CONTACTS
SUBJECTS
Progress Recover 6th Relapse Stage IV Cancer IBC with Radiation Trea
0803 -
0803 - ..
0804 - Summary/Objective
0805 -
080501 - Follow up ref SDS 87 0000.
080502 -
080503 - Productive meeting today.
080504 -
080505 - [On 090218 1205 Millie reports to medical team on results of
080506 - meeting with primary care physician at Kaiser today on 090213.
080507 - ref SDS C4 TH6U
080509 - ..
080510 - [On 090312 meeting with Tara in Breast Care Clinic at UCSF on
080511 - response to treatment with radiation and hyperthermia.
080512 - ref SDS D6 0001
080514 - ..
080515 - [On 090312 meeting with Doctor Hsu and Chris in Radiation
080516 - Oncology on response to treatment. ref SDS D6 02AC
080517 -
080518 -
080519 -
080520 -
080521 -
080522 -
080524 - ..
0806 -
0807 -
0808 - Progress
0809 -
080901 - Dislocated Shoulder Recovering Complicates Patient Profile
080902 -
080903 - Doctor Johnson asked Millie about the fall on 090122 that caused
080904 - severe dislocated shoulder, and gash above the right eye, ref SDS 99
080905 - 0001, and was reported to the medical team in Millie's letter the next
080906 - day on 090123. ref SDS A1 KR8Y He seemed familiar with treatment in
080907 - the Emergency Room Department that required several reduction
080908 - procedures to re-set the shoulder, and that xray tests showed the 2nd
080909 - attempt was successful. The doctor also seemed aware of the medical
080910 - chart on Millie's follow up meeting with the Orthopedic Department on
080911 - 090129 1330, that found the shoulder is recovering normally.
080913 - ..
080914 - [...below in the record today on 090213 1140 medical chart
080915 - "Review of Systems" section describes " Recent dislocation,
080916 - right shoulder with fracture right humeral head."
080917 - ref SDS 0 WE7K
080919 - ..
080920 - [...below in the record today on 090213 1140 medical chart
080921 - "Physicial examination" section describes "right upper arm
080922 - bruised and tender." ref SDS 0 YE3P
080924 - ..
080925 - [...below in this record today on 090213 1140 the medical
080926 - chart Imaging lists xrays and CT tests taken in ER to treat
080927 - Millie's injuries. ref SDS 0 WO8H
080929 - ..
080930 - The doctor was pleased that Mike took immediate action in Orthopedics
080931 - on 090129 removing the few stitches for the wound above the right eye,
080932 - even though this conflicts with Kaiser policy. Doctor Johnson feels
080933 - Mike was correct using physician discretion for medical necessity that
080934 - saved Millie and the ER staff from stress and trauma spending hours
080935 - scheduling another visit, and waiting for care in the ER to remove
080936 - stitches that was accomplished in 2 minutes in the Orthopedics
080937 - Department. ref SDS A5 01FH
080939 - ..
080940 - The doctor asked about progress recovering from the dislocated
080941 - shoulder, and cited Millie's letter to the medical team on 090203 1417
080942 - which reported bruising spread from the shoulder and left arm to above
080943 - the right hip. ref SDS A9 IS6R
080945 - ..
080946 - Later that night on 090203 2217 Millie had severe pain in the upper
080947 - right arm (below the shoulder) that prevented sleep. ref SDS B0 KE5I
080948 - She arranged bedding to sleep more vertical, and increased treatment
080949 - with Vicadin to prescribed limits. These remedies gave enough relief
080950 - to fall asleep. ref SDS B0 KL92 The record on 090203 2217 further
080951 - reports expansion of severe bruising. ref SDS B0 4K5I
080953 - ..
080954 - Millie thanked Doctor Johnson for responding quickly to her call on
080955 - 090203 asking for emergency relief from rising pain. Sometimes
080956 - doctors don't have time to return emergency calls, forcing patients to
080957 - suffer for days. In this case, Arlette returned Millie's call for
080958 - Doctor Johnson the next day on 090204, shown in Millie's letter to the
080959 - doctor on 090204 1528. ref SDS B2 135F, confirming that he prescribed
080960 - taking up to a double dose of Vicadin and Tylenol pain medication,
080961 - ref SDS B2 D64T, and that, if needed, Doctor Johnson will prescribe
080962 - stronger, morphine-based care. ref SDS B2 D64W
080964 - ..
080965 - Today, Doctor Johnson was pleased that increasing medication was
080966 - effective controlling pain, also, noted in Millie's letter on 090204.
080967 - ref SDS B2 D64T
080969 - ..
080970 - The following day on 090205 Doctor Hsu examined Millie's right arm and
080971 - shoulder. He was startled to see severe bruising, and attributed this
080972 - in part to Millie being on Coumadin for blood thinner to treat
080973 - pulmonary embolism. ref SDS B6 FQ9S
080975 - ..
080976 - Last week on 090209 Doctor Hsu manipulated the injured right arm and
080977 - shoulder in order to take xrays for planning Millie's radiation
080978 - treatments. Kaiser policy to immobilize the arm 24-7 was ignored for
080979 - medical necessity that required deference to doctor discretion giving
080980 - priority to treat Millie's 6th relapse of cancer in time to be
080981 - effective. ref SDS C0 MN4L This was reported in a letter to the
080982 - medical team sent yesterday on 090212, with the agenda for meeting
080983 - with Doctor Johnson today. A copy notified Doctor Boulris in the
080984 - Orthopedic Department that medical necessity required moving the arm
080985 - in conflict with Kaiser's policy for 24-7 immobilization. ref SDS C2
080986 - 0W6Y
080988 - ..
080989 - Doctor Johnson indicated UCSF made the right choice on moving Millie's
080990 - arm for xrays to expedite treating her cancer that presents an
080991 - aggressive life and death scenario, discussed below. ref SDS 0 GC6N
080992 - If the medical team loses control of the cancer, then delayed healing
080993 - of the right arm and shoulder won't matter.
080995 - ..
080996 - Doctor Johnson further concurred today with Tara's analysis during the
080997 - meeting at UCSF on 090129, which was reported in Millie's letter to
080998 - the medical team the next day on 090130, and advising that UCSF
080999 - correlated elevated vitals with Millie suffering pain. Millie related
081000 - during the meeting today that she worries about over-medicating, as
081001 - set out in the letter on 090130. ref SDS A6 AY7T
081002 -
081003 - [...below in the record today on 090213 1140 medical chart
081004 - "Review of Systems" section describes " Recent dislocation,
081005 - right shoulder with fracture right humeral head."
081006 - ref SDS 0 WE7K
081008 - ..
081009 - [...below in the record today on 090213 1140 medical chart
081010 - "Physicial examination" section describes "right upper arm
081011 - bruised and tender." ref SDS 0 YE3P
081013 - ..
081014 - Millie reported feeling better today because bruising has actually
081015 - begun to subside for the past 3 or 4 days, and, pain now seems less
081016 - severe, so medication has not been needed, as set out in the letter to
081017 - the medical team yesterday on 090212. ref SDS C2 1N3R
081019 - ..
081020 - Doctor Johnson expressed strong concern about the letter saying Millie
081021 - has not taken Vicadin for several days. He emphasized that Millie
081022 - should take medication in prescribed dose to control pain, rather than
081023 - try to "tough it out," and that Millie should contact him immediately
081024 - to prescribe stronger medication for additional pain relief, as
081025 - related by Arlette on 090204, and confirmed in Millie's letter at that
081026 - time, ref SDS B2 D64T, as just discussed today, per above. ref SDS 0
081027 - 8V4M
081028 -
081030 - ..
081031 - Low Blood Counts Should Rise from Ending Chemotherapy on 090122
081032 -
081033 - Doctor Johnson explained today that Millie's fall on 090122, which
081034 - dislocated her shoulder and opened a big cut above the right eye, may
081035 - relate to continuous low blood counts that signal fatigue from
081036 - treatments with sunitinib, reported on 090122. Muscle weakness and
081037 - pain in the feet, also caused by sunitinib, were likely factors that
081038 - caused the fall, reported on 090120. ref SDS 96 3E4K Case study on
081039 - 081205 listing labs through 090129 shows difficulty maintaining blood
081040 - counts, ref SDS 83 EC5N, leading to cytopenia, and pancytopenia
081041 - diagnosed by Doctor Johnson at Kaiser on 081219 1140, ref SDS 87 LS6K,
081042 - due to the UCSF sunitinib protocol that began on 081114, reported
081043 - during the meeting at UCSF on 081113 0800. ref SDS 80 OG5H
081044 -
081045 - [...below in this record today on 090213 1140 the medical
081046 - chart Assessment reports anemia due to chemotherapy.
081047 - ref SDS 0 IH88
081049 - ..
081050 - [On 090609 1427 Kaiser plans blood transfusions to enable
081051 - Millie to cope with severe effects reducing blood counts
081052 - that expose risks of infection, and cause pain and
081053 - suffering getting Gemzar treatments. ref SDS F9 WU3N
081055 - ..
081056 - Doctor Johnson indicated that blood counts should begin to rise now
081057 - that Millie has ended chemotherapy, ordered by Doctor Rugo on 090122,
081058 - due to progression of cancer, ref SDS A0 AT6N, and will be treated
081059 - with radiation and hyperthermia ordered on 090119, reported on 090130.
081060 - ref SDS A6 4S8O
081061 -
081062 - [On 090309 1500 blood test at Kaiser shows some blood
081063 - counts have begun to improve about 45 days after ending
081064 - chemotherapy. ref SDS D0 OT8J
081065 -
081066 -
081068 - ..
081069 - Cancer Advancing Rapidly Requires Immediate Treatment
081070 - Examination Finds Rapidly Expanding IBC Aligns Rising CA 15-3 303
081071 -
081072 - Doctor Johnson had a copy of Millie's letter to the medical team
081073 - yesterday, on 090212; he had marked the section that reports
081074 - increasing IBC disease, and expressed worry about delayed treatment.
081075 - ref SDS C2 1N3X
081077 - ..
081078 - The doctor examined Millie and observed severe IBC expanding in the
081079 - 6th relapse, a complete reversal from the previous examination on
081080 - 081219, that showed substantial recovery. ref SDS 87 3L9L IBC
081081 - nodularity is prominent in the breastbone area, and spilling onto the
081082 - right breast, and extending now across the left chest and toward the
081083 - neck. IBC rash is solid and dark, and envelops the left chest wall
081084 - and wraps toward the back, and onto the left abdomen. The upper left
081085 - arm has very dark IBC rash with bumpy skin, though no nodularity yet.
081087 - ..
081088 - [On 090325 0830 Doctor Johnson examination finds reduced
081089 - IBC nodularity after radiation and hyperthermia treatment
081090 - ends 2 weeks earlier on 090317. ref SDS E2 W13H
081092 - ..
081093 - [On 090325 0830 Doctor Johnson indicates examination
081094 - finding reduced IBC symptoms and decline of cancer marker
081095 - CA 15-3 251 for first time in over a year signal strong
081096 - response to treatment with radiation and hyperthermia begun
081097 - on 090219 and completed on 090317. ref SDS E2 P369
081098 -
081099 -
081101 - ..
081102 - Bruising Right Arm Shoulder Hip Increased by Coumadin
081103 -
081104 - Examination of right shoulder and arm shows severe bruising with deep
081105 - red coloration from shoulder to below the elbow. Bruising also
081106 - extends about an inch or so below the shoulder onto the upper chest.
081107 - There is a small area of bruising roughly 1 to 2 inches in diameter on
081108 - the lower right side above the hip. The doctor recalled this was
081109 - reported in Millie's letter to the medical team on 090203. ref SDS A9
081110 - IS6R He indicated bruising seen today is consistent with Millie's
081111 - injury, and is more severe because Millie takes daily Coumadin for
081112 - blood thinner to control pulmonary embolism. This aligns with Doctor
081113 - Hsu's analysis at UCSF on 090205. ref SDS B6 FQ9S
081115 - ..
081116 - The doctor was pleased to hear during the meeting today that bruising
081117 - has begun to subside, per above. ref SDS 0 8U6O He seemed to say
081118 - recovery from bruising will be slowed by daily Coumadin treatments.
081119 -
081120 - [...below in the record today on 090213 1140 medical chart
081121 - "Review of Systems" section describes " Recent dislocation,
081122 - right shoulder with fracture right humeral head."
