THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rod@welchco.com


S U M M A R Y


DIARY: October 22, 2009 07:00 AM Thursday; Rod Welch

Heart bypass CABG x4 surgery at VA to resolve 4 artery blockages.

1...Summary/Objective
2...Preventive Management Achalasia Investigate Avoid Cardiac Arrest
3...Achalasia Avoid Cardiac Arrest During Heart Surgery Proactive Planning
4...VA Computer Records Proactive Case Mangement Improve Patient Outcomes
5...CABG x4 - Coronary Artery Bypass Graft - Quadruple Heart Surgery
6...Quadruple Bypass Surgery resolve Coronrary Artery Restrictions
7...Doctor Tseng Attending Quadruple Bypass Heart Surgery
8...CABG Successful Last 8 - 15 Years - CABG x4 Reduced Survival
9...Complications CABG Surgery


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CONTACTS 

SUBJECTS
Background Heart Bypass Surgery Quadruple (4) Coronary Artery Bypass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
0703 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0703 -    ..
0704 - Summary/Objective                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
0705 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
070501 - Follow up ref SDS 12 0000. ref SDS 11 0000.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
070502 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070503 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070504 -            [On 100928 0706 received VA's report on surgery today, prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
070505 -            by Neil. ref SDS 23 C58I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
070507 -             ..
070508 -            [On 140213 0830 meeting at VA consider performing CT and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
070509 -            related tests to evaluate regression of atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
070510 -            lesions based on labs showing elevated LDL-C, but also high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
070511 -            HDL and low triglycerides (TG), which could signal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
070512 -            discordance, i.e., low LDL-P, ref SDS 30 JZ4O, which is the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
070513 -            healthiest condition for CVD patients, shown by research on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
070514 -            131125 0005. ref SDS 29 FI3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
070516 -             ..
070517 -            [On 151019 0930 Radiology report on CCTA test performed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
070518 -            151019, indicates calcification in original bypassed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070519 -            arteries has increased since CABG +4 surgery on 091022,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
070520 -            ref SDS 31 J14N; seems conflicting with this research on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
070521 -            131125, theorizing atherosclerosis plaques regress rapidly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
070522 -            with elevated HDL and EPCs. ref SDS 29 RA7K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
070524 -             ..
070525 -            [On 181102 1928 study in Denmark found 8-10 year survivors                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
070526 -            after CABG surgery have an increased mortality of between                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
070527 -            60 and 80 per cent when compared with the general                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
070528 -            population.  This may be due to the fact that the disease                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
070529 -            is progressive and that the atherosclerosis or hardening of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
070530 -            the arteries increases, or that the implanted material                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
070531 -            begins to fail. ref SDS 35 144J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
070533 -             ..
070534 -            [On 190527 0857 letter asks Doctor Simpson's take on this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
070535 -            article on Denmark study finding significantly increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
070536 -            mortality 8-10 years after heart bypass, in relation to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
070537 -            CABG x4 in this case 10 years ago on 091022, and 2-CCTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
070538 -            studies which reported bypassed blood vessels contain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
070539 -            significant plaque. ref SDS 37 NE56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
070541 -             ..
070542 -            [On 190101 0730 case study report for hike on 191210, felt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
070543 -            pressure in chest, similar to feeling hiking up 1st hill at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
070544 -            Lafayette Reservoir that was reported to doctor Lee at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
070545 -            VA on 090908, and which led to having CABG x4 today on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
070546 -            091022.  Chest pain on 191210, resolves within a mile and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
070547 -            did not recur, despite hiking uphills of 1 mile and over 15                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
070548 -            mile hike. ref SDS 36 YTWS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
070550 -             ..
070551 -            [On 191228 1416 letter to Doctor Simpson in Cardiology at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
070552 -            VAMCSF notifies chest pain on hills hiking 20 miles,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070553 -            similar to report to Doctor Lee on 090908, leading to CABG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
070554 -            x4 on 091022. ref SDS 38 B64Y  Seems like bypass saphenous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
070555 -            graft failed under elevated load wearing elastic bandage on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
070556 -            left knee. ref SDS 38 B665  Pause hiking until hear from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
070557 -            the doctor. ref SDS 38 B668                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
070559 -             ..
