Welch Company
San Francisco, CA
S U M M A R Y
DIARY: September 22, 2009 00:28 AM Tuesday;
Rod Welch
Millie notifies medical team meeting at Kaiser on Sep 21 found significant
recovery from 8th relapse of cancer; continue Gemzar chemotherapy.
1...Summary/Objective
2...Medical Chart
..............
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CONTACTS
SUBJECTS
Default Null Subject Account for Blank Record
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 16 0000, ref SDS 14 0000.
040502 -
040503 -
040504 -
040506 - ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 090920 1010 Millie sent a letter to the medical team submitting the
040902 - agenda for meeting while Millie is hospitalized for treatment of
040903 - painful breathing, with the primary care physician, Doctor Johnson, to
040904 - review progress recovering from Millie's 8the relapse of cancer, and
040905 - approve starting next cycle of Gemzar. ref SDS 0 VF5H
040906 -
040907 -
040908 -
040909 -
040911 - ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Yesterday, on 090921 1026, Millie sent a letter notifying the medical
041302 - team she was hospitalized again to recover from painful breathing.
041303 - ref SDS 16 VF5H
041305 - ..
041306 - Later, in the afternoon, Doctor Johnson visited Millie in her
041307 - hospital room and performed an examination. He reviewed results of
041308 - the CT test on Saturday, and approved Millie to get treatment for
041309 - recovering from cancer on Wednesday, 090923.
041311 - ..
041312 - Sent a letter to the medical team confirming understandings from
041313 - meeting on Millie's next treatment...
041314 -
041315 - 1. Subject: Meeting at Kaiser on Treatment Plan 8th Relapse Cancer Breathing Problems
041316 - Date: Tue, 22 Sep 2009 01:22:04 -0700
041338 - ..
041339 - 3. This confirms understandings from the meeting yesterday in my
041340 - hospital room at Kaiser in Walnut Creek.
041342 - ..
041343 - 4. Your examination found substantial recovery from IBC after
041344 - completing the 2nd cycle of Gemzar, as reported in the letter
041345 - to the medical team earlier yesterday, shown below. You
041346 - further found that my ANC (NEUTS at UCSF) blood counts from the
041347 - lab yesterday morning continue to show sufficient strength for
041348 - me to get further chemotherapy, even though a lot of other
041349 - blood elements [in the lab] have suddenly fallen outside target
041350 - ranges.
041352 - ..
041353 - 5. By copy to Gloria at the Coagulation Control Clinic in
041354 - Martinez, report comments from the hospital pharmacy, who met
041355 - with me yesterday just prior to your arrival and stayed for you
041356 - to hear their explanation of having reduced my Coumadin the
041357 - past two days to account for effects of the antibiotics. They
041358 - further explained my INR test yesterday was too low, showing
041359 - they reduced too far, and so increased my dose for tomorrow to
041360 - increase INR back to within the 2.0 to 3.0 safe range.
041362 - ..
041363 - 6. At this time, I am scheduled to begin the 3rd cycle of Gemzar
041364 - on Wednesday.
041366 - ..
041367 - 7. In the meeting yesterday, you discussed delaying my treatment a
041368 - week to continue evaluating recent temperature elevations,
041369 - which required care in the Emergency Department this past
041370 - Saturday on 090919. Kaiser is treating me with antibiotics,
041371 - based on elevated Bands in the blood test on 090919. You
041372 - seemed to say, Bands are still elevated in the lab today, and
041373 - further noted there have been no findings of what is causing
041374 - elevated temperature and persistent difficulty breathing.
041375 - These symptoms continue despite treatment with antibiotics the
041376 - past 3 days.
041378 - ..
041379 - 8. You explained my difficulty breathing may be caused by
041380 - radiation injury to my lungs, evidenced by ground glass
041381 - opacities previously cited by Doctor Rugo during the meeting at
041382 - UCSF on 090514. ref SDS 10 NL9I
041384 - ..
041385 - 9. Ground glass opacities are cited again in the CT test performed
041386 - on Saturday, 090919, ref SDS 15 AK5H, though without
041387 - substantial increase since the prior test on 090612 (this is
041388 - hazy in the report, which also refers to the test "last month,"
041389 - since the "last test" was on 090720, possibly suggesting a
041390 - mistake in the CT test report).