081123 - ref SDS 0 WE7K
081125 - ..
081126 - [...below in the record today on 090213 1140 medical chart
081127 - "Physicial examination" section describes "right upper arm
081128 - bruised and tender." ref SDS 0 YE3P
081129 -
081130 -
081132 - ..
081133 - Coagulation Control Case Manager Notified to Adjust Coumadin
081134 - Shoulder Injury Severe Bruising Coumadin Case Manager Notofied
081135 -
081136 - Doctor Johnson asked if the Coagulation Control Department has
081137 - commented on adjusting Millie's Coumadin in light of the shoulder
081138 - injury, and severe bruising?
081140 - ..
081141 - Millie advised that her PE case manager, Gloria, was notified
081142 - beginning with the letter on 090123 initially reporting that the ER
081143 - doctor ordered Coumadin held for 2 days, and asking the case manager
081144 - to prescribe adjustments, if needed. ref SDS A1 KR5V Later that day,
081145 - Gloria called and concurred with initial ER guidance. ref SDS A2 MG5L
081146 - Millie has continued to update Gloria as part of the medical team on
081147 - bruising issues caused by the shoulder injury, most recently in the
081148 - letter yesterday on 090212. ref SDS C2 1N4W
081149 -
081151 - ..
081152 - Lymphadenopathy Palpated Again Left Supraclavicular
081153 -
081154 - Today, The doctor palpated rising lymphadenopathy in the left
081155 - supraclavicular, confirming findings by Doctor Hsu during examination
081156 - at UCSF on 090205, ref SDS B6 OH88, and reflecting a complete reversal
081157 - of Millie's recovery evident on 081219. ref SDS 87 3L9L
081158 -
081159 - [On 090325 0830 examination at Kaiser finds reduced
081160 - lymphadenopathy in left supraclaficular a week after completing
081161 - radiation and hyperthermia treatment at UCSF. ref SDS E2 P36J
081163 - ..
081164 - The doctor noted that findings today of rising IBC symptoms also
081165 - reverse favorable CT scan on 091230 that showed no evidence of rising
081166 - cancer, resolving the problem reported for the CT scan on 081107,
081167 - reported on 081113. ref SDS 81 5O6N Lymphadenopathy palpated in the
081168 - left supraclavicular today aligns with findings on 080829, and on
081169 - again 081024, ref SDS 75 PV5I, and further reverses favorable findings
081170 - during examination on 081219, ref SDS 87 3L9L, and listed in the
081171 - medical chart. ref SDS 87 HT6V
081172 -
081173 - [...below in this record on 090213 medical chart reports in
081174 - Reviedw of Systems worsening IBC. ref SDS 0 EF8U
081176 - ..
081177 - [...below in this record on 090213 medical chart reports
081178 - examination finding increased IBC rash, ref SDS 0 YD5X, and LN
081179 - palpable in right neck, ref SDS 0 YD5U; further summarized in
081180 - assessment. ref SDS 0 KG6O
081182 - ..
081183 - [On 090218 1205 Millie's letter to the medical team reports
081184 - meeting with primary care physician today at Kaiser.
081185 - ref SDS C4 TH6U
081187 - ..
081188 - [On 090223 0237 Millie's letter to medical team reports
081189 - examination at Kaiser today concurs with findings at UCSF
081190 - palpating lymph node again in left supraclavicular. ref SDS C8
081191 - T48X
081192 -
081193 -
081195 - ..
081196 - Lucky 8-year Survival Stage IV Cancer Very Difficult
081197 -
081198 - The doctor said Millie has been very lucky surviving stage IV cancer
081199 - much longer than anyone expected. He noted that IBC is very
081200 - aggressive, so surviving for a long time, going on 8 years and now 7
081201 - relapses, listed on 090122. ref SDS A0 J34U, is remarkable longevity.
081202 - Living with stage IV cancer for many years, as Millie has, is
081203 - difficult, because chemotherapy side effects are difficult to tolerate
081204 - and so reduce desire and willingness to continue treatments, which may
081205 - or may not lead to a normal quality of life. Cancer is constantly
081206 - mutating to defeat treatments, so patients require comprehensive case
081207 - management to find and provide treatments in time to be effective
081208 - preventing disease from cascading out of control. Chemotherapy
081209 - weakens the immune system, which causes patients to suffer other ills
081210 - that cause death, e.g., pneumonia, and make recovery from cancer very
081211 - difficult. Case study today shows (below) that Millie's patient
081212 - history has expanded into medical problems that greatly complicate
081213 - case management. ref SDS 0 AC6G
081215 - ..
081216 - Complexity of expanding medical problems that occur with successful
081217 - oncology care disrupts a well ordered record, essential for effective
081218 - care. Communication through converstaion in meetings and calls
081219 - becomes difficult to document, causing people to get mixed up.
081220 - Confusion increases errors and omissions, illustrated by the example
081221 - in NWO, ref OF 6 PXWX, drawn from case study on 040416. ref SDS 16
081222 - GN7J Errors and omissions cause delays for rework treating the
081223 - patient. Delayed treatment enables cancer to cascade out of control,
081224 - so that treatment cannot be effective, leading to death, as explained
081225 - by Doctor Johnson during the meeting at Kaiser on 030606. ref SDS 12
081226 - N27L
081228 - ..
081229 - [On 090415 1424 Millie reports difficult communications getting
081230 - results of CT and lab tests at Kaiser on 090413 for meeting at
081231 - UCSF on 090423. ref SDS F0 JT7H
081232 -
081234 - ..
081235 - Cancer Continual Treatment 8-years Complicates Case Management
081236 - Communication Synergy Doctor Patient Partnership Facilitates Care
081237 -
081238 - The doctor noted that positive synergy from communication through
081239 - "yeoman's work" enabling doctor/patient partnership, called out in
081240 - Kaiser's Healthwise Handbook, reviewed on 990625, ref SDS 1 4185, has
081241 - yielded a "medical miracle" extending Millie's survival by orders of
081242 - magnitude, shown below in the doctor's graph of disease trajectory,
081243 - ref SDS 0 4W72, and with exceptional high "quality of life," discussed
081244 - above. ref SDS 0 NY7L Doctor Johnson advised that creating a "well
081245 - ordered record" on complex care takes time and skill, cited below.
081246 - ref SDS 0 9L8O He explained that most patients and doctors do not
081247 - have assistance preparing a daily diary in SDS, like this one, for the
081248 - medical team to manage difficult problems, so that small details do
081249 - not "fall through the cracks," shown by case study below, ref SDS 0
081250 - LH6F, and which arise from prolonged medical care that creates an
081251 - extremely complex patient profile, see further case study below,
081252 - ref SDS 0 AC6G,
081253 -
081254 - [...below communication optimizes synergy between experience
081255 - and research from providing team care at Kaiser, and
081256 - comprehensive care at UCSF. ref SDS 0 685I
081258 - ..
081259 - [On 090330 2351 letter to medical team commends UCSF support
081260 - for patient assistance role evident from inquiries for another
081261 - patient. ref SDS E4 ZV6W
081263 - ..
081264 - [On 090725 Doctor Johnson described doctor/patient partnership
081265 - in Millie's case doing yeoman's work to keep a well ordered
081266 - record for effective case management. ref SDS G5 T58R
081268 - ..
081269 - [On 090725 "evidence based" medical practice requires a well
081270 - ordered record, which takes yeoman's work that complements
081271 - mainstream technology for health care case management.
081272 - ref SDS G5 MP8O
081274 - ..
081275 - The importance of communication for case management from developing a
081276 - comprehensive record of patient history was noted in a letter last
081277 - week. On 090206, Doctor Stritter credited Millie's medical team for
081278 - effective communication controlling clinical, logistical and financial
081279 - complexities surviving very aggressive cancer much longer than
081280 - normally expected, ref SDS B9 7Q7J, again cited by the doctor today,
081281 - per below. ref SDS 0 4W72
081283 - ..
081284 - On 081017 Doctor Rugo thanked the medical team for help coordinating
081285 - the UCSF work plan on 081016 that guided Kaiser's collaboration on
081286 - very complex activities getting Millie ready to start treatment at
081287 - UCSF. ref SDS 73 RI6I
081289 - ..
081290 - Previously on 080605, the Surgery Department commended Oncology for
081291 - comprehensive referral that makes work faster and easier to get things
081292 - done in time to be effective. ref SDS 65 635W Doctor Johnson
081293 - explained that managing complex details, now for Millie's 8th year of
081294 - continual treatment, requires constant vigilegence that becomes a
081295 - heavy burden. Long term survival is very difficult, because little
081296 - things "slip through the cracks," and go unnoticed until big problems
081297 - suddenly emerge that overwhelm medical care. Without proactive
081298 - management, cancer quickly cascades out of control causing life to
081299 - suddenly slip away. Working on small details is annoying, i.e.,
081300 - emotionally traumatic, noted by the surgeon on 080708, ref SDS 67
081301 - OK8M, and explained in NWO. ref OF 6 0468
081302 -
081304 - ..
081305 - Falling Through the Cracks Mistakes Increase for Long-term Survival
081306 -
081307 - Last week on 090205, Doctor Johnson urged proactive management to
081308 - prevent issues in Millie's care from "falling through the cracks."
081309 - ref SDS B7 278T A few months earlier, during a meeting at Kaiser on
081310 - 081219, the doctor discovered someone had changed details in his
081311 - referral order previously entered in the computer on 081210 for Millie
081312 - to get a CT test on 081230. Checking the record on 081219 enabled
081313 - discovery to make corrections in time to maintain patient care.
081314 - ref SDS 87 V76L Experience using good management to improve
081315 - communications with the CT Department on 081219, supports the doctor's
081316 - letter on 090205.
081318 - ..
081319 - Today, Doctor Johnson was pleased that Pam was able to take immediate
081320 - action solving problems in the Outside Referrals Department, so that
081321 - Millie's care at UCSF was not delayed by authorization processing,
081322 - reported on 090202. ref SDS A7 5R7O
081323 -
081325 - ..
081326 - CT Department Doctor's Order Ignored Confusing Report Issued
081327 -
081328 - Doctor Johnson was disappointed today that despite having corrected
081329 - the CT e-consult referral to order a consolidated report on test
081330 - findings, the doctor's order was still ignored when Kaiser issued
081331 - separate reports that caused confusion and delay applying CT test work
081332 - product for patient care at UCSF on 090108, as shown in Millie's
081333 - letter to the medical team the next day on 090109. ref SDS 92 UE6X
081335 - ..
081336 - On 090106 Chris in Radiology Department confirmed that the e-consult
081337 - referral prepared by Doctor Johnson in the Oncology Department ordered
081338 - a consolidated report for Millie's test in the CT Department on
081339 - 081230. ref SDS 89 OO82
081341 - ..
081342 - Today, the doctor indicated risks of communication misunderstanding
081343 - and the high cost of medical mistakes, reviewed on 990912, ref SDS 2
081344 - 0001, that occur from issuing separate reports for a single radiology
081345 - test cannot be justified, even by goals to increase revenue from
081346 - billings for multiple reports, reported on 090109. ref SDS 93 CE7R
081347 - For example, reports get separated and issued on different days; and
081348 - nobody was aware multiple reports were issued, shown in the record on
081349 - 081113. ref SDS 80 VL5L On 081218 Tara advised that Kaiser did not
081350 - submit to UCSF the 2nd report on the neck for the CT test on 081107,
081351 - and asked Millie to submit the report to UCSF. ref SDS 86 LM4I
081352 - Additionally, common findings that overlap scanned areas, e.g.,
081353 - supraclavicular in the neck, and axillary regions in the chest, are
081354 - described differently in each report. The same nodes are reported in
081355 - different sizes in different reports, shown in the record on 090108.
081356 - ref SDS 92 UE6X
081358 - ..
081359 - Getting multiple reports for the same test increases potential for
081360 - "things to fall the cracks," because busy people are easily confused,
081361 - and make mistakes when complexity of health care increases, as related
081362 - in the doctor's letter last week on 090205. ref SDS B7 278T
081364 - ..
081365 - Billings can be supported without reducing the quality of patient care
081366 - by entering a line in CT test reports showing the scan register number
081367 - where data for each CT scan pass is presented. Studying the issue and
081368 - devising even a simple solution takes time. The challenge for busy CT
081369 - Department managers is making time to figure out solutions that
081370 - balance requirements for increasing revenue and also improve quality
081371 - care.