070560 -            [On 200103 0700 treadmill stress test found no evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
070561 -            blocked blood vessels, including coronary artery bypass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
070562 -            grafts. ref SDS 39 TS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
070564 -             ..
070565 -            [On 200124 0705 cardiac catheterization IVUS angiogram                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
070566 -            found no evidence blocked coronary artery bypass grafts;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
070567 -            found 1 branch vessel with 80-90% blockage; doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
070568 -            described best condition every seen 10 years after CABG;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
070569 -            told patient to keep doing whatever he is doing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
070570 -            ref SDS 40 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
070571 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070572 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070573 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070574 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070575 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070577 -  ..
0706 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0707 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0708 - Background                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
0709 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
070901 - On 081207 record hiking with Millie mostly at Lafayette Reservoir,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
070902 - averaged 6 miles per day 4 - 6 days a week. ref SDS 4 X64F  This was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
070903 - level of walking resulted in HDL 30, very high risk for CVD/CAD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
070905 -  ..
070906 - On 090916 VA performed stress test, which indicated possible heart                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
070907 - and circulation problems - CVD/CAD.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
070909 -  ..
070910 - On 091002 met with Doctor Egan, Cardiologist at the VA.  The doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
070911 - advised that 10 of 11 test points in the stress test showed positive                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
070912 - for circulation problems, i.e., CVD/CAD, and so the doctor ordered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
070913 - angiogram. ref SDS 6 1W5I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070915 -  ..
070916 - On 091006 0843 Karen called and scheduled angiogram test on 091020 at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
070917 - the VA in San Francisco. ref SDS 7 1W5I  Received a letter from Karen                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
070918 - on 091006 at 1045 confirming schedule for the test which requires                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
070919 - arriving at the VA on 091019 to do prep for the test on 091020.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070920 - ref SDS 7 GK8L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
070922 -  ..
070923 - On 091007 0021 sent a letter notifying the medical team that Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
070924 - Egan's treatment plan is being implemented, and asked a question about                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
070925 - the cause of pain based on level of effort. ref SDS 8 4Z75                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
070927 -  ..
070928 - On 091007 0818 received letter from Karen at VA in San Francisco                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
070929 - responding to the letter this morning asking the medical team for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
070930 - cause of chest pain that correlates to level of effort.  Doctor Egan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
070931 - has not had time to respond.  Karen attributes pain to possible                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070932 - angina, but does not explain what causes pain. ref SDS 9 A68H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
070934 -  ..
070935 - 091019 1300 meeting at VA in Cardiology for blood test to prepare for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
070936 - angiogram test tomorrow, ref SDS 10 X59F, per Karen's letter on 091007                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
070937 - 0818. ref SDS 9 A68H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
070939 -  ..
070940 - 091020 0700 meeting at VA in San Francisco for angiogram test delayed,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
070941 - ref SDS 11 01F9, explained in the record on 091019 1300. ref SDS 10 VH6Q                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
070943 -  ..
070944 - 091021 0716 Meeting at VA to complete angiogram test orientation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
070945 - meeting, ref SDS 12 01F9, and perform test.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
070947 -  ..
070948 - On 091022 0700 Doctor Tseng, Neal, Joe, Casey, Paula, and others                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
070949 - performed the surgery. ref SDS 0 01F9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
070950 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070951 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
070953 -  ..
0710 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0711 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0712 - Progress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0713 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
071301 - Doctor Sarah Gebauer and Jusin arrived about 0645 in the ICU and tried                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
071302 - to set some IVs for heart bypass surgery required by the angiogram                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
071303 - test yesterday on 091021 0716, ref SDS 12 7L43; and as shown in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
071304 - Sarah's work plan later yesterday evening on 091021 0716. ref SDS 12                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
071305 - PL81                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
071307 -  ..