041391 -
041392 - [On 091112 0930, medical chart for meeting with Millie
041393 - seems to have text from CT test today, on 090919, and
041394 - reports finding no pulmonary embolism, and that some ground
041395 - glass opacity nodules in the lungs have resolved, and new
041396 - ones have appeared in other areas of the lungs. ref SDS 18
041397 - RU6R
041399 - ..
041400 - 10. You seemed to say today that Kaiser does not have treatment for
041401 - this condition of diminished breathing due to radiation injury.
041402 - Research on 090415 shows ground glass opacities can be treated,
041403 - so that my breathing is restored. ref SDS 9 LG9L
041405 - ..
041406 - 11. By copy I am asking Doctor Rugo and Doctor Hsu to submit a work
041407 - plan for me to recover from radiation injury suffered during
041408 - treatment in Doctor Hus's Department at UCSF in February and
041409 - March on Kaiser referral Authorization #A023141470 dated 090202
041410 - [reprted on, ref SDS 6 278T
041412 - ..
041413 - 12. You indicated today that time is of the essence for me to get
041414 - treatment recovering from breathing problems, explaining
041415 - radiation injury will worsen without treatment.
041417 - ..
041418 - 13. You further noted during the meeting that cancer may be a
041419 - contributing factor to my recent history of elevated
041420 - temperature the past several weeks, along with lung infection
041421 - from ground glass opacities caused by radiation treatments.
041422 - Since examination and testing in the Emergency Department
041423 - beginning on Saturday, and continuing in the hospital the past
041424 - two days found no evidence of pneumonia, which was a concern
041425 - Doctor Hsu raised originally on 090403, ref SDS 8 Z66M, you
041426 - feel it is important to treat my cancer in order to reduce the
041427 - risk of continuing high temperature.
041429 - ..
041430 - 14. There is also risk of unknown infection being compounded by
041431 - chemotherapy, presenting a "darned if you, and darned if you
041432 - don't" dilemma.
041434 - ..
041435 - 15. Since Gemzar treatment being given at Kaiser was prescribed by
041436 - Doctor Rugo on 090716, [ref SDS 12 EE6P], following Doctor
041437 - Hsu's work plan using MPA for me to recover from IBC caused by
041438 - mistakes performing radiation, I would like Doctor Rugo's
041439 - comment on whether to delay starting the 3rd cycle of Gemzar on
041440 - Wednesday in connection with the fever issue.
041442 - ..
041443 - 16. I am concerned that fever will continue to occur, until the
041444 - ground glass opacities problem is solved, and this could delay
041445 - treating my cancer forever allowing disease to spin out of
041446 - control, as nearly occurred due to delays starting treatment in
041447 - early February [... noted in Doctor Rugo's letter on 090202
041448 - 1932. ref SDS 4 Y15J - as well, during the meeting at Kaiser
041449 - yesterday on 090921, Doctor Johnson commented that even though
041450 - all of the 40 or so radiology tests for the past 8 years show
041451 - no evidence that cancer has spread to internal organs, the
041452 - doctor feels that there is likely cancer in Millie's lungs or
041453 - other internal organs at a level below detection by radiology
041454 - testing. Millie's goals are to get targeted treatment in time
041455 - to maintain this favorable condition...]. If Doctor Rugo does
041456 - not respond, then I assume she concurs with the strategy
041457 - discussed today that on balance we should go ahead with Gemzar
041458 - on Wednesday to maintain my recovery from IBC, and address
041459 - temperature issues with Tylenol that has worked the past
041460 - several weeks, until this past Saturday.
041461 -
041462 - [On 100204 1325 Millie's notifies Kaiser to perform blood
041463 - draws in Power Port because visible cancer and lymphedema
041464 - that prevent IV needle penetrations in her left arm are now
041465 - likely occurring in the right arm, though not visible at
041466 - the moment, but rising shown by rising cancer marker.
041467 - ref SDS 20 SB7V
041469 - ..
041470 - 17. Since this is a UCSF responsibility to recover from mistakes
041471 - performing radiation treatments, I also ask for examination by
041472 - a cardio-pulmnary specialist, or such other medical discipline
041473 - qualified to provide care at UCSF for my breathing symptoms.