081372 -
081373 - [On 090325 0830 Doctor Johnson ordered CT test and specified
081374 - again consolidating findings in a single report in order to
081375 - avoid problems discussed today. ref SDS E2 LX5J
081377 - ..
081378 - [On 090311 changes in Kaiser procedures delay work with calls
081379 - that take over an hour on hold, and then cannot implement
081380 - instructions from health care provider the day before for
081381 - getting a report on labs to prepare for a productive meeting on
081382 - patient responding to treatment. ref SDS D5 6Z4F
081383 -
081384 -
081386 - ..
081387 - Disorder Case Management Medical Chart Complexity Compounds
081388 - Medical Chart Disorder Case Study Case Management Complex Too Hard
081389 - Case Study Disorder Medical Chart Compounds Complexity Case Management
081390 - Well Ordered Record Difficult Maintain for Long-term Cancer Survivors
081391 -
081392 - Disorder in the medical chart eventually overwhelms case management.
081393 - Doctors and nurses get confused, mixed up, and annoyed....
081394 -
081395 - 1. Massive papers spill on floor.............. 041018, ref2SDS 24 QU6F
081396 - 2. Treatment planning too difficult........... 041130, ref2SDS 27 YR8F
081397 - 3. Treatment rationale cannot find............ 041230, ref2SDS 28 XQ84
081398 - 4. Pathology reports missing.................. 050907, ref3SDS 33 FB6X
081399 - 5. PET scan files cannot find................. 050907, ref3SDS 33 FA57
081400 - 6. Medical records wrong patient.............. 050907, ref3SDS 33 028E
081401 - 7. Biopsy results 2 years late................ 060711, ref4SDS 40 RK4L
081402 - 8. Time Out evaluate surgery unnecessary...... 050913, ref3SDS 34 5T4J
081403 - 9. Medical chart mixed up at UCSF............. 080219, ref5SDS 58 L18L
081404 - 10. Accuracy annoying.......................... 080708, ref6SDS 67 OK8M
081405 - 11. Biopsy schedule change 5 times............. 081106, ref7SDS 77 IP6O
081407 - ..
081408 - Rising complexity from expanding medical problems makes survival
081409 - difficult with continual treatment because many factors need to be
081410 - balanced, and this "balancing" of efforts across multiple disciplines
081411 - further complicates communication, which increases chances of
081412 - mistakes.
081413 -
081414 - [...below in this record on 090213 1140 the doctor draws a
081415 - graph showing Millie is a stastical "miracle" surviving a
081416 - disease for 7 years with normal longevity of 3 years; x and
081417 - y axes correlate falling quality of life mapped against
081418 - constant treatments over time that bring mounting physical
081419 - and emotional distress that drives patients to give up.
081420 - ref SDS 0 4W72
081422 - ..
081423 - [On 090415 1424 Millie reports difficult communications
081424 - getting results of CT and lab tests at Kaiser on 090413 for
081425 - meeting at UCSF on 090423. ref SDS F0 JT7H
081427 - ..
081428 - [On 090725 Doctor Johnson described doctor/patient
081429 - partnership in Millie's case doing yeoman's work to keep a
081430 - well ordered record for effective case management.
081431 - ref SDS G5 T58R
081433 - ..
081434 - [On 090725 "evidence based" medical practice requires a
081435 - well ordered record, which takes yeoman's work that
081436 - complements mainstream technology for health care case
081437 - management. ref SDS G5 MP8O
081438 -
081439 -
081441 - ..
081442 - Emotional Stress Cancer Survival Medical Professionals Surprised
081443 -
081444 - Millie related a rush of mixed feelings well up, when medical
081445 - professionals express disbelief that she is still alive. Joy, guilt,
081446 - elation, worry, and doubt flood the mind, as occurred in the Surgery
081447 - Department on 080606. ref SDS 66 0T6I Later on 080719, Sharee and
081448 - Julie were surprised seeing Millie come into Chemotherapy Clinic for
081449 - additional care, 18 months after starting treatment on referral at
081450 - UCSF. ref SDS 68 SR3J
081451 -
081453 - ..
081454 - Cancer 7th Relapse Urgency for Timely Care Worry About Delays
081455 - Waiting for Water to Boil Worry Stress Rises When Treatment Delayed
081456 -
081457 - The doctor reviewed prior discussions on importance of timely
081458 - treatment for Millie's next relapse of cancer. Case study on 090122
081459 - shows Millie's 7th relapse of cancer is her 6th relapse of IBC.
081460 - ref SDS A0 J34U Equally, the study on 041230, shows Kaiser's
081461 - continuing advice that each relapse narrows the margin for delay
081462 - starting new treatment in time to be effective. ref SDS 28 P19O
081464 - ..
081465 - Today, Doctor Johnson repeated the reminder on 090123, that UCSF needs
081466 - to develop a list of "targeted" therapies that avoid delays treating
081467 - Millie's cancer as a chronic disease. ref SDS A3 RK6O On 081219,
081468 - Doctor Johnson emphasized coordinating with Doctor Rugo to start
081469 - Millie's treatment quickly, because her cancer has become more
081470 - aggressive after 6 relapses, and so can spiral out of control, if
081471 - treatment is delayed. ref SDS 87 KU6F On 030606 the doctor explained
081472 - recovery from cancer requires timely examination and diagnosis in
081473 - order to start treatment before disease cascades out of control.
081474 - ref SDS 12 N27L
081476 - ..
081477 - [below, in the record today on 090213 1140 the doctor urges
081478 - diligence to avoid delays from things "falling through the
081479 - cracks," per above, ref SDS 0 6L7I, starting Millie's next
081480 - treatment at UCSF for the 7th relapse in time to be
081481 - effective. ref SDS 0 WZ6K
081483 - ..
081484 - Millie said the past few weeks she feels emotionally crushed and lost
081485 - in a maze of problems that delayed hyperthermia treatment at UCSF.
081486 - Now there is a glimmer of hope, because Doctor Rugo got treatment that
081487 - was needed on 090129 moved up 2 weeks from 090219 to 090205. This
081488 - week has been devestating waiting day after day while cancer grows and
081489 - travels to who knows where, reported in Millie's letter to the medical
081490 - team yesterday on 090212. ref SDS C2 1N3X
081492 - ..
081493 - The doctor explained that UCSF needs time to develop a work plan on
081494 - the computer, and to build molds that optimize radiation to complement
081495 - hyperthermia treatments, prescribed by Doctor Rugo as essential for
081496 - local control in time to be effective for Millie to recover from the
081497 - 6th relapse of IBC, as cited in Millie's letter to the medical team on
081498 - 090130. ref SDS A6 AY9Q Sometimes scientists, researchers, and
081499 - doctors sacrafice good results to make the "perfect" plan. Delayed
081500 - treatment risks losing control of aggressive cancers, as discussed
081501 - previously on 081024, ref SDS 75 BO9F, Since Doctor Rugo notified
081502 - everyone on 090203 that Millie needs urgent treatment quickly,
081503 - ref SDS A8 Y15J, and since treatment was advanced 2 weeks, there is
081504 - hope the UCSF treatment plan will be accomplished in time to be
081505 - effective.
081507 - ..
081508 - Doctor Johnson concurred with Doctor Hsu's analysis on 090209, that
081509 - since delay caused Millie's cancer to spread, layout and manufacture
081510 - of molds for radiation treatments are more complicated, and so take
081511 - more time to ensure accuracy. ref SDS C0 TW7O He feels that even
081512 - though Millie's cancer is getting worse every day without treatment,
081513 - Kaiser and Millie should allow UCSF time for accurate work to avoid
081514 - mistakes, otherwise treatment will not be effective. He noted that
081515 - doctors constantly face the "life and death" dilemma of balancing time
081516 - for accuracy against starting work in time to be effective. These are
081517 - complex, difficult decisions. People responsible for doing the work
081518 - should make the call they feel will yield the best results. Since
081519 - doctors have many demands on their time, mistakes striking the "right"
081520 - balance are always a risk. Doctor Johnson provides backup so that
081521 - Millie does not "fall through the cracks" due to busy minds at UCSF
081522 - missing small details that are critical to her care.
081524 - ..
081525 - Millie recalled Doctor Rugo commended Doctor Johnson's 2nd opinion
081526 - backup review at Kaiser for aiding Millie's care at UCSF, reported in
081527 - the meeting on 080306 0830. ref SDS 60 JT3L
081528 -
081529 - [....below Doctor Johnson discusses importance of
081530 - collaboration between Kaiser and UCSF for comprehensive
081531 - care in Millie's case. ref SDS 0 685I
081533 - ..
081534 - Millie is worried that by the time radiation and hyperthermia starts
081535 - on 090219, the plan for conditions on 090209 will be obsolete, causing
081536 - failure of treatment, or more delay to prepare a new plan that cannot
081537 - succeed because cancer has become too severe for treatment to be
081538 - effective.
081540 - ..
081541 - Doctor Johnson noted that, when patients need urgent treatment.
081542 - waiting for the orderly process of medical practice can be frustrating
081543 - for everyone, sometimes described as "waiting for the water to boil."
081544 - On 050913 the doctor was worried that delaying mastectomy surgery to
081545 - evaluate risks called out in Kaiser's policy and procedures for "Time
081546 - Out," would lose a window of opportunity, ref SDS 34 5T4J, for saving
081547 - Millie's life. ref SDS 34 5T5N A month later on 051005, things seemed
081548 - different and surgery was described as "palliation," rather than life
081549 - saving. ref SDS 35 6A4N
081551 - ..
081552 - Obviously, life and death decisions are hard. Many give up on being
081553 - diagnosed with stage IV cancer, which often signals demise within
081554 - months. Doctor Johnson first discussed the challenge of advanced
081555 - cancer on 040614. ref SDS 20 SZ3I This was discussed again when
081556 - Millie relapsed the 4th time on 061201. ref SDS 48 TE9I
081558 - ..
081559 - A Wellness Community seminar on 081018, ref SDS 74 IS5L, correlated
081560 - Millie's good fortune surviving stage IV cancer for 8 years, cited
081561 - during the meeting today, per above, ref SDS 0 NY7L, supports research
081562 - showing regular exercise can be a factor that complements good medical
081563 - treatment. ref SDS 74 4G7N Until recent months, when Millie was
081564 - switched to sunitinib, she had worked hard for many years to implement
081565 - self-help through vigorous daily exercise. Case study on 090120 shows
081566 - how synergy has been degraded with loss of exercise due to treatments
081567 - with sunitinib. ref SDS 96 3E4K
081568 -
081570 - ..
081571 - Case Study Synergy Doctor/Patient Partnership Solves Complex Problems
081572 - Complexity Compunds Patient History Overwhelms Case Management
081573 - Case Management Difficult Patient History Grows Increasingly Complex
081574 - Patient History Grows Progressively Complex Overwhelms Case Management
081575 -
081576 - Recently on 090206 the doctor who presented at the Wellness Community
081577 - further commented in a letter that managing clinical, logistical, and
081578 - financial complexities of health care takes a lot of effort that
081579 - becomes increasingly harder, noted today by Millie feeling emotionally
081580 - crushed, per above, ref SDS 0 NY8H, from work to survive beyond life
081581 - expectancy for stage IV inflammatory breast cancer (IBC). ref SDS B9
081582 - 7Q7J
081584 - ..
081585 - [On 090325 0830 Doctor pleased Millie taking cruise for needed
081586 - rest to recover from stress and exhaustion assisting medical
081587 - team with case management, per examples below, and feeling
081588 - better with cancer marker coming down, and energy recovering
081589 - after ending treatment with radiation and hyperthermia with
081590 - evident favorable response. ref SDS E2 M35H
081591 -
081593 - ..
081594 - Dilemma Medical Problems Compound from Success Solving Complex Problems
081595 - Case Study Longevity Success Increases Complexity Medical Problems
081596 - Synergy Doctor/Patient Partnership Solves Complex Medical Problems
081597 -
081598 - Surviving cultural resistance against making sense of complex medical
081599 - problems in time to provide effective care requires communication to
081600 - coordinate a diverse medical team, aided by doctor/patient
081601 - partnerhsip, noted by the doctor today, per above. ref SDS 0 FZ4H
081602 -
081603 - [...below, doctor prognosis less than 1 year to live.