071308 - This morning, there were further difficulties getting blood to flow                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
071309 - through catheters, as encountered yesterday in ICU, reported on 091021                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
071310 - 0716. ref SDS 12 737P  Sarah decided to complete the work in the OR                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
071311 - using a sonogram to find veins and arteries with sufficient blood flow                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
071312 - in the left and right arms for placing IV catheters required for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
071313 - heart surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
071314 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071315 -        [...below on 091022 0700 later in the morning, Sarah and Justin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
071316 -        had further difficulties setting IVs using sonogram technology                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
071317 -        to locate veins and arteries.  Doctor Brezinski provided                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071318 -        assistance and training to complete IV catheters required for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
071319 -        CABG surgery, ref SDS 0 LN71, though he too had problems                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071320 -        performing the work. ref SDS 0 LN9T                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
071322 -         ..
071323 -        [On 091101 0910 Joy placed a catheter in the right arm above                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
071324 -        the wrist; used hot towel with a tournaquet to do this on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
071325 -        first attempt. ref SDS 16 EX3P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
071327 -         ..
071328 -        [On 110429 1230 case study on similar problems at VA in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
071329 -        Martinez, getting adequate blood flow through IV catheter,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
071330 -        related to dehydration from heavy exercise and low water                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071331 -        intake hours before medical care; solved by getting another                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
071332 -        nurse to complete work. ref SDS 25 SR8M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
071334 -         ..
071335 -        [On 091219 0600 4 days after Heller Myotomy surgery planning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
071336 -        discharge or following day; therefore standard protocol to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
071337 -        replace IV catheter not followed to avoid expense and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
071338 -        inconvenience to patient. ref SDS 19 0L46                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
071340 -         ..
071341 -        [On 091228 1049 notified Doctor Egan in Cardiology at VA in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
071342 -        Martinez, and also Doctor Sandhu in Primary Care of successful                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
071343 -        heart surgery on 091022. ref SDS 20 JN9X                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
071345 -  ..
071346 - About 0700, Doctor Brzezinski, Chief of Anesthesia, arrived in ICU.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
071347 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071348 -            Marek Brzezinski, MD, PhD                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
071349 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071350 -              http://profiles.ucsf.edu/marek.brzezinski                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
071351 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071352 -            Title   Professor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
071353 -            School  UCSF School of Medicine                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
071354 -            Department         Anesthesia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
071355 -            Address            4150 Clement St                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
071356 -            San Francisco CA 94121                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
071357 -            Phone   415-221-4810x4454                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
071358 -            Email   Marek.Brzezinski@ucsf.edu                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
071359 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071361 -             ..
071362 -            Office Location & Contact                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
071363 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071364 -              http://health.usnews.com/doctors/marek-brzezinski-432418                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
071365 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071366 -            4150 Clement St                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
071367 -            Anesthesiology Services (129)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
071368 -            Va Medical Center                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
071369 -            San Francisco, CA 94121                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
071370 -            (415) 750-2069                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
071372 -  ..
071373 - Justin, Sarah, and Doctor Brzezinski wheeled the gurney from ICU into                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
071374 - the OR.  The OR was busy when we arrived, so the team wheeled the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
071375 - gurney down the hall to an administrative area, where they continued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
071376 - working on anesthesia IV chatheters to prepare for surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
071378 -  ..
071379 - In the OR holding area, Doctor Brzezinski gave instructions for Sarah                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
071380 - and Justin to place IVs in both arms.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
071381 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071382 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
071383 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
0714 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     

SUBJECTS
Default Null Subject Account for Blank Record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
0803 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
080401 -  ..
080402 - Preventive Management Achalasia Investigate Avoid Cardiac Arrest                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
080403 - Achalasia Avoid Cardiac Arrest During Heart Surgery Proactive Planning                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
080404 - VA Computer Records Proactive Case Mangement Improve Patient Outcomes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080405 - 
080406 - Asked Doctor Brzezinski to explain precautions the team will take to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080407 - accomodate achalasia, discussed previously with Doctor Tseng during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080408 - the meeting yesterday on 091021 0716 at 1429? ref SDS 12 R78O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080410 -  ..