041475 - ..
041476 - 18. Finally, I was very pleased today during the meeting to commend
041477 - the Emergency Department for improving services.
041479 - ..
041480 - 19. On 090720 I was treated in the ER for difficult and painful
041481 - breathing, the same as this past Saturday on 090919. At that
041482 - time on 090720, there was a mix up in the ER ordering my CT
041483 - test without using the Power Port. This caused emotional
041484 - trauma for the nurse who tried with great skill and persistence
041485 - to place a conventional IV in my right arm. The effort was
041486 - unsuccessful causing pain and suffering with several tries,
041487 - because my right arm has significant diminished capacity for IV
041488 - blood flow, as reported in the record on 090720. ref SDS 13
041489 - OK8L
041491 - ..
041492 - 20. Thankfully, this past Saturday, the prior problems were
041493 - resolved with training and orientation for the ER staff to now
041494 - use Power Port technology for drawing blood and setting up for
041495 - CT tests. It was a pleasure to commend Doctor Lilenstein, and
041496 - the nursing staff, including Linda, Shelby, and Michelle. As
041497 - you can see, they were an outstanding team collaborating with
041498 - the patient assistant to access my port using a Lifeguard Huber
041499 - needle of 1" and with high-strength steel, as required for
041500 - doing another CT test. ref SDS 15 1K6M
041502 - ..
041503 - 21. Danial Linnen, in the ICU Department, also deserves credit for
041504 - coordinating between ER and the CT Department to arrange for my
041505 - CT test using the Bard Power Port. ref SDS 15 04G4
041507 - ..
041508 - 22. This was not an easy job. Wound up taking 6 hours to finally
041509 - get my CT test on Saturday.
041511 - ..
041512 - 23. There was however a mistake that resulted in not using the
041513 - Power Port after all [reported on 090919 0742. ref SDS 15
041514 - MI9Q], causing further emotional trauma for the CT Technician
041515 - staff who ultimately was forced to make several unsuccessful
041516 - attempts to stick me with needles for a conventional IV,
041517 - ref SDS 15 6Q9G, as occurred previously on 090720. ref SDS 13
041518 - ER38 Investment doing surgery to swap out the port catheter
041519 - for a Power Port, and time and expense for orientation and
041520 - training the ER staff directed toward avoiding trauma to the
041521 - staff and patients, and to save time and money with numerous
041522 - failures injecting needles for a conventional IV -- all of this
041523 - was ultimately lost on Saturday.
041524 -
041525 - [On 100218 1000 Cassandra reports Kaiser CT Department has
041526 - recently upgraded to develop protocol for using Power Port
041527 - to inject contrast testing medium. ref SDS 21 M67K
041529 - ..
041530 - 24. Why?
041532 - ..
041533 - 25. Danial did his "homework." 090919 0742, ref SDS 15 MI9Q
041535 - ..
041536 - 26. Danial found that Bard, who manufacturer's the Power Port,
041537 - specifies using only Bard Huber needles. He noticed in the CT
041538 - Department at 1700 that the medical team in the ER at 1000 used
041539 - a Lifeguard Huber needle. He therefore ordered the CT test
041540 - delayed, while he searched Kaiser supplies for a Bard Huber
041541 - needle to exchange for the Lifeguard needle. He couldn't find
041542 - a Bard Huber needle, because Kaiser in Walnut Creek has
041543 - standardized on using Lifeguard Huber needles, reported by
041544 - Paula Vannicola on 081017. ref SDS 2 045H
041546 - ..
041547 - 27. Similarly, neither Danial nor the CT staff could access my
041548 - patient history showing numerous successful CT tests using the
041549 - Lifeguard Huber needle connected to a Bard Power Port. You
041550 - might wonder why I didn't say anything. At that point, I was
041551 - in shock that this could be happening. Like events in the CT
041552 - Department on 081107, when you are the object of discussion,
041553 - helping competent, busy people is very difficult. ref SDS 3
041554 - AN6H
041556 - ..
041557 - 28. So, again CT tests that take 20 minutes with the Power Port
041558 - wind up taking several hours, with a lot of time and money
041559 - wasted, along with pain and suffering, when people get confused
041560 - and misdirected, even though everyone is working hard trying to
041561 - do the "right thing."