081604 - ref SDS 0 9L7N
081606 - ..
081607 - Case study on 061018 1003 cites this record for advantages of
081608 - doctor/patient partnership. ref SDS 46 H79G
081610 - ..
081611 - Case Study Changing Treatment Takes More Work for Each Relapse
081612 - Level of Effort Increases Exponentially with Each Change in Treatment
081613 -
081614 -
081615 - 1. Discovering IBC took 34 tasks
081616 - over 3 years..................... 040517. ref SDS 19 MD5W
081618 - ..
081619 - 2. Discovering pulmonary embolism and
081620 - starting treatment took 20 tasks
081621 - over 8 months.................... 060722. ref SDS 41 SV3K
081623 - ..
081624 - 3. Power Port for CT tests took 62
081625 - tasks over 6 months for successful
081626 - application at CT Department
081627 - in Walnut Creek.................. 080502, ref SDS 64 VG5J
081629 - ..
081630 - 4. Biopsy at Kaiser ordered by Doctor
081631 - Rugo to test for status change took
081632 - 50 tasks over 2 months and was
081633 - negative......................... 081016, ref SDS 72 W26G
081635 - ..
081636 - 5. Sunitinib study treatment at UCSF
081637 - getting referral from Kaiser required
081638 - 13 action items and more than
081639 - 100 tasks for just 4
081640 - weeks............................ 081029, ref SDS 76 CH6G
081642 - ..
081643 - 6. Radiation Hyperthermia referral,
081644 - schedule, and start urgent treatment
081645 - in time to be effective took
081646 - 120 tasks over 3
081647 - weeks............................ 090220, ref SDS C6 4V5M
081649 - ..
081650 - 7. MPA treatment at UCSF to recover from
081651 - medical mistakes getting radiation that
081652 - caused progression of cancer and
081653 - breathing problems took
081654 - 160 tasks over 8
081655 - weeks............................ 090616, ref SDS G0 IK6K
081657 - ..
081658 - This multiplying of effort required to get things done working through
081659 - multiple layers of providers and management at Kaiser and UCSF can
081660 - become crushing under the weight of patient history that compounds
081661 - complexity exponentially with each relapse.
081662 -
081663 -
081665 - ..
081666 - Indian Wise Man Invented Chess Good Ideas Multiply Exponentially
081667 - Innovation and Determination Overcome Denial Despair Fear Ignorance
081668 - Chess Indian Fable Wiseman Discovered Power of Knowledge Conquers Denial
081669 -
081670 - Today, Doctor Johnson described an Indian fable comparing Millie's
081671 - longevity surviving cancer to the good fortune of an ancient wise man.
081673 - ..
081674 - For inventing the complex game of chess, with millions of moves
081675 - compared to checkers, the emporer offered a reward. The inventor
081676 - requested a single grain of rice on the first square of the
081677 - chessboard, and doubling for each square on the board. The emporer
081678 - was elated by so seemingly modest payment, until he was later told
081679 - that royal granaries had been emptied by doubling the rice 63 times.
081681 - ..
081682 - Doctor Johnson explained today that the "wise man" accomodated
081683 - realities that expectations of expanding "rewards" were too good to be
081684 - true, and so "wisely" agreed to reduce payment to fit the Emporer's
081685 - budget.
081687 - ..
081688 - Research shows this fable is alternatively described as...
081689 -
081690 - Second half of the chessboard...
081691 - Nationmaster.com Encyclopedia
081692 -
081693 - http://www.nationmaster.com/encyclopedia/Second-Half-of-the-Chessboard
081695 - ..
081696 - Wheat and Chessboard Problem
081697 - Wikipedia.org
081698 -
081699 - http://en.wikipedia.org/wiki/Wheat_and_chessboard_problem
081701 - ..
081702 - The Rajah's Rice: A Mathematical Folktale from India (Tales of
081703 - Myth & Legend) (Hardcover); by David Barry (Author), Donna
081704 - Perrone (Illustrator)
081705 - Amazon.com
081706 -
081707 - http://www.amazon.com/Rajahs-Rice-Mathematical-Folktale-Legend/dp/0716765683
081709 - ..
081710 - India Invented the Game of Chess
081711 - Bolojj.com
081712 - Random Thoughts
081713 -
081714 - http://www.boloji.com/rt3/rt254.htm
081715 -
081717 - ..
081718 - Millie's Care Over Budget Kaiser Resists Insurance Obligations
081719 - Cancer Long-term Survival Compounds Efforts Overwhelms Health Care
081720 -
081721 - The doctor feels today, that, like the emporer in India, ref SDS 0
081722 - IH6J, wisdom must soon prevail over hope and blind optimism in
081723 - Millie's fight agaist cancer. He fears the time may be near to
081724 - accomodate realities of rising time, cost, and effort to overcome
081725 - resistance to good management, leading to ending health care delivery
081726 - for Millie promised by Kaisr in the insurance agreement.
081728 - ..
081729 - The doctor then related that he has been told that Kaiser will not pay
081730 - more money for Millie to recover from the next relapse, i.e., that
081731 - Millie's "account" is now over budget. He indicated after Millie
081732 - completes radiation and hyperthermia, like the Emporer, Kaiser will
081733 - resist paying more money on the insurance "deal" with Millie, per the
081734 - doctor's story above. ref SDS 0 4N5K Previously, on 081112, Doctor
081735 - Johnson cited rising pressures in the oncology department to reduce
081736 - costs. ref SDS 78 YH8I On 090121, Millie used the occassion of her
081737 - 73rd birthday to thank the doctor for resisting pressures that prevent
081738 - good management. ref SDS 97 F23Y
081739 -
081740 -
081742 - ..
081743 - Statistical Miracle Millie Survives Longer than Expected
081744 - Health Care Capacity Overwhelmed for Long-term Cancer Survivors
081745 - Graph Quality of Life Eventually Declines Rapidly for Cancer Patients
081746 -
081747 - In the examination room today, the doctor taped a sheet of paper to
081748 - the computer screen. He drew a graph to help explain that Millie is a
081749 - stastical "miracle" surviving a disease now going on 8 years with
081750 - normal longevity less than 3 years. He showed x and y axes that
081751 - correlate falling quality of life mapped against constant treatments
081752 - over time that bring mounting physical and emotional distress to the
081753 - patient fighting disease, and growing stress on health care providers
081754 - with expanding details to manage that increase mistakes, delays,
081755 - frustrations, and costs, also, discussed above listing examples.
081756 - ref SDS 0 NY7L
081758 - ..
081759 - Cancer Patient quality of life with continuous treatment...
081760 -
081761 - |
081762 - 100% |-------------------------\
081763 - | \
081764 - | \
081765 - F | |
081766 - | |
081767 - | |
081768 - +-----------------------------------------
081769 - T
081771 - ..
081772 - F = Falling quality of life
081773 - T = Treatment over Time - months/years
081774 -
081775 - [...below in this record on 090213 1140 doctor feels Millie
081776 - has less than a year to live. ref SDS 0 9L7N
081777 -
081778 - [...below in this record on 090213 1140 the doctor
081779 - explained Kaiser Hospice care support. ref SDS 0 IW8N
081781 - ..
081782 - [...below in this record on 090213 1140 the medical chart
081783 - cites discussion of survival trajectory and hospice care.
081784 - ref SDS 0 KG8X
081786 - ..
081787 - [On 090325 0830 the doctor drew the graph again, and added
081788 - a mark indicating Millie is near the end of sustainable
081789 - quality of life, and will soon suffer rapid decline.
081790 - ref SDS E2 P39M
081792 - ..
081793 - [On 090725 Doctor Johnson described doctor/patient
081794 - partnership in Millie's case doing yeoman's work to keep a
081795 - well ordered record for effective case management.
081796 - ref SDS G5 T58R
081798 - ..
081799 - [On 090725 "evidence based" medical practice requires a
081800 - well ordered record, which takes yeoman's work that
081801 - complements mainstream technology for health care case
081802 - management. ref SDS G5 MP8O
081803 -
081804 -
081806 - ..
081807 - Quality of Life Like Torture Treatment Delayed Cancer Spreading
081808 -
081809 - Millie said the last few months have been difficult. Quality of life
081810 - has seemed like torture. She wanted to die to escape side effects
081811 - from sunitinib treatments with cyclophosphamide and Methotrexate.
081812 - Since ending treatments on 090122, energy improved with side effects
081813 - subsiding. However, the past 2 weeks. delay getting hyperthermia
081814 - treatment has allowed IBC to spread, and this has caused pain and loss
081815 - of energy, similar to getting chemotherapy.
081816 -
081817 - [...below, doctor concerned delays starting next treatment
081818 - will be still more difficult to avoid, expects Millie has
081819 - less than a year to live. ref SDS 0 9L7N
081820 -
081822 - ..
081823 - Chronic Disease New Phase Control Millie's Cancer Now More Difficult
081824 -
081825 - The doctor said that sudden change from subsiding IBC during
081826 - examination at Kaiser on 081219, to rapidly expanding involvement seen
081827 - today signals mutation in Millie's cancer cells to a much more
081828 - aggressive disease that will be more difficult to treat going forward.
081829 - He feels this represents a new phase of care that requires treating
081830 - Millie's cancer as a "chronic disease." The doctor previously
081831 - discussed the challenge of increasingly aggressive cancer on 081219,
081832 - ref SDS 87 KU6F, and earlier on 081024 emphasized urgency to get
081833 - treatment quickly in time to be effective. ref SDS 75 BO9F
081835 - ..
081836 - [On 090312 0800 meeting at UCSF explained rapid reversal from
081837 - recovery to expanding IBC reflects mutation of cancer cells
081838 - into more aggressive disease that resists treatment.
081839 - ref SDS D6 XJ4I
081841 - ..
081842 - Discussion today aligns with Doctor Johnson's call in the afternoon on
081843 - 090123 1326, responding to Millie's letter early in the morning on
081844 - 090123 0129, and reporting that Doctor Rugo diagnosed relapse and
081845 - planned to start a new treatment on 090129, ref SDS A1 KR4P The
081846 - doctor concurred with UCSF analysis that Millie suffered 6th IBC
081847 - relapse, shown by the cancer marker CA 15-3 303 in labs at Kaiser on
081848 - 090116, which was suddenly 3 times higher than prior levels.
081849 - ref SDS A3 RK6O
081850 -
081851 -
081853 - ..
081854 - Diminishing Treatment Options 7th Relapse Cancer Chronic Disease
081855 - Patient Profile Difficult Complex Requires Proactive Management
081856 - Narrow Patient Profile Needs Proactive Management No Margin for Error
081857 -
081858 - During the meeting today at Kaiser, the doctor explained again that
081859 - Millie's cancer has mutated through multiple relapses to resist
081860 - treatments available at Kaiser, as presented during the call on 090123
081861 - 1326. ref SDS A3 RK6O Since Millie has been treated with all of the
081862 - drugs available at Kaiser, she faces severely diminishing treatment
081863 - options. The doctor therefore wants UCSF Cancer Center to treat
081864 - Millie's cancer as a chronic disease, discussed during the call a few
081865 - weeks ago on 090123 1326, ref SDS A3 OZ6N, and citing the call a few
081866 - days earlier from UCSF asking for a case study on Millie's patient
081867 - history showing UCSF plans for treating Millie, reported on 090121
081868 - 1017. ref SDS 98 EV53
081869 -
081871 - ..
081872 - Narrow Margin for Error Tretment Delayed Causes Denial Treatment
081873 - Complex Patient History Narrow Margin for Delay Starting Treatment
081874 - Patient Profile Complex Needs Timely Treatment Narrow Margin for Delay
081875 -
081876 - Doctor Johnson clarified today that treating Millie's cancer as a
081877 - chronic disease requires proactive management to deliver treatment in
081878 - time to be effective. This requires a well ordered record for
081879 - accurate understanding of patient history.
081880 -
081881 - [On 090725 Doctor Johnson described doctor/patient
081882 - partnership in Millie's case doing yeoman's work to keep
081883 - a well ordered record for effective case management.
081884 - ref SDS G5 T58R
081886 - ..
081887 - [On 090725 "evidence based" medical practice requires a
081888 - well ordered record, which takes yeoman's work that
081889 - complements mainstream technology for health care case
081890 - management. ref SDS G5 MP8O
081892 - ..
