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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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 F (36.8 C) | 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 -