041563 - ..
041564 - 29. The ER Department showed on 090919 that Health Care providers
041565 - can apply "Lessons Learned" to save time and money. ref SDS 15
041566 - QZ45
041568 - ..
041569 - 30. By copy to Doctor Mates and Doctor Davidson recommend the CT
041570 - Department prepare a protocol for performing CT tests injecting
041571 - contrast medium using Power Ports with Lifeguard Huber needles.
041572 - Patients can then refer the team to the protocol, which can be
041573 - cited in the referral for fast review on the computer, when
041574 - needed. This would strengthen the doctor patient partnership
041575 - which Kaiser promotes for cost effective care, reviewed on
041576 - 990625. ref SDS 1 4185
041577 -
041578 - [On 100218 1000 Cassandra reports Kaiser CT Department has
041579 - recently upgraded to develop protocol for using Power Port
041580 - to inject contrast testing medium. ref SDS 21 M67K
041582 - ..
041583 - 31. Thanks for a productive meeting today. Look forward to hearing
041584 - from UCSF on the treatment plan to recover normal breathing,
041585 - and comment on starting the 3rd cycle of Gemzar on Wednesday
041586 - after I am released from the hospital tomorrow recovering from
041587 - elevated fever.
041589 - ..
041590 - 32. We also need the treatment plan from UCSF on PARP and other
041591 - protocols presented by Doctor Rugo on 090616 [advising that
041592 - Kaiser and UCSF agreed Millie's next treatment after MPA would
041593 - be with PARP, ref SDS 11 KD6L, and], which are "targeted" for
041594 - cancer and so avoid concerns about high temperature problems.
041595 - If it turns out that Gemzar presents too great a risk for my
041596 - patient profile, which has always been an issue, then we need
041597 - to transition to a new regimen in time to maintain my current
041598 - recovery, as reported by Doctor Johnson today. [On 090909
041599 - Doctor Johnson reported he now has time to review targeted
041600 - treatments, ref SDS 14 QX88, for Millie's patient profile
041601 - listed in 2nd opinion, including PARP, received on 090204.
041602 - ref SDS 5 9J6Y]
041603 -
041604 - [On 091027 0830 Doctor reported receiving Millie's letter,
041605 - and that the medical team has not had time to complete
041606 - review of follow on treatments targeted to Millie's patient
041607 - profile, including PARP. ref SDS 17 0M3H
041609 - ..
041610 - [On 100112 0830 Doctor Johnson reviews published guidance
041611 - on 2nd opinion PARP therapy targeted to treat Millie's
041612 - cancer with triple negavie patient profile. ref SDS 19 N586
041613 -
041619 -
041620 -
041622 - ..
0417 -
0418 -
0419 - 2126
0420 -
042001 - Medical Chart
042002 -
042003 - A week later on 090929, received the doctor's medical chart for the
042004 - meeting yesterday at Kaiser on 090921...
042005 -
042006 - 1. Hospital Note 09/21/09
042009 - Received: 9/29/09 9:05 AM
042011 - ..
042012 - 2. Mon Sep 21, 2009 1728
042014 - ..
042015 - 3. Note Text Oncology Note
042017 - ..
042018 - 4. Subjective:
042019 -
042020 - Mildred A Buck is a 73 Y female with a history of IBC of left
042021 - breast who was initially diagnosed 03/04/02. S/P AC x's 4 from
042022 - 04/23/02 through 07/01/02 followed by Taxotere ending 12/04/02.