081893 - Case study on Doctor Johnson explaining need for timely treatment,
081894 - reported on 041230, ref SDS 28 P19O, shows the doctor advised that
081895 - Millie's expanding patient profile for treatment history (shown in
081896 - part on 090204 1747, ref SDS B3 4Q5X, and listed in total here,
081897 - presents narrowing margin for error starting treatment quickly for
081898 - each new relapse...
081900 - ..
081901 - Case Study Patient Profile Narrow Margin Starting Next Treatment
081902 - Patient Profile Complex Needs Timely Treatment Narrow Margin for Delay
081903 -
081904 - Total Surgery Chemo Radiation
081905 - 1. Surgery left breast sentinal 1 1
081906 - node.......................... 020312, ref SDS 3 Q78M
081907 - 2. Triple negative ER PR
081908 - HER2 neu...................... 020321, ref SDS 4 6Q6J
081909 - 3. Stage IIA diagnosis tumor
081910 - left breast................... 020321, ref SDS 4 6Q4U
081911 - 4. Adjuvant Phase I treatment begins 2 1
081912 - left breast cancer with 4 cycles
081913 - Adriamycin Cytoxan
081914 - (AC).......................... 020423, ref SDS 5 0001
081915 - 5. AC ends after 2 cycles; Taxotere 3 2
081916 - substituted for last 2 cycles Phase
081917 - I treatment because PET scan on
081918 - 020529 shows cancer rising and
081919 - cancer marker CA 15-3 rises
081920 - significantly above 80
081921 - to 117........................ 020603, ref SDS 6 4X5K
081922 - 6. Radiation change plan from 4 4 1
081923 - to 6 week treatment
081924 - regimen....................... 020708, ref SDS 7 AN6I
081925 - 7. Taxotere 4 cycles begin Phase
081926 - II adjuvant treatment
081927 - after radiation............... 020918, ref SDS 9 0J7H
081928 - 8. Phase II adjuvant treatment
081929 - ends complete Taxotere 4th
081930 - cycle (total 6)............... 021210, ref SDS 10 F5Z5
081931 - 9. IBC 3 symptoms identified PET
081932 - test 021218, reported meeting
081933 - at Kaiser..................... 030109, ref SDS 11 L66M
081934 - examination finds rash aligns
081935 - with PET scan symptoms of
081936 - IBC, diagnosed as
081937 - Cellulitis.................... 030109, ref SDS 11 KW5F
081938 - 10. Patient requests emergency
081939 - meeting examin inflamation left
081940 - breast and resume treatment;
081941 - Kaiser deferred treatment pending
081942 - confirmation by next CT
081943 - test.......................... 030606, ref SDS 12 NE7L
081944 - 11. CT test shows IBC symptoms of
081945 - cancer relapse; Millie requests
081946 - biopsy to verify treatment should
081947 - be started; Kaiser defers biopsy
081948 - and treatment pending more
081949 - data.......................... 030710, ref SDS 13 5T3K
081950 - 12. Biopsy left supraclavicular
081951 - positive; breast cancer relapse
081952 - diagnosed; prescribe treatment
081953 - clinical trial................ 040318, ref SDS 15 WA4H
081954 - 13. Rash inflammation left breast
081955 - delays treatment diagnosed
081956 - and treated again for
081957 - Cellulitis.................... 040318, ref SDS 15 IM6J
081958 - 14. Patient requests biopsy during
081959 - minor surgery for port catheter
081960 - evaluate rising rash left
081961 - breast misdiagnosed as
081962 - Cellulitis.................... 040419, ref SDS 17 1572
081963 - 15. Bevacizumab (Avastin) Taxotere 5 3
081964 - clinical trial begin.......... 040420, ref SDS 18 9Z5J
081965 - 16. Secondary IBC left breast
081966 - diagnosis from biopsy
081967 - pathology report.............. 040517, ref SDS 19 7D6F
081968 - 17. Stage IV changed from II...... 040614, ref SDS 20 6M9H
081969 - 18. Pulmonary embolism diagnosed
081970 - caused by bevacizumab; treatment
081971 - for cancer in clinical
081972 - trial ends.................... 041104, ref SDS 25 RZ4I
081973 - 19. Andriamycin Cytoxan begin 4 6
081974 - cycles to qualify for
081975 - clinical trial................ 050104, ref SDS 29 407N
081976 - 20. Capeticabine (Xeloda) and Taxotere 7 4
081977 - begin treatment because cancer
081978 - progressed again with
081979 - Andriamycin Cytoxan........... 050329, ref SDS 31 E87M
081980 - 21. IBC subsides complete response
081981 - with capecitabine and
081982 - Taxotere...................... 050729, ref SDS 32 YY7F
081983 - 22. Pulmonary embolism treatment
081984 - Coumadin ended rather than
081985 - 10 day pause for
081986 - surgery....................... 051007, ref SDS 35 RZ4I
081987 - 23. Mastectomey left breast....... 051021, ref SDS 37 0001 8 2
081988 - 24. Lymphedema left arm........... 060308, ref SDS 38 0001
081989 - 25. Pneumonia treated in ER....... 060607, ref SDS 39 PR5R
081990 - 26. Capecitabine Taxotere resumed 9
081991 - IBC relapse................... 060711, ref SDS 40 025H
081992 - 27. Pulmonary embolism relapse
081993 - diagnosed CT test; treatment
081994 - resumed....................... 061002, ref SDS 45 MI5I
081995 - 28. Cellulitis left arm........... 061027, ref SDS 47 0001
081996 - 29. IBC progression diagnosed end
081997 - capecitabine and Taxotere
081998 - plan treatment with Navelbine
081999 - or Gemzar..................... 061201, ref SDS 48 ZZ9N
082000 - 30. IBC spread to right breast.... 061208, ref SDS 49 AX6G
082001 - 31. Clinical trial Kaiser referral
082002 - to UCSF for treatment cetuximab
082003 - and Carboplatin prescribed for
082004 - 4th relapse IBC............... 070105, ref SDS 50 PK68
082005 - 32. Cetuximab clinical trial 10 5
082006 - begins........................ 070201, ref SDS 51 0001
082007 - 33. IBC spread to upper left
082008 - arm........................... 070301, ref SDS 52 4140
082009 - 34. Carboplatin added to cetuximab 11 6
082010 - after progression of
082011 - IBC........................... 080313, ref SDS 61 TZ8I
082012 - 35. Neupogen prescribed to prevent
082013 - missing treatments with Carboplain
082014 - that cause low blood
082015 - counts........................ 080403, ref SDS 62 XV4G
082016 - 36. Sunitinib clinical trial at UCSF 12 7
082017 - prescribed recover from 5th
082018 - relapse IBC................... 081016, ref SDS 72 J38U
082019 - 37. Multiple relapse creates
082020 - aggressive robust cancer spreads
082021 - quickly, resists treatments
082022 - at Kaiser..................... 081024, ref SDS 75 BO9F
082023 - 38. Image tests................... 081112, ref SDS 79 GM3N
082024 - 39. Sunitinib excellent response
082025 - IBC nearly fully
082026 - subsides...................... 081218, ref SDS 86 VD4F
082027 - 40. Low tolerance treatment
082028 - side effects.................. 090118, ref SDS 95 UC41
082029 - 41. Treatment history
082030 - summary....................... 090121, ref SDS 98 H16M
082031 - 42. Sunitinib ends due to
082032 - progresson Millie suffers
082033 - 7th relapse cancer............ 090122, ref SDS A0 J47F
082034 - 43. Dislocated right shoulder..... 090122, ref SDS 99 0001
082035 - 44. Research possible follow
082036 - on treatments................. 090204, ref SDS B3 RN9G
082037 - 45. Treatment options diminish
082038 - none at Kaiser................ 090213, ref SDS 0 PL5K
082039 - 46. CA 15-3 cancer marker case
082040 - study mapped against
082041 - treatments.................... 090323, ref SDS E0 J13O
082042 - 47. Radiation 4 weeks 4 times per 13 2
082043 - week begins................... 090219, ref SDS C5 E57G
082044 - 48. Radiaton treatment plan and
082045 - dose levels received from
082046 - UCSF.......................... 090226, ref SDS C9 D452
082047 - 49. Radiation hyperthermia 4 weeks
082048 - ends 090317; examination finds
082049 - significant recovery in
082050 - treated areas................. 090325, ref SDS E2 P369
082051 - 50. Breathing and cough problems
082052 - reported to medical
082053 - team.......................... 090403, ref SDS E7 UV4U
082054 - 51. 7th relapse IBC spreads
082055 - lower left arm................ 090415, ref SDS F1 E042
082056 - 52. MPA clinical trial proposed 14 8
082057 - to Kaiser by UCSF............. 090514, ref SDS F5 A13N
082058 - 53. Breathing problems caused by rise
082059 - of ground glass opacities in lungs
082060 - from radiation injury following
082061 - treatments in Feb Mar,
082062 - reported by Doctor
082063 - Rugo.......................... 090514, ref SDS F5 NL9I
082064 - 54. Breathing problems caused by
082065 - IBC not treated due to mistake
082066 - performing radiation at UCSF in
082067 - Feb and Mar; untreated IBC in
082068 - breastbone area causing cancer
082069 - spread to lungs, diagnosed by
082070 - Doctor Hsu.................... 090609, ref SDS F8 W65W
082071 - 55. MPA prescribed by Doctor Hsu
082072 - to recover from radiation
082073 - treatment mistake causing
082074 - progression of IBC and
082075 - new breathing
082076 - problems...................... 090609, ref SDS F8 W66W
082077 - 56. MPA clinical trial treatment
082078 - begins recovery from 8th
082079 - relaspe of cancer............. 090616, ref SDS G0 D647
082080 - 57. IBC recovery with MPA ends after
082081 - just 1 cycle, because Millie suffers
082082 - increased breathing problems, and
082083 - side effects of MPA are pulmonary
082084 - embolism which is high risk for
082085 - Millie, reported in case study on
082086 - 060722, ref SDS 41 6G6O; UCSF proposes
082087 - treatment with Gemzar at Kaiser to
082088 - mitigate damages because UCSF did
082089 - not have time to research and prescribe
082090 - the next targeted drug for treating
082091 - Millie's cancer as a chronic
082092 - disease ordered by
082093 - Kaiser........................ 090716 0830, ref SDS G2 YG8Y
082094 - 58. Breathing problems worsen Millie
082095 - treated in Kaiser Emergency Department
082096 - inhaler prescribed to
082097 - reduce pain from
082098 - breathing .................... 090720 1437, ref SDS G4 GE5H
082099 - 59. Gemzar single-agent chemotherapy 15 9
082100 - started at Kaiser prescribed by
082101 - UCSF to replace MPA "targeted" to
082102 - Millie's patient profile to
082103 - recover from UCSF medical
082104 - mistakes performing
082105 - radiation..................... 090728 0930, ref SDS G6 W65H
082106 - 60. Millie falls going downstairs
082107 - at home suffers back
082108 - injury........................ 090728 2043, ref SDS G7 RB5J
082109 - 61. Breathing problems worsen Millie
082110 - treated in Kaiser Emergency
082111 - Department
082112 - again......................... 090919 0742, ref SDS G9 PQ4U
082113 - 62. Cancer spreads and breathing
082114 - problems caused by medical mistakes
082115 - performing radiation at UCSF; Millie
082116 - requests treatment for 9th
082117 - relapse....................... 091019 0007, ref SDS H1 0Z9S
082118 - 63. Navelbine single-agent chemotherapy 16 10
082119 - started at Kaiser to replace Gemzar
082120 - for Millie to recover from
082121 - 9th relapse................... 091118 0730, ref SDS H4 625I
082122 - 64. Shingles diagnosed severe painful
082123 - facial blisters and painful; side
082124 - effect from Navelbine chemotherapy
082125 - for stage V cancer patient; treatment
082126 - with Zovirax - Acyclovir 800 mg tablets,
082127 - and Prednisone 20 mg
082128 - tablets....................... 100104 1115, ref SDS H6 0P9S
082129 - 65. Shingles relapse after 2 months
082130 - and following 3-prior 10-day
082131 - treatments.................... 100218 1000, ref SDS I0 PP5Y
082132 - 66. Breathing improves with reduced
082133 - ground glass opacity nodules in
082134 - lungs shown by CT test on 100218
082135 - and reported during meeting
082136 - with doctor at
082137 - Kaiser........................ 100302 0830, ref SDS I1 FB85
082138 - 67. Blood counts sudden, significant
082139 - decline danger with Abraxane causing
082140 - further low blood counts that can
082141 - cause shingles to recur, which will
082142 - require pausing Abraxane and
082143 - risks losing control of
082144 - cancer........................ 100302 0830, ref SDS I1 IC4N
082145 - 68. Abraxane single-agent chemotehrapy 17 11
082146 - started at Kaiser to replace Navelbine
082147 - for Millie to recover from 10th relapse;
082148 - cancer marker CA 15-3 428 rises
082149 - significantly................. 100303 0730, ref SDS I2 625I
082150 - 69. Cancer progresses, with Abraxane
082151 - chemotherapy, mostly on right side
082152 - caused by UCSF medical mistakes;
082153 - Millie requests switch to targeted
082154 - treatment with PARP or equal in time
082155 - to be effective recovering
082156 - from UCSF medical
082157 - mistakes...................... 100501 1037, ref SDS I3 U45P
082158 - 70. Cancer marker rises to
082159 - CA 15-3 511................... 100511 0900, ref SDS I4 L54I
082160 - 71. Kaiser refuses treatment for
082161 - Millie to recover from UCSF medical
082162 - mistakes, becasue Kaiser could not
082163 - communicate with UCSF by telephone
082164 - nor email for a month; offers only
082165 - Hospice medication for pain and
082166 - suffering; Millie forced
082167 - to choose Hospice............. 100601 0830, ref SDS I5 4H3K
082168 - 72. Cancer marker rises to
082169 - CA 15-3 1116.................. 100622 0900, ref SDS I6 L54I
082171 - ..