080411 - Doctor Brzezinski was not familiar with achalasia.  He seemed to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
080412 - indicate his review of the medical chart did not reveal this problem.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080413 - The doctor asked if achalasia has been reported to the VA?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
080414 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080415 -            [On 100928 0706 received CD with VA medical records on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080416 -            heart surgery, showing incorrectly patient was "educated"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080417 -            which means notified to be prepared for post-op conditions.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080418 -            ref SDS 18 4Q4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
080420 -             ..
080421 -            [On 100928 0706 medical chart review shows no consideration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
080422 -            in Neil's preop check list, ref DRP 1 L44F, to avoid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080423 -            aspiration from achalasia. ref SDS 25 L44F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080425 -  ..
080426 - Briefly explained achalasia causes vomitting and breathing problems,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080427 - when laying flat for surgery.  The VA has been working the achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080428 - problem in this case beginning with barrium swallow test on 050714,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080429 - ref SDS 1 2I9J, and later examination in GI Clinic on 051202 1430.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
080430 - ref SDS 2 5B5K, noted in discussion with Doctor Tseng and the CT team                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080431 - yesterday on 091021 0716 at 1429. ref SDS 12 LJ7Y  At that time, the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
080432 - surgery team planned for special configuration to prevent aspiration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080433 - problems from escalating out of control during surgery today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
080434 - ref SDS 12 R78O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080436 -  ..
080437 - Doctor Brzezinski indicated that his anesthesia team has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
080438 - responsibility for patient safety during surgery.  He concurred that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080439 - not eating since Monday helps control the vomitting problem,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
080440 - recommended by Doctor Hoffman on 091019 1300. ref SDS 10 ZZ80  Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080441 - Brzezinski further seemed to indicate that breathing problems, choking                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080442 - and drowning present significant risks of fatality during long                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
080443 - procedures required for heart surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080445 -  ..
080446 - Discussed keeping the patient slightly tilted, so the head and neck                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080447 - are above the stomach to prevent backflow into the esophagus,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
080448 - previously reviewed with Doctor Tseng's team yesterday. ref SDS 12                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
080449 - KL5I  The doctor seemed to say there will be a tube down my throat                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
080450 - that will suction backflow, so this should not be a problem.  He will                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080451 - also place a towel under my head so I am comfortable until anestheais                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080452 - takes effect, and the team can place the suction tube down the throat.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080454 -  ..
080455 - While Sarah and Justin continued work placing IVs, Doctor Brzezinski                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080456 - walked across the aisle to a workstation.  He used the VA comnputer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080457 - system to research VA Progress Notes for patient history on achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080459 -  ..
080460 - After about 10 minutes, Doctor Brzezinski reported he could not find                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080461 - anything on achalasia in the VA computer on this case.  He asked for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080462 - dates of prior work.  Difficulty today finding patient history in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080463 - medical chart on the VA computer occurred yesterday during a meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080464 - with the surgery team to plan for CABG, reported on 091021 0716.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
080465 - ref SDS 12 LJ7L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080467 -  ..
080468 - Suggested checking VA records in Martinez, for Doctor Lee on 051202,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080469 - when achalasia was diagnosed. ref SDS 2 5B5K  SDS records list                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080470 - extensive follow up, beginning with endoscopy procedure on 051209                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
080471 - 1130. ref SDS 3 0001                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
080472 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080473 -        [On 091219 0600 report to Doctor Ratcliffe on benefits of VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
080474 -        computer records supported through doctor patient partnership.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080475 -        ref SDS 19 Z990                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
080477 -  ..
080478 - Doctor Brzezinski found VA records on patient history of achalasia.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080479 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080480 -        [On 091030 0800 at 1406 meeting with Doctor Stewart proposes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
080481 -        resolving achalasia with Heller Myotomy surgery in December a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080482 -        few months after heart surgery. ref SDS 15 KE3B                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
080483 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080484 -        [On 091030 0800 at 1440 meeting with medical team, including                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
080485 -        Doctor Ratcliff concerned about maintaining nutrition to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080486 -        recover from heart surgery while digestion is problematic due                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080487 -        to achalasia; proposed feeding tube for several months until                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080488 -        Heller Myotomy surgery. ref SDS 15 03GF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080490 -         ..