042023 - She had recurrent disease noted initially in the cervical LN's
042024 - 03/03/04. On E2100 Study with Taxol/Avastin, but she had a PE
042025 - noted on CT 11/03/2004. Then, because of progression of
042026 - disease, the patient was started on Taxotere and Xeloda
042027 - 4/15/05. She had a total of 8 cycles ending 9/16/05. She had
042028 - a palliative left mastectomy performed 10/21/05. Then her left
042029 - chest lesions began expanding again. The patient started
042030 - Taxotere and Xeloda again 07/21/06 for 7 cycles. She was
042031 - started on a Clinical Trial 02/01/07 at UCSF and was randomized
042032 - to the Erbitux only (no Carbo) Arm. She had weekly Carboplatin
042033 - added 03/13/08 because of progression of disease. Her disease
042034 - progressed again and she began a Phase I/II Study of Sunitinib
042035 - (SU11248) at UCSF 11/14/08. Lengthy discussion about current
042036 - status and response to therapy. Because of cytopenia, MTX to be
042037 - D/C'd and Sutent and CTX held and then dose reduced. The
042038 - patient started hyperthermia/XRT at UCSF 02/19/09 and completed
042039 - it 03/17/09. She has started the MPA Clinical Trial at UCSF
042040 - 06/16/09 but this has been D/C'd. She started Gemzar 07/28/09
042041 - and received Wk #1 Of Cycle #2 08/26/09. She was admitted to
042042 - the hospital for fever 09/19/09. No source has been determined
042043 - at this time.
042045 - ..
042046 - 5. Objective:
042047 - PE:
042048 - BP 96/64 | Pulse 80 | Temp 98.2 øF (36.8 øC) | Resp 16 | Ht 5' 2" | Wt 140 lb
042049 - (63.504 kg) | SpO2 98% | Breastfeeding? No
042050 - Eyes: normal conjunctiva
042051 - Chest wall: marked decrease in cutaneous lesions
042052 - Ext: decreased LUE lymphedema
042054 - ..
042055 - 6. Lab:
042056 - PFT'
042057 - - No obstruction
042058 - - Good response to bronchodilators
042059 - - Moderate decrease in diffusion capacity
042061 - ..
042062 - 7. WBC 4.6 K/uL
042063 - RBC L 3.03 M/uL
042064 - Hemoglobin L 8.8 g/dL
042065 - Hematocrit L 27.0 %
042066 - MCV 89 fL
042067 - RDW H 20.6 %
042068 - Plt 344 K/uL
042070 - ..
042071 - 8. BUN 9 mg/dL
042072 - Chloride 102 mEq/L
042073 - CO2 24 mEq/L
042074 - Creatinine 0.65 mg/dL
042075 - Glucose Random 93 mg/dL
042076 - Potassium 4.6 mEq/L
042077 - Sodium L 133 mEq/L
042078 - Anion Gap 7 mEq/L
042080 - ..
042081 - 9. CA 15-3
042082 - -----------
042083 - 346 H
042084 - 335 H
042085 - 350 ?
042086 - 389 H
042087 - 289 H
042088 - 320 H
042089 - 271 H
042090 - 251 H
042092 - ..
042093 - 10. PT, Patient H 18.6 Sec
042094 - PT INR 1.9 Ratio
042096 - ..
042097 - 11. 09/19/09
042098 - Urine Culture
042099 - SOURCE: CLEAN CATCH URINE
042100 - Final Report
042101 - <50,000 COL/ML MIXED ENTERIC FLORABlood Culture TEST IN LABSOURCE: BLOODBlood
042102 - Culture TEST IN LAB
042103 - SOURCE: BLOOD
042105 - ..
042106 - 12. Imaging:
042107 -
042108 - 09/19/09 WCR ROTHDAR CT THORAX W CONTRAST - Since July 20, 2009
042109 - CT scan of the chest, there has been resolution of many of the
042110 - pulmonary opacities but there are now many new ones, especially
042111 - in the left lower lobe and in the right upper lobe. The left
042112 - pleural effusion is much smaller. Otherwise, no change.
042114 - ..
042115 - 13. 09/19/09 WCR LILIEND CHEST, SINGLE - Since July 31, 2009, no
042116 - change.
042118 - ..
042119 - 14. Assessment:
042120 - 1. Fever
042121 - 2. Metastatic breast cancer (IBC) lung, lymph node and chest wall; S/P
042122 - hyperthermia/XRT
042123 - 3. S/P Gemzar with mixed response
042124 - 4. DOE; due to radiation injury, bronchospasm and decreased diffusion capacity
042125 - (as per PFT's)
042126 - 5. Lymphedema improved
042128 - ..
042129 - 15. Plan:
042130 - 1. Continue current management
042131 - 2. OK to D/C when stable
042132 -
042135 -
042136 -
042137 -
042138 -
042139 -
042140 -
042141 -
042142 -
0422 -