082172 - Previously, providers could work around routine snafus. Now, however,
082173 - small delays have the effect of denying treatment. Treating Millie's
082174 - complex condition therefore requires streamlining delivery of care to
082175 - avoid delays.
082177 - ..
082178 - [On 090325 0830 chronic delays at Kaiser submitting lab results
082179 - to Kaiser shown in case study. ref SDS E2 KZ6N
082181 - ..
082182 - [On 090325 0830 Doctor Johnson approves schedule for UCSF plan
082183 - treating Millie's cancer as chronic disease, and orders medical
082184 - tests at Kaiser for UCSF assessment of treatment plan.
082185 - ref SDS E2 P36O
082187 - ..
082188 - [On 090725 1343 Doctor Johnson credits "yeoman's work"
082189 - performing case management for extending Millie's survival
082190 - nearly 10 years treating her cancer as a "chronic disease."
082191 - ref SDS G5 T58R
082193 - ..
082194 - [On 100730 2146 Millie died on 100729; Pam's letter notes good
082195 - case management extended her mom's life. ref SDS I7 ZH7N
082196 -
082197 -
082199 - ..
082200 - Medical Team Fosters Courage Difficult Future Living with Cancer
082201 - Life Slipping Away No More Treatments Doctor Rugo Provided Timely Hope
082202 - Doctor Johnson Transcends Resistance to Health Care Referral Innovation
082203 -
082204 - Millie thanked Doctor Johnson for always being there for her in this
082205 - struggle, including referral to Doctor Rugo at UCSF on 070105.
082206 - ref SDS 50 PK68 Referral took a lot of courage to deploy medical
082207 - resources on 061208 through referral to UCSF. ref SDS 49 I14L Hearing
082208 - today, 2 years later, that Doctor Johnson's treatment plan, which was
082209 - strongly resisted for nearly a year at Kaiser, has been strongly
082210 - vindicated, gives Millie confidence facing the future.
082212 - ..
082213 - Millie recalled feeling life slipping away last October. Being told
082214 - suddenly on 081016 that cancer had relapsed for the 5th time, and
082215 - there was no plan for her care, because she has been treated with all
082216 - of the chemotherapy drugs for breast cancer that are available at
082217 - Kaiser, seemed very gloomy. At that time on 081016, sitting up on the
082218 - examination table, Millie asked...
082219 -
082220 - What's going to happen to me?
082222 - ..
082223 - Doctor Rugo put her arm around Millie, and said...
082224 -
082225 - "Don't worry. We're not going to let anything happen to you."
082227 - ..
082228 - Today, Millie still feels encouragement facing a 7th relapse of
082229 - cancer, because experience shows Kaiser and UCSF working together
082230 - provide outstanding care in time to be effective, noted in her letter
082231 - commending the medical team on 081016. ref SDS 72 J35X
082232 -
082233 - [On 090218 1205 letter to the medical team confirms Doctor
082234 - Rugo's staff scheduled meeting on 090312 0800 to review
082235 - progress. ref SDS C4 TH6U
082237 - ..
082238 - [On 090324 0548 Millie reports to medical team being
082239 - encouraged, ref SDS E1 CT4U, after completing treatments at
082240 - UCSF with radiation and hyperthermia on 090317, and getting
082241 - favorable prognosis from Doctor Hsu during the meeting on
082242 - 090312. ref SDS D6 AH6L
082244 - ..
082245 - [On 090326 0058 Millie's letter to medical team confirms
082246 - understandings on favorable examiantion at Kaiser finding
082247 - strong response to treatment and reports success with
082248 - treatment with radiation and hyperthermia at UCSF is very
082249 - encouraging. ref SDS E3 DV4Q
082250 -
082251 -
082253 - ..
082254 - Communication Synergy Kaiser Team Care UCSF Comprehensive Care
082255 -
082256 - Doctor Johnson indicated his practice providing backup opinion and
082257 - support on Millie's care for Doctor Rugo at UCSF, noted by Brigid
082258 - during the meeting on 080306, ref SDS 60 JT3L (cited above,
082259 - ref SDS 0 RG8G, combines experience treating Millie for 7-years at
082260 - Kaiser, with a strong research program at UCSF discovering new
082261 - treatments and modalities. Synergy between experience and research
082262 - optimizes Millie's medical care through communication practices that
082263 - integrate Kaiser's team care case management with the UCSF model of
082264 - comprehensive care, also, noted above. ref SDS 0 FZ4H
082266 - ..
082267 - On 070610 0900 Doctor Johnson reported the right channels of
082268 - communication were now open for coordination between Kaiser and UCSF
082269 - on Millie's care. ref SDS 55 OG7F The doctor's report today on Millie
082270 - beating the odds for surviving stage IV cancer by a wide margin,
082271 - demonstrates this has been a successful collaboration, per above.
082272 - ref SDS 0 NY7L (see as well the doctor's graph on cancer survival,
082273 - also above. ref SDS 0 4W72)
082275 - ..
082276 - Millie said again that she has been blessed with a great medical team
082277 - shown by case study on using 2nd opinions...
082279 - ..
082280 - Case Study 2nd Opinions Collaboration Extends Quality of Life
082281 - 2nd Opinions Case Study Collaboration Extends Quality of Life
082282 -
082283 -
082284 - 1. Healthwise Handbood presents Kaiser's
082285 - policy to rely on 2nd opinions that
082286 - expand experience and expertise
082287 - for comprehensive patient
082288 - care................................. 990625, ref SDS 1 455N
082290 - ..
082291 - 2. Doctor Johnson relying on 2nd opinion from
082292 - Doctor Moini for backup on optimizing Millie's
082293 - care, since Doctor Moini performed Millie's
082294 - first radiation treatments on referral to
082295 - Mt Diablo Hospital; there is no record showing
082296 - a 2nd opinion, nor any communication,
082297 - collaboration, coordination ever
082298 - occurred............................. 020726, ref SDS 8 YO6K
082300 - ..
082301 - 3. Millie requests assistance from primary care
082302 - physician at Kaiser to order 2nd opinions from
082303 - Cancer Centers to assess recurrence of cancer,
082304 - and treatment plan to delay recovery, until
082305 - after treating rash on left breast
082306 - for Cellulitis....................... 040318, ref SDS 15 AW6M
082307 - doctor recommends getting 2nd opinion
082308 - from Kaiser Tumor Board before consulting
082309 - Cancer Centers for 2nd opinion on
082310 - work plan to recover from
082311 - recurrent cancer..................... 040318, ref SDS 15 SU60
082313 - ..
082314 - 4. Doctor Riley-Paull in Surgery relying on
082315 - 2nd opinion from Oncology Department
082316 - to evaluate Millie's recovery
082317 - from surgery......................... 040419, ref SDS 17 V17L
082319 - ..
082320 - 5. Millie requests 2nd opinion from Surgery
082321 - on diagnosis in Oncology that inflammation
082322 - on left breast was changed from Cellulitis
082323 - to reaction to radiation treatments
082324 - received 2 years earlier in
082325 - July 2002............................ 040419, ref SDS 17 789F
082326 - surgery 2nd opinion pathology for
082327 - biopsy on 040419 reported inflammation
082328 - on left breast is inflammatory
082329 - breast cancer IBC.................... 040517, ref SDS 19 7D6F
082330 - 2nd opinion diagnosing IBC changed
082331 - Millie's cancer from stage II to
082332 - stage IV............................. 040614, ref SDS 20 6M9H
082333 - prognosis for survival was changed
082334 - from 5 years to less than
082335 - 1 year (months)...................... 040614, ref SDS 20 QH8F
082337 - ..
082338 - 6. Tumor Board 2nd opinion received for hearing
082339 - at Kaiser on 040414 says... Discussion was
082340 - held and the prior scans were reviewed. The
082341 - patient has been placed in a clinical trial.
082342 - The question is should she get the left neck
082343 - irratiation. This could be done
082344 - post [mastectomy]
082345 - surgery.............................. 040517, ref SDS 19 F77M
082347 - ..
082348 - 7. Millie requests reconsideration by Tumor Board
082349 - of new evidence since pathology on biopsy that
082350 - diagnosed IBC on 040419 was not available
082351 - to the Tumor Board on 040414, and so
082352 - could not be cited in Board's
082353 - opinion.............................. 040614, ref SDS 20 4R59
082355 - ..
082356 - 8. Kaiser deferred reconsideration by Tumor
082357 - Board to update 2nd opinion with new evidence,
082358 - until after Millie was treated for several
082359 - months with bevacizumab
082360 - and Taxotere......................... 040614, ref SDS 20 Y06M
082362 - ..
082363 - 9. Millie asks again for assistance getting
082364 - 2nd opinion from Cancer Centers on changing
082365 - diagnosis to IBC, and changing prognosis
082366 - to less than a year to live; doctor proposes
082367 - waiting until after several months of
082368 - treatment with bevacizumab and
082369 - Taxotere............................. 040614, ref SDS 20 AW6M
082371 - ..
082372 - 10. Millie requests 2nd opinion support from
082373 - Tumor Board planned by the doctor in the
082374 - meeting on 040614, to evaluate treatment
082375 - for changes in diagnosis and prognosis;
082376 - new symptoms of pulmonary emoblism,
082377 - and public reporting of deaths from
082378 - bevacuzumab causing blood clots
082379 - suggest increased scrutiney is
082380 - needed............................... 040812, ref SDS 21 FV6O
082382 - ..
082383 - 11. Doctor Johnson indicated 2nd opinion is useful
082384 - in Millie's case, and that Kaiser pays for 2nd
082385 - opinion consultations, when recommendations
082386 - are implemented with positive
082387 - results for patient
082388 - care................................. 040909, ref SDS 22 X836
082390 - ..
082391 - 12. Millie asked Kaiser to order 2nd opinions
082392 - from Cancer Centers to assist Kaiser with
082393 - treatment that optimizes recovery from
082394 - delay diagnosing and treating her IBC,
082395 - and now symptoms of pulmonary
082396 - embolism............................. 040909, ref SDS 22 UW6G
082398 - ..
082399 - 13. Millie ordered 2nd opinions from UCSF and
082400 - Stanford Cancer Centers because Kaiser failed
082401 - to order the work, and because her symptoms
082402 - of pulmonary embolism have been diagnosed at
082403 - Kaiser as lack of fitness on grounds that CT
082404 - testing does not find PE; while news reports
082405 - that her treatment for cancer with
082406 - bevacizumab caused death of
082407 - other patients due to blood
082408 - clots................................ 041005, ref SDS 23 RZ4I
082410 - ..