080491 -        [On 100911 0800 VA credited for improving speed of access                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080492 -        to computer records; discussed "Knowledge Management loop"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
080493 -        that redundancy and ignoring the record collapses                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
080494 -        productivity and vitiates care because health care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
080495 -        professionals do not have command and control of the record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
080496 -        on patient history, ref SDS 22 OL50, citing case study of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080497 -        work at VA today on 091021. ref SDS 12 FB5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
080499 -         ..
080500 -        [On 110429 1230 challenges persist getting medical records                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080501 -        in time to be effective for health care decisions.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
080502 -        ref SDS 25 NM9G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
080504 -         ..
080505 -        [On 110727 1238 Melissa had difficulty using the VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
080506 -        computer in the Martinez Primary Care Department to find                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080507 -        Doctor Egan's work plan in the Cardiology Department on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
080508 -        adding mercury to the lab. ref SDS 26 A25H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
080510 -  ..
080511 - With Doctor Brzezinski researching the achalasia problem for scope of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080512 - anesthesia measures during the operation, Sarah and Justin continued                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080513 - work setting IV catheters.  Sarah was frustrated because the sonogram                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080514 - showed clearly where blood flowed.  The team could see what looked                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
080515 - like veins, and the veins felt like there was a strong pulse.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
080516 - However, nothing worked.  Sarah made 2 tries on the right arm.  Justin                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080517 - tried twice on the left arm.  Everything failed and arms hurt.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
080519 -  ..
080520 - After completing review of achalasia issue, Doctor Brzezinski assisted                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080521 - Sarah and Justin.  He provided pointers on good practice and tips on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080522 - setting IV catheters.  The doctor cited a paper he has written on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
080523 - performing IVs, which will be published next month.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080525 -  ..
080526 - Requested a copy of the paper.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
080528 -  ..
080529 - Doctor Brzezinski indicated he would submit a copy to the patient.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
080530 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080531 -            [On 091219 0600 Doctor Brzezinski visited briefly months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
080532 -            after heart surgery, and while recovering from another                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
080533 -            surgery to treat achalasia, ref SDS 19 0O59, apologized                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
080534 -            forgetting to submit his paper, and cited Internet release;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080535 -            nothing in that release seems to present ideas on better IV                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080536 -            work. ref SDS 19 KA6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080538 -  ..
080539 - The doctor also had problems setting IV catheters.  After more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
080540 - attempts, IVs were successfully placed in the top of the left hand,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080541 - the inner wrist on the right arm, and bicept in the right arm.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
080542 - Another catheter was placed in the inner elbow of the left arm.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080543 - will greatly complicate working after surgery today.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080544 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080545 -        [On 091101 0910 Joy placed a catheter in the right arm above                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
080546 -        the wrist; used hot towel with a tournaquet to do this on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080547 -        first attempt. ref SDS 16 EX3P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080549 -         ..
080550 -        [On 110429 1230 case study on similar problems at VA in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
080551 -        Martinez, getting adequate blood flow through IV catheter,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
080552 -        related to dehydration from heavy exercise and low water                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080553 -        intake hours before medical care; solved by getting another                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
080554 -        nurse to complete work. ref SDS 25 SR8M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
080556 -  ..
080557 - Doctor Brzezinski seemed to say several more IVs would be needed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
080558 - during the operation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080560 -  ..
080561 - The doctor further advised that this case will require a cardio                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080562 - pulmonary heart bypass pump listed in Sarah's review of the work plan                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080563 - on 091021 0716, ref SDS 12 PL9U, and to solve the achalasia vomitting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080564 - and breathing problems during heart surgery today.  He feels research                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080565 - on the VA computer, guided by the SDS record through doctor/patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080566 - partnership, revealed high risk condition, discussed above,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080567 - ref SDS 0 JF9K, so that measures can be used to prevent complications                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080568 - that could otherwise cause death during surgery, as planned by Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080569 - Tseng, during the meeting with the CT team yesterday, reported, 091021                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080570 - 0716, ref SDS 12 R78O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080572 -         ..
