supraclavicular to find the lump for
040925 - biopsy. Millie used her hand to move the doctor's hand to feel the
040926 - location of the swelled lymph node. Doctor Kahn marked the location
040927 - for the biopsy puncture.
040929 - ..
040930 - The doctor asked Millie if risks of core biopsy have been explained,
040931 - and whether Millie is sure she wants to have this test performed?
040933 - ..
040934 - Millie recalled that Doctor Daamen discussed risks of core biopsy on
040935 - 081022. ref SDS 5 HH99 Earlier, Doctor Wong at Kaiser Head and Neck
040936 - presented risks of core biopsy during a meeting on 081024. ref SDS 8
040937 - W183 The doctor at that time on 081024 deferred the work until today,
040938 - 081107. A few days later the work was deferred again until 081117.
040940 - ..
040941 - Millie said that the test was ordered by the primary care physician to
040942 - implement work prescribed by her doctor on referral at UCSF. There
040943 - has been a lot of communication on the importance of this test for
040944 - Millie's treatment prospects, which was reviewed thoroughly with
040945 - Doctor Daamen for the FNA biopsy at Kaiser on 081022. ref SDS 5 RS8M
040947 - ..
040948 - The date of the test has been changed 5 or 6 times. Consideration was
040949 - given to doing the test at UCSF using an FNA procedure in order to
040950 - avoid risks of core biopsy. The primary care physician in Oncology
040951 - notified the medical team on 081103 that the procedure would be done
040952 - at Kaiser. ref SDS 11 2M64 Millie has relied on the primary care
040953 - physician for 8 years. Yesterday, Doctor Daamen made special effort
040954 - to expedite the test. ref SDS 13 5F5H This record seems to indicate
040955 - Kaiser feels the test should be done today, if possible.
040957 - ..
040958 - Doctor Kahn assurred Millie he can do the test today, if she is sure
040959 - about having it done.
040961 - ..
040962 - Doctor Kahn explained his prior work history working as a bio-chemist,
040963 - and in that role he would examine biopsy tissue. He explained that
040964 - his work as a surgeon is only to extract tissue, and so he cannot
040965 - perform analysis today.
040967 - ..
040968 - Doctor Kahn explained that Friday is not a good day to draw biopsy
040969 - tissue, because labs cannot provide same day nor next day service. He
040970 - said the tissue will not be examined for several days, and pathology
040971 - could take several more days or a week.
040973 - ..
040974 - Millie asked if the doctor feels the biopsy should be deferred until
040975 - Monday?
040977 - ..
040978 - The doctor said it all depends on what the patient wants. He will do
040979 - biopsy extraction today, if asked. Otherwise he will reschedule.
040981 - ..
040982 - Millie noted that the date and time of the biopsy has been changed
040983 - many times by Kaiser, and yesterday Doctor Daamen seemed certain the
040984 - work should be done today.
040986 - ..
040987 - Doctor Kahn walked across the hall to a closet and inspected core
040988 - biopsy equipment from inventory. He selected an instrument and walked
040989 - back to the examination room.
040991 - ..
040992 - The nurse said from the other room that there is another core biopsy
040993 - tool which has a smaller diameter pucture element than what the doctor
040994 - initially selected. This suggests he was looking together with a
040995 - nurse in the inventory room, since there had been no nurse in the
040996 - examination room to that point. The doctor asked the nurse to bring
040997 - the other tool, noting that a smaller diameter needle reduces
040998 - discomfort and risk to the patient. The nurse brought a second core
040999 - bioopsy tool, and said it has a 2 mm needle, which is the size
041000 - mentinoed by Doctor Daamen in her call yesterday. ref SDS 13 F54O
041001 - Doctor Kahn looked at product specifications on the core biopsy needle
041002 - he first drew from inventory and noted it has a smaller needle,
041003 - something like 1.67 mm. He decided to use the smaller 1.67 mm needle
041004 - for Millie's core biopys.
041006 - ..
041007 - Doctor Kahn related discussions earlier today with Doctor Daamen about
041008 - reducing risks of nerve damage performing the core biopsy today.
041010 - ..
041011 - He indicated the core biopsy procedure for Millie is a little tricky,
041012 - implementing Doctor Daamen's suggestion to access the lump in the neck
041013 - with the biopsy needle at an angle in order to reduce risks of nerve
041014 - damage, since the much smaller needle for FNA procedure on 081022 had
041015 - influenced nerve tissue in the area of the lump, which Millie
041016 - experienced as an electrical jolt going down her arm. ref SDS 5 6Q5J
041018 - ..
041019 - Doctor Kahn's explanation of risk management aligns with Doctor
041020 - Daamen's call yesterday morning on 081106. ref SDS 13 XL6F
041022 - ..
041023 - Doctor Kahn decided to use the smaller 1.67 mm needle to further
041024 - reduce risks of nerve damage, and complement accessing the lump at an
041025 - angle during the core biopsy procedure.
041027 - ..
041028 - The doctor initially used a needle syrenge to inject local antesthetic
041029 - at the location of the core biopsy penetration. This is similar to
041030 - the FNA procedure on 081022. ref SDS 5 NZ5N
041032 - ..