082411 - 14. 2nd opinion from UCSF on 041018 applied; Kaiser
082412 - orders emergency CT test with special (thin slice)
082413 - process not used in prior CT tests for Millie, and
082414 - which discovered Millie has pulmonary embolism;
082415 - she must end treatment with bevacizumab and
082416 - begin lifetime treatment with warfarin
082417 - (Coumadin) in order to avoid
082418 - death................................ 041104, ref SDS 25 RZ4I
082420 - ..
082421 - 15. 2nd opinion issued by Doctor Benz at UCSF
082422 - received from Kaiser recommends against
082423 - surgery and radiation to treat
082424 - Millie's breast cancer............... 041117, ref SDS 26 OU4U
082425 - and recommends instead systemic
082426 - treatment for cancer with capecitabine
082427 - and Taxotere......................... 041117, ref SDS 26 OU6S
082429 - ..
082430 - 16. Kaiser policy synthesize recommendations
082431 - from 2nd opinions, received from Stanford
082432 - and from UCSF Cancer Centers for
082433 - Millie's care........................ 041130, ref SDS 27 5X4J
082435 - ..
082436 - 17. Doctor Johnson prescribes Adriamycin Cytoxan (AC)
082437 - recommended in Standford 2nd opinion, and
082438 - in order to qualify Millie for clinical
082439 - trial with capecitabine recommended
082440 - by UCSF 2nd opinion
082441 - proposal............................. 041230, ref SDS 28 YR8F
082443 - ..
082444 - 18. Kaiser ends AC due to progression of cancer,
082445 - and prescribes capecitabine and Taxotere
082446 - for Millie's 3rd relapse
082447 - of cancer............................ 050329, ref SDS 31 T58M
082449 - ..
082450 - 19. Millie achieves significant recovery
082451 - with IBC rash completely subsided for
082452 - 1st time in patient history, and applying
082453 - UCSF 2nd opinion for treatment
082454 - with capeticabine and
082455 - Taxotere............................. 050727, ref SDS 32 YY7F
082457 - ..
082458 - 20. Kaiser objects to patient getting 2nd
082459 - opinions on having mastectomy surgery,
082460 - on grounds that delaying surgery for
082461 - "Time Out" to review risks and
082462 - benefits imperials patient's
082463 - life................................. 050913, ref SDS 34 5T5N
082465 - ..
082466 - 21. Doctor Johnson implements 2nd opinion
082467 - received from Doctor Bailey to order
082468 - PET scan test and additional treatment
082469 - for Millie with capeticabine Taxotere
082470 - prior to mastectomy
082471 - surgery.............................. 051007, ref SDS 34 T699
082473 - ..
082474 - 22. Doctor Johnson orders retest of biopsy
082475 - tissue for status change to expand Millie's
082476 - treatment options recommended
082477 - by Kaiser internal 2nd
082478 - opinion.............................. 051007, ref SDS 35 KE5L
082480 - ..
082481 - 23. Kaiser implements 2nd opinion of Doctor
082482 - Grissom to perform thin slice biopsies for
082483 - defining boundaries of mastectomy
082484 - surgery based on pathology
082485 - finding no evidence of
082486 - IBC.................................. 051012, ref SDS 36 DG6J
082488 - ..
082489 - 24. After mastectomy surgery, cancer progressed
082490 - in July 2006; Kaiser prescribed capecitabine
082491 - Taxotere again, recommended in first UCSF
082492 - 2nd opinion; this was less effective on
082493 - 4th relaspe, so Millie got another 2nd
082494 - opinion from Doctor Benz at UCSF
082495 - who recommended treatment with
082496 - cetuximab............................ 060929, ref SDS 44 UI9K
082498 - ..
082499 - 25. Doctor Johnson implemented 2nd opinion
082500 - ordering Kaiser referral for Millie to UCSF
082501 - for treatment with cetuximab that improves
082502 - survival and quality of life for Millie to
082503 - recover from 5th relapse, since Millie's cancer
082504 - cells have mutated to resist chemotherapy, while
082505 - cetuximab is "targeted" to kill only
082506 - cancer cells......................... 070105, ref SDS 50 PK7L
082507 - 2-years later - cetuxiab proved to
082508 - be extremely effective supressing Millie's
082509 - cancer without pain and suffering, and
082510 - minimal side effects enablng high
082511 - quality of life until
082512 - 6th relapse.......................... 081016, ref SDS 72 J34U
082514 - ..
082515 - 26. Doctor Johnson notes in medical chart work plan
082516 - to treat next relapse at UCSF; he asks Millie
082517 - to coordinate UCSF on submitting list of follow
082518 - agents "targeted" to cells that "treat cancer
082519 - as a chronic disease," because Millie's cancer
082520 - has mutated to resist chemotherapy agents
082521 - available at Kaiser, and there is a narrow
082522 - margin for delay starting
082523 - treatment for future
082524 - relapses............................. 080829, ref SDS 69 PX5V
082525 - Millie notifies medical team as
082526 - requested............................ 080829, ref SDS 70 RP9R
082528 - ..
082529 - 27. Doctor Rugo advises UCSF has more drugs
082530 - lined up to treat Millie's complex
082531 - patient profile...................... 081016, ref SDS 72 NW6M
082533 - ..
082534 - 28. Doctor Johson at Kaiser asks again for list
082535 - of follow on drugs UCSF plans for treating
082536 - future relapses, since Millie's patient profile
082537 - has narrowing margin for
082538 - delays............................... 081024, ref SDS 75 PU6M
082540 - ..
082541 - 29. Doctor Johnson disappointed UCSF has not had
082542 - time to submit list of "targeted" agents for
082543 - for treating Millie's cancer as chronic disease
082544 - requested on 080829; he requests letter
082545 - from UCSF showing plans for treating
082546 - Millie's next relapse so there is
082547 - time to be prepared.................. 081219, ref SDS 87 V93O
082549 - ..
082550 - 30. Glenna calls for Doctor Rugo worried about
082551 - Millie's cancer worsening during pause of
082552 - treatment with sunitinib for blood counts to
082553 - recover; Doctor Rugo wants to get a list
082554 - of follow on treatments from Millie's
082555 - records on UCSF's work identifying
082556 - treatments for Millie................ 090121, ref SDS 98 EV53
082558 - ..
082559 - 31. Doctor Johnson advises Millie again to
082560 - get list of treatments from UCSF for
082561 - future relapses...................... 090123, ref SDS A3 8K6K
082563 - ..
082564 - 32. Millie asks Doctor Rugo again for proactive
082565 - planning listing follow on treatments
082566 - to be prepared for future
082567 - relapses............................. 090204, ref SDS B1 278T
082569 - ..
082570 - 33. Doctor Rugo notifies medical team Millie's
082571 - patient profile is very complex, so research
082572 - to identify follow on treatments is not easy;
082573 - UCSF wants to talk about follow on treatment
082574 - options after the next relapse
082575 - instead of being prepared
082576 - ahead of time........................ 090204, ref SDS B4 063I
082578 - ..
082579 - 34. 2nd opinion received from Stritter Medical
082580 - Services lists 10 follow on treatments,
082581 - including PARP, to treat Millie's complex
082582 - patient profile so the medical team
082583 - is prepared for Millie's next
082584 - relapse.............................. 090204, ref SDS B3 4R3S
082586 - ..
082587 - 35. Doctor Johnson requests 2nd opinion list
082588 - of follow on treatments so UCSF can be
082589 - prepared for Millie's next relapse
082590 - after completing radiation
082591 - and hyperthermia on
082592 - 090317............................... 090325, ref SDS E2 GO4O
082594 - ..
082595 - 36. 2nd opinion research follow on treatments
082596 - for Millie's future relapses submitted
082597 - to the Kaiser and UCSF medical
082598 - team................................. 090326, ref SDS E3 DW5S
082600 - ..
082601 - 37. Doctor Rugo advises Kaiser and UCSF have
082602 - agreed in correspondence that UCSF will
082603 - treat Millie's next relapse after MPA
082604 - with PARP listed in the
082605 - 2nd opinion.......................... 090616, ref SDS G0 KD6L
082606 - confirmed in letter to medical
082607 - team PARP to treat Millie's
082608 - cancer as chronic
082609 - disease.............................. 090616, ref SDS G1 VS9P
082611 - ..
082612 - 38. Tara advises PARP not ready because UCSF
082613 - ended Millie's treatment with MPA earlier
082614 - than expected due to radiation injury
082615 - Millie suffered caused by UCSF
082616 - medical mistakes..................... 090716, ref SDS G3 EE6P
082618 - ..
082619 - 39. Doctor Johnson reports having time to review
082620 - 2nd opinion and coordinate with UCSF on
082621 - treatments targeted to Millie's
082622 - patient profile...................... 090909, ref SDS G8 VF60
082624 - ..
082625 - 40. Millie asks medical team about progress
082626 - starting PARP, and review of other targeted
082627 - therapies, confirming understandings
082628 - from Doctor Johnson on
082629 - 090909............................... 090922, ref SDS H0 NW6S
082631 - ..
082632 - 41. Doctor Johnson disclosed that medical team
082633 - still has not had enough time to review follow
082634 - on treatments for Millie, and that he has not
082635 - heard from Doctor Rugo on UCSF's
082636 - progress starting the PARP
082637 - protocol............................. 091027, ref SDS H2 GN5G
082639 - ..
082640 - 42. Millie submits agenda for meeting at Kaiser
082641 - on 091112, requesting standard of care to
082642 - compare trade-offs on 10 or so treatments
082643 - targeted to Millie's patient
082644 - profile.............................. 091112, ref SDS H3 LE3R
082646 - ..
082647 - 43. Doctor Johnson reviews published guidance
082648 - on 2nd opinion PARP therapy targeted to treat
082649 - Millie's cancer with triple negavie
082650 - patient profile...................... 100112, ref SDS H8 N586
082651 - confirmed in letter to medical
082652 - team................................. 100120, ref SDS H9 HL7Y
082653 -
082655 - ..
082656 - Cancer 6th Relapse Mutates into Aggressive Disease Resists Treatment
082657 - Radiation Hyperthermia Palliation May Sustain Millie 3 - 6 Months
082658 - Chronic Disease Treatment Strategy Planning Begin for 7th Relapse
082659 -
082660 - The doctor said that modern medicine, even with strong team care at
082661 - Kaiser and research at UCSF, cannot sustain life forever. Millie now
082662 - suffering a 6th relapse is statistically facing much bigger battle in
082663 - the weeks and months ahead. Cancer cells that survived Millie's
082664 - treatments the past 8 years have mutated through successive treatments
082665 - into a more robust, aggressive metastatic disease that resists
082666 - treatment with chemotherapy.
082667 -
082668 - [On 090601 0818 Brad, Kaiser Oncology Pharmacist, calls and
082669 - warns Millie that treatment with Gemzar chemotherapy may not be
082670 - effective, because Millie's patient profile of 8 relapses has
082671 - mutated her cancer to resist chemotherapy. ref SDS F7 JH4K
082673 - ..
082674 - Doctor Johnson further noted that UCSF and others are searching for
082675 - new technologies, like cetuximab and Carbolatin that sustained Millie
082676 - the past 2 years. He explained that hyperthermia prescribed by Doctor
082677 - Rugo on 090129 is a "palliative" solution that may last 3 - 6 months,
082678 - hopefully longer, before Millie will need maintenance treatment for
082679 - cancer as a chronic disease to prevent progression from getting out of
082680 - control.
082681 -
082682 - [...below, in this record on 090213 1140 doctor indicates may
082683 - have less than a year to live. ref SDS 0 9L7N
082685 - ..
082686 - [On 090218 1205 Millie's letter to the medical team reports
082687 - prognosis on response to treatment with radiation and
082688 - hyperthermia; advises Millie will need treatment in 3 - 6
082689 - months for cancer as a chronic disease. ref SDS C4 TH6U
082691 - ..
082692 - [On 090220 1548 BSD professional paper received from UCSF
082693 - explaining hyperthermia and radiation prescribed by Doctor Rugo
082694 - to accomplish local control of advancing IBC disease, explains
082695 - hyperthermia can be used for palliation. ref SDS C7 01G6
082696 -
082697 -
082699 - ..