080573 -        [On 091023 0445 woke up in panic with tubes in the throat that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
080574 -        seemed to restrict breathing and prevented talking, so could                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
080575 -        not explain to the nurse feeling extreme duress. ref SDS 14 01F9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
080577 -         ..
080578 -        [On 091219 0600 report to Doctor Ratcliffe on benefits of VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
080579 -        computer records supported through doctor patient partnership.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080580 -        ref SDS 19 FX3M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
080582 -         ..
080583 -        [On 100928 0706 received CD with VA medical records on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
080584 -        heart surgery, showing incorrectly patient was "educated"                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
080585 -        which means notified to be prepared for post-op                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080586 -        conditions that cause anxiety and fear, in this case                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080587 -        having a tube inserted into the throat needed to prevent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080588 -        complications from achalasia during heart surgry.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
080589 -        ref SDS 23 4Q4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
080591 -         ..
080592 -        [On 100928 0706 review of Medical Chart pre-procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
080593 -        Anesthesia planning report makes no mention of planning to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
080594 -        avoid complications due to achalasia performing heart surgery,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080595 -        ref SDS 23 WP4F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
080597 -         ..
080598 -        [On 100928 0706 review of Medical Chart pre-procedure shows                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080599 -        Doctor Brzezinski amended Anesthesia work plan filed on 091021,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
080600 -        the next day on 091022 0926, ref SDS 23 EK6G, after meeting in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
080601 -        OR with patient, per above. ref SDS 0 JF9K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
080603 -         ..
080604 -        [On 100928 0706 review of Medical Chart post-procedure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
080605 -        Operation Report cites complications due to achalasia                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
080606 -        performing heart surgery, ref SDS 23 633I, and discloses                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
080607 -        cardioplmonry bypass was applied. ref SDS 23 MP5K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
080608 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080609 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
080611 -  ..
0807 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0808 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0809 - 0731                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
0810 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081001 - CABG x4 - Coronary Artery Bypass Graft - Quadruple Heart Surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081002 - Quadruple Bypass Surgery resolve Coronrary Artery Restrictions                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081003 - 
081004 - Finally wheeled into OR, after anesthesia team completed initial prep,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081005 - per above, ref SDS 0 01F9, including plans to manage complications                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081006 - from achalasia, per above, ref SDS 0 JF9K, and implementing work plans                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081007 - developed with attending physician, Doctor Elaine Tseng, and the CT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081008 - surgery team yesterday, on 091021 0716 at 1429. ref SDS 12 FB5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081010 -  ..
081011 - Purpose of surgery today, is to relieve severe CVD/CAD symptoms that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081012 - occurred due to low HDL 30, despite patient hiking 3 - 8 miles per                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081013 - day, 4 - 6 days per week the past 4 years, shown by case study on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081014 - 081207 0700. ref SDS 4 X64F  This level of effort was not enough to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081015 - raise HDL > 60, considered a theraputic condition that regresses                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081016 - plaque in blood vessels.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081018 -             ..
081019 -            [On 100928 0706 review Medical Chart Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081020 -            reporting 4 bypass grafts performed for CABG surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081021 -            ref SDS 23 HT9G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081023 -             ..
081024 -            [On 131121 0930 Karen advised that Doctor Tseng promoted to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081025 -            Chief of Surgery. ref SDS 28 NQ31, and cited in letter to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081026 -            Karen the next day on 131125 0005. ref SDS 29 UK3O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081028 -             ..
081029 -            [On 131125 0005 research found HDL > 60 together with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
081030 -            elevated EPCs regress cholesterol plaque buildup in blood                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081031 -            vessels, through reverse cholesterol transport, which is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081032 -            the healthiest condition for CVD patients. ref SDS 29 HG7N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081034 -             ..
081035 -            [On 140213 0830 meeting at VA consider performing CT and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
081036 -            related tests to evaluate regression of atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081037 -            lesions based on labs showing elevated LDL-C, but also high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081038 -            HDL and low triglycerides (TG), which could signal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081039 -            discordance, i.e., low LDL-P, ref SDS 30 JZ4O, which is the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081040 -            healthiest condition for CVD patients, shown by research on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081041 -            131125 0005. ref SDS 29 FI3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081043 -             ..