041033 - The doctor opened the core biopsy equipment sealed in plastic
041034 - wrapping. He put on plastic gloves that are packaged with the core
041035 - biopsy equipment. He then removed a small razor blade-like instrument
041036 - from the packaging.
041038 - ..
041039 - During the meeting, Doctor Kahn received several, perhaps 3, calls on
041040 - a cell phone. This interrupted the meeting for several minutes while
041041 - the doctor removed the sanitation gloves, used the cell phone for a
041042 - conversation, then put the gloves on again. After each call, there
041043 - was time allocated to review of previously discussed issues in order
041044 - to reorient the doctor to current business. After the 2nd, 3rd, or
041045 - 4th call, there was consideration that turning off the cell phone
041046 - would allow callers to leave messages, so that attention could be
041047 - focused to expedite Millie's biopsy. This would reduce risks of
041048 - mistakes, and afterward permit full attention to address subsequent
041049 - business of calles who might leave messages.
041051 - ..
041052 - Doctor Kahn turned off the cell phone.
041055 - ..
041056 - Core Biopsy Test Status Change Completed Minimizes Risk
041058 - The doctor used the razor blade instrument to make an incision
041059 - approzimately 3 mm at the location marked earlier, per above, slightly
041060 - off center from the lump in the left supraclavicular. ref SDS 0 487F
041062 - ..
041063 - The doctor angled the core biopsy needle which is 12" - 16" including
041064 - the tissue extraction part, and then pressed this forward into the
041065 - lump. Millie felt minimal discomfort. Upon reaching the target
041066 - destination, the doctor executed the core biopsy "gun" process that
041067 - extracted the tissue, which happened quickly and without pain, as
041068 - explained explained yesterday by Doctor Daamen. ref SDS 13 MR9H
041070 - [On 081113 Millie received from Doctor Daamen at Kaiser partial
041071 - results of the biopsy performed today. ref SDS 19 QY5I
041073 - ..
041074 - [On 081119 Kaiser submitted summary of final pathology report,
041075 - ref SDS 20 5O8G, for the biopsy today on 081107, ref SDS 0
041076 - 496L, and it appears status is unchanged, still ER PR Her2neu
041077 - triple negative. ref SDS 20 UQ5P
041079 - ..
041080 - This work was accomplished with great surgical skill and attention to
041081 - patient physical safety and emotional comfort. Doctor Kahn's practice
041082 - of explaining each step was helpful to alert the patient for being
041083 - prepared to accept the core biopsy process. In particular, planning
041084 - by Doctor Daamen and Doctor Kahn was successful missing nerve tissue,
041085 - since Millie did not experience prior jolting sensation that occurred
041086 - with the FNA procedure on 081022. ref SDS 5 6Q5J
041088 - ..
041089 - Doctor Kahn reported feeling that he extracted sufficient tissue to
041090 - test for status change from the swelled lymph node in the left
041091 - supraclavicular. which was diagnosed with adenopathy from the biopsy
041092 - on 081022, reported the next day by Doctor Daamen. ref SDS 7 4Q9Q
041093 - He placed the tissue in the formalin fixed specimen container and
041094 - marked for analysis at the lab.
041096 - [On 081111 Millie notified medical team that all tests in
041097 - the UCSF work plan have been completed for Millie to start
041098 - treatment with the sunitinib metronomic protocol.
041099 - ref SDS 17 WP8G
041101 - ..
041102 - At the end of the meeting, Doctor Kahn advised that he did the work
041103 - today for Doctor Dammen, and so Doctor Daamen will provide follow up
041104 - coordination and communication. Doctor Kahn expects that Millie will
041105 - hear from Doctor Daamen next week with pathology on lab findings.
041106 - Doctor Kahn suggested calling Doctor Daamen, if the pathology report
041107 - for the biopsy today is not received next week.
041109 - [On 081113 Millie asks Doctor Daamen for report on results
041110 - of biopsy test today for status change. ref SDS 18 IV4V
041112 - ..
041113 - [On 081113 Millie received from Doctor Daamen at Kaiser
041114 - partial results of the biopsy performed today. ref SDS 19
041115 - QY5I
041117 - ..
041118 - [On 081119 Kaiser submitted a summary of results taken from
041119 - the final pathology report for the biopsy on 081107, and it
041120 - appears that status is unchanged, still triple negative.
041121 - ref SDS 20 5O76
041123 - ..
041124 - Doctor Kahn placed a standard bandage on the biopsy wound, measuring
041125 - approximately 1.5" by 3". He also provided an ice pack, and gave
041126 - Millie instructions to apply pressure on the ice pack for 20 minutes
041127 - or so, long enough for the blood to clot.
041129 - [On 081109 bandage removed; no evident bleeding, nor
041130 - internal clotting. ref SDS 16 I88G
041134 - ..
0414 - 1845
041501 - At home, Millie removed the ice pack from her neck.
041503 - There was no indication of bleeding or swelling, indicating blood
041504 - clots did not occur, which had concerned Doctor
041505 - Wong on 081024.