082700 - UCSF Schedules Meeting for Post Radiation Hyperthermia Care
082701 - Streamline Delivery Care Reduce Risks Small Delays Denying Treatment
082702 - Proactive Management Essential Treat Next Relapse as Chronic Disease
082703 - Complex Case Management 8-years Treatment Magnifies Small Mistakes
082704 -
082705 - The doctor said Millie should therefore meet with Doctor Rugo and
082706 - start planning for follow on treatments after radiation and
082707 - hyperthermia, so that the next treatment is ready to go when relapse
082708 - occurs again, repeating prior guidance during the call on 090123,
082709 - ref SDS A3 RK6O, and also meetings at Kaiser on 081219, ref SDS 87
082710 - EL5J, and earlier on 081024, ref SDS 75 BO9F, and on 080829.
082712 - ..
082713 - [On 090218 1205 Millie's letter notifies medical team that
082714 - Doctor Johnson has ordered Millie's continued care at UCSF,
082715 - citing prior instructions on 080829, 081026, 081219, and on
082716 - 090123, all authorizing UCSF to begin planning for Millie's
082717 - next treatment, so that past delays are avoided, because
082718 - Millie's cancer has mutated through multiple relapses
082719 - (total of 7 so far) into a very aggressive disease which
082720 - requires treatment quickly in order to be effective.
082721 - ref SDS C4 TH6U
082723 - ..
082724 - After 8 years, Millie's long-term care has become so complex (see
082725 - above, ref SDS 0 NY7L) that little details get overlooked more easily
082726 - and "fall through the cracks." Kaiser has been effective for a long
082727 - time containing effects of medical mistakes, reported on 040416.
082728 - ref SDS 16 GN7J Millie suffering a 7th relapse of stage IV cancer now
082729 - magnifies small issues quickly into critical life and death mistakes,
082730 - cited above. ref SDS 0 R75G Millie's expanding patient profile
082731 - narrows the margin for error, discussed above. ref SDS 0 ES7I This
082732 - makes Millie high risk for rapid decline if treatment is delayed,
082733 - noted by the doctor in the graph (see above, ref SDS 0 4W72), and so
082734 - requires proactive management that streamlines delivery of care at
082735 - UCSF to treat Millie's cancer as a chronic disease.
082737 - ..
082738 - [On 090415 1424 Millie reports difficult communications getting
082739 - results of CT and lab tests at Kaiser on 090413 for meeting at
082740 - UCSF on 090423. ref SDS F0 JT7H
082742 - ..
082743 - This repeats advice that was difficult to implement for the 5th
082744 - relapse of IBC, shown by planning on 081024, ref SDS 75 BO9F, again on
082745 - 081219, ref SDS 87 H85I, and most recently on 090123 approving
082746 - treatment of Millie's 6th relapse. ref SDS A3 RK6O
082747 -
082748 - [...above doctor initially emphasized importance of timely,
082749 - thorough communication to prevent critical details from falling
082750 - through the cracks. ref SDS 0 6L7I
082752 - ..
082753 - [...below Doctor Johnson schedules next review at Kaiser in 4
082754 - weeks, rather than 8 weeks used the past 2 years, in order to
082755 - provide timely support for UCSF starting Millie's next
082756 - treatment in time to prevent losing control of cancer.
082757 - ref SDS 0 QX5O
082759 - ..
082760 - [...below medical chart prescribes work plan to follow up with
082761 - Doctor Rugo at UCSF. ref SDS 0 4P9K
082763 - ..
082764 - [On 090218 1205 letter to the medical team confirms Doctor
082765 - Rugo's staff scheduled meeting on 090312 0800 to review
082766 - progress. ref SDS C4 TH6U
082768 - ..
082769 - Doctor Johnson asked about Millie's letter to the medical team on
082770 - 090204 requesting Doctor Rugo submit strategy to continue management
082771 - of assessment and planning for Millie's care after hyperthermia
082772 - treatment during the next month or so in the UCSF Radiation Oncology
082773 - Department. ref SDS B1 278T
082775 - ..
082776 - Millie advised that Lena called on 090210, a week after Doctor Rugo's
082777 - letter on 090204, and said the doctor scheduled a meeting on 090312 to
082778 - review Millie's response to treatment. ref SDS C1 XU5N
082779 -
082780 - [...below in this record on 090213 1140 Doctor Johnson
082781 - schedules next lab at Kaiser on 090309 so there is time to
082782 - process results and submit report during the meeting at UCSF on
082783 - 090312 to evaluate response to treatment. ref SDS 0 WY5M
082785 - ..
082786 - [On 090220 1548 research paper received from UCSF explains
082787 - hyperthermia heats cancer cells enabling increased delivery
082788 - of drugs through the circulation system, which thereby
082789 - kills more cancer cells, and further enhances drug toxicity
082790 - in cancer cells rendered resistant to chemotherapy drugs
082791 - through mutation, increasing efficiency of treatments.
082792 - ref SDS C7 0129
082794 - ..
082795 - [On 090220 1548 paper received from UCSF describes hyperthermia
082796 - combined with ionizing radiation provides effective treatment
082797 - even for mutated cancer cells that resist treatment with
082798 - chemotherapy. ref SDS C7 00FS Since hyperthermia combined with
082799 - radiation and/or chemotherapy, ref SDS C7 0129, "kills" cancer
082800 - cells, ref SDS C7 00EI, this does not seem to fit the model of
082801 - "palliation" as mere relief from suffering while cancer
082802 - progresses toward near term demise. "Killing" cancer cells
082803 - through heat sounds like aggressive curative therapy.
082804 - ref SDS C7 GK6F
082806 - ..
082807 - [On 090220 1548 hyperthermia provides palliation relief from
082808 - pain with rising cancer, and from side effects of chemotherapy
082809 - and radiation treatments, and even where there is no hope for
082810 - survival, reported in BSD 2002 research paper received from
082811 - UCSF. ref SDS C7 01G6
082813 - ..
082814 - [On 090310 0351 Millie's letter to medical team submits agenda
082815 - for meeting to evaluate response to treatment and begin
082816 - planning on treatment of next relapse as chronic disease.
082817 - ref SDS D1 O64Y
082819 - ..
082820 - [On 090310 1735 letter from Tara proposes deferring meeting on
082821 - 090312 for evaluating response to treatment and whether
082822 - adjustments to treatment are needed. ref SDS D2 PR4Y
082824 - ..
082825 - [On 090311 1047 Millie's letter to primary care physician
082826 - presents agenda for meeting with medical team at UCSF on 090312
082827 - to begin planning treating Millie's IBC cancer as a chronic
082828 - disease. ref SDS D3 TE4U
082830 - ..
082831 - [On 090311 1431 Millie's letter to UCSF responds to Tara's
082832 - letter on 090310 1935 proposing to defer meeting on 090312, and
082833 - Millie requests date to reschedule meeting with Doctor Rugo for
082834 - planning treatment of Millie's IBC as a chronic disease.
082835 - ref SDS D4 O15X
082837 - ..
082838 - [On 090312 0800 meeting with UCSF examination in Breast Care
082839 - Clinic finds good response to treatment the past 3 weeks with
082840 - radiation and hyperthermia, ref SDS D6 9L7K; Tara will report
082841 - to Doctor Rugo who has a number of planning options for
082842 - treating Millie's IBC as a chronic disease. ref SDS D6 QQ9L
082844 - ..
082845 - [On 090312 0800 meeting with UCSF examination in radiation
082846 - oncology department concurs with preliminary opinion in Breast
082847 - Care Clinic that Millie shows good response to treatment,
082848 - ref SDS D6 F893; and Doctor Hsu advised that Millie can get
082849 - more treatment to continue recovery from IBC by combining
082850 - hyperthermia with other modalities, except she has no further
082851 - tolerance for radiation. ref SDS D6 DY8O
082852 -
082853 -
082855 - ..
082856 - Religion Journey of Vigorous Productive Life to Eternal Peace
082857 - Less than Year to Live Transition through Religion Toward Rest Peace
082858 -
082859 - Doctor Johnson offered a poignant, inspiring explanation of religion
082860 - and faith that help people transition from a vigorous, productive life
082861 - toward peace and eternity. Previously, on 050913 the doctor used
082862 - religous reference to encourage patient approval for surgery.
082863 - ref SDS 34 5T5N Today, the Doctor Johnson cited pictures of Einstein
082864 - in his later years with craggy face, and disheveld hair having come to
082865 - symbolize wisdom beyond science and knowledge.
082867 - ..
082868 - Religion offers trans-cultural experience for ending the journey of
082869 - life, captured in the simplicity of Einstein's famous comment that
082870 - "God does not play dice with the universe," discussing quantum
082871 - mechanics with Neils Bohr, reviewed on 040312. ref SDS 14 UZ8M The
082872 - doctor offered today a theory of religion as the "science of life,"
082873 - which "connects the dots" across the vast expanse of time and distance
082874 - beyond comprehension in the here and now of a single life, and
082875 - reflecting perspective in NWO. ref OF 7 42FF
082876 -
082878 - ..
082879 - Year or Less to Live
082880 -
082881 - Millie asked how long she has to live?
082883 - ..
082884 - The doctor said maybe a year.
082886 - ..
082887 - Doctor Johnson explained that since Millie's cancer has mutated into a
082888 - very aggressive disease, finding and delivering treatment in time to
082889 - be effective gets harder with each relapse. That's why he has
082890 - emphasized for months the UCSF Cancer Center should have treatments
082891 - lined up for treating Millie's cancer as a chronic disease, per above.
082892 - ref SDS 0 WZ6K
082894 - ..
082895 - Negative synergy from case management practices that neglect patients
082896 - who survive longer than expected, discussed above. ref SDS 0 4W72,
082897 - accelerates complexity that compounds errors and delay from negligent
082898 - case management, shown by problems ordering Millie's treatment of the
082899 - 6th relapse listed on 081016, ref SDS 72 J36R, and similar problems
082900 - ordering Millie's current treatment (see case study above, ref SDS 0
082901 - LH6F). Since Millie has a narrowing margin for error that delays
082902 - treatment, per above, ref SDS 0 PL5K, survival within this narrow
082903 - window is overwhelmed by negligence in health care delivery.
082904 -
082905 - [...below Doctor Johnson schedules next review at Kaiser in
082906 - 4 weeks, rather than 8 weeks used the past 2 years, in
082907 - order to provide timely support for UCSF starting Millie's
082908 - next treatment in time to prevent losing control of cancer.
082909 - ref SDS 0 QX5O
082911 - ..
082912 - [On 090218 1205 Millie's letter notifies medical team that
082913 - Doctor Johnson has ordered Millie's continued care at UCSF,
082914 - citing prior instructions on 080829, 081026, 081219, and on
082915 - 090123, all authorizing UCSF to begin planning for Millie's
082916 - next treatment, so that past delays are avoided, because
082917 - Millie's cancer has mutated through multiple relapses
082918 - (total of 7 so far) into a very aggressive disease which
082919 - requires treatment quickly in order to be effective.
082920 - ref SDS C4 TH6U
082922 - ..
082923 - [On 090325 0830 the doctor drew the graph again, per above,
082924 - ref SDS 0 4W72, and added a mark indicating Millie is near
082925 - the end of sustainable quality of life, and will soon
082926 - suffer rapid decline. ref SDS E2 P39M
082928 - ..
082929 - Doctor Johnson said that in the months ahead Millie should take her
082930 - remaining time to do things she has always wanted to do.
082932 - ..
082933 - Millie asked if she should go ahead with a vacation planned with her
082934 - daughter for 2 weeks in late April. Will cancer be so bad that her
082935 - strength will be gone? She does not want to be a burden to others.
082937 - ..
082938 - The doctor said that by all means Millie should continue with vacation
082939 - plans. He feels that in April Millie will still have vitality to
082940 - enjoy time with daughter on vacation.
082941 -
082942 -
082944 - ..
082945 - Hospice Care Patients Avoid Discomfort of Decline
082946 -
082947 - Millie asked if she will suffer significantly from pain and decline of
082948 - normal functions?
082950 - ..
082951 - The doctor advised that rather than spend more effort on treatment to
082952 - extend Millie's quality of life at ECOG performance score 0, shown in
082953 - the medical chart today, per below, ref SDS 0 YF9L, costs can be
082954 - reduced to meet concerns of the Emporer in the "Indian Chess fable,"
082955 - discussed above, ref SDS 0 4N5K, Kaiser can provide Hospice care to
082956 - ensure Millie does not suffer pain and anguish as cancer progresses
082957 - untreated to conclusion, discussed with the Doctor's graph on
082958 - longevity above. ref SDS 0 4W72