081044 -            [On 190101 0730 case study report for hike on 191210, felt                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081045 -            pressure in chest, similar to feeling hiking up 1st hill at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081046 -            Lafayette Reservoir that was reported to doctor Lee at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081047 -            VA on 090908, and which led to having CABG x4 today on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081048 -            091022.  Chest pain on 191210, resolves within a mile and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081049 -            did not recur, despite hiking uphills of 1 mile and over 15                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081050 -            mile hike. ref SDS 36 YTWS                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081052 -             ..
081053 -            [On 191228 1416 letter to Doctor Simpson in Cardiology at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081054 -            VAMCSF notifies chest pain on hills hiking 20 miles,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081055 -            similar to report to Doctor Lee on 090908, leading to CABG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081056 -            x4 on 091022. ref SDS 38 B64Y  Seems like bypass saphenous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081057 -            graft failed under elevated load wearing elastic bandage on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081058 -            left knee. ref SDS 38 B665  Pause hiking until hear from                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081059 -            the doctor. ref SDS 38 B668                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081061 -             ..
081062 -            [On 200103 0700 treadmill stress test found no evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081063 -            blocked blood vessels, including coronary artery bypass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081064 -            grafts. ref SDS 39 TS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081066 -             ..
081067 -            [On 200124 0705 cardiac catheterization IVUS angiogram                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081068 -            found no evidence blocked coronary artery bypass grafts;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081069 -            found 1 branch vessel with 80-90% blockage; doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081070 -            described best condition every seen 10 years after CABG;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081071 -            told patient to keep doing whatever he is doing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081072 -            ref SDS 40 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081074 -  ..
081075 - Doctor Brzezinski placed a Cordis catheter in the right neck, which                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081076 - included an inner catheter that sets probes deep into the chest around                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081077 - the heart for monitoring the work.  The main catheter delivers                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081078 - medication to maintain heart function during the procedure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081079 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081080 -        [On 091030 0810 CT test to evaluate achalasia and fluid on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081081 -        lungs indicates possible DVT at the location where the Cordis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081082 -        catheter was placed for heart surgery; sonogram test confirmed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081083 -        DVT, which delays discharge and requires warfarin treatment.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081084 -        ref SDS 15 1N6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081086 -         ..
081087 -        [On 100405 2302 letter from Candi reporting she reviewed the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
081088 -        record on Eddie's memorial services, ref SDS 21 295S; and,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
081089 -        seems to have followed several links to discover heart surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081090 -        today. ref SDS 21 4R6N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081092 -  ..
081093 - Doctor Tseng called and reported she was leaving Moffit Field, about                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081094 - 50 miles south of San Francisco.  She is expected to arrive by 1100 to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081095 - do the operation, after all of the preparation.  This aligns with work                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081096 - plan presented by the doctor yesterday on 091021 0716. ref SDS 12 3V4N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081098 -  ..
081099 - Recognized Paula, KC, and Neal from the meeting yesterday afternoon,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081100 - reported on 091021 0716. ref SDS 12 P34P                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081101 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081102 -        [On 091119 1000 Neil approved ending Amiodarone on 091122, 30                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081103 -        days after surgery on 091022. ref SDS 17 LC5F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081104 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081105 -        [On 110406 1230 treadmill stress test performed; initial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081106 -        indications are 100% performance, with one node showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081107 -        possible slight irregularity. ref SDS 24 OF8F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081108 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081109 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081111 -  ..
0812 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0813 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
0814 - 0930                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
0815 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081501 - Doctor Tseng Attending Quadruple Bypass Heart Surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081502 - 
081503 - Asleep for remainder of operation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081505 -  ..
081506 - Quadruple bypass heart surgery resolved 2 major and a 3rd possible                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081507 - coronrary artery blockages discovered during angiogram test yesterday                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081508 - on 091021 0716. ref SDS 12 7L43, and following stress test ordered by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081509 - Doctor Lee on 090908 1130. ref SDS 5 H27N  Surgery today was                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081510 - recommended by Doctor Shunk following angiogram test, again yesterday.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081511 - ref SDS 12 7L61  CABG 4x may reflect a 4th blockage discovered with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081512 - sonogram radiology, reported on 091021 0716, ref SDS 12 TD60, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
081513 - implemented planning by the Cardiothoracic (CT) surgery team during                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081514 - the meeting in the ICU, also, on 091021 0716 at 1429. ref SDS 12 FB5N                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081516 -             ..
081517 -            [On 100928 0706 review Progress Notes reporting 4 bypass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
081518 -            grafts performed for CABG surgery. ref SDS 23 HT9G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081520 -  ..
081521 - The operation was apparently completed about 1800, so it was a long                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081522 - day with multiple complications, shown by Neals' excellent report in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081523 - the VA's medical chart. ref DRP 1 S89M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081525 -  ..
081526 - Paula made an incision on the inner side of the right leg to harvest                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081527 - vein tissue for performing quadruple heart bypass surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081529 -  ..
081530 - After surgical opening was closed, an inventory discovered needle                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081531 - count was one short.  Doctor Tseng ordered an xray study to verify                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081532 - harmful needle was not inside the patient.  In addition to reporting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081533 - what was found, the Radiology department affirmatively reported a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081534 - finding that anything even suspicious of a needle was not found (see                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081535 - report in the record, shown in the record on 100928 0706. ref SDS 23                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081536 - 0W4O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081538 -         ..
081539 -        [On 100928 0706 received VA's report on surgery today, prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081540 -        by Neil. ref SDS 23 C58I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081542 -         ..
081543 -        [On 100928 0706 VA Progress Notes for pre-op surgery review                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081544 -        reports Special Tests Yes:  Carotid Ultrasound, age > 60, TIA,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081545 -        CVA, prior vascular surgery. ref DRP 1 I26M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081547 -         ..
081548 -        [On 130122 1330 visited Doctor Tseng briefly and thanked her                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
081549 -        for excellent work performing CABG 4x surgery, reflecting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081550 -        patient history showing good recovery; Doctor Tseng indicates                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081551 -        peripheral neuropathy parathesia not expected due to surgery 3                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081552 -        years later. ref SDS 27 LM8K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081554 -  ..
081555 - Planned to watch World Series game this evening at 1900, between the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081556 - Yankees and Angels, but did not wake up until the next day about 0640.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081557 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081558 -        [On 091023 0445 woke up in panic with tubes in the throat that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081559 -        seemed to restrict breathing and prevented talking, so could                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081560 -        not explain to the nurse extreme duress. ref SDS 14 01F9                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081562 -         ..
081563 -        [On 091030 0800 medical team, including Doctor Ratcliff                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081564 -        concerned about how to maintain nutrition for the patient to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081565 -        recover from heart surgery while digestion remains problematic                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081566 -        due to achalasia; proposes feeding tube for several months                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081567 -        until Heller Myotomy surgery. ref SDS 15 03GF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081569 -         ..
081570 -        [On 091219 0600 at 1104 visited with Doctor Ratcliffe and the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081571 -        Cardiothoracic (CT) surgery team; was pleased to commend Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081572 -        Tseng and the VA for outstanding care. ref SDS 19 0M6S;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081573 -        discussed doing clinical trial to improve patient outcomes with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081574 -        stronger case management through better communication that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081575 -        reduces mistakes. ref SDS 19 Z990                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081577 -  ..
081578 - Need VA's records on doctor's notes to report other work performed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081579 - for heart surgery today, e.g., who made the chest incision; what                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081580 - findings were made, particulars of the work to address findings?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081581 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081582 -            [On 091208 1300 ordered VA's records on the operation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081583 -            today, and for the period in the hospital. ref SDS 18 EK6I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081585 -             ..
081586 -            [On 100928 0706 received VA's report on surgery today, prepared                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081587 -            by Neil. ref SDS 23 C58I                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081589 -             ..
081590 -            [On 100928 0706 review Medical Chart Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081591 -            reporting 4 bypass grafts performed for CABG surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081592 -            ref SDS 23 HT9G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081594 -             ..
081595 -            [On 140213 0830 meeting at VA consider performing CT and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
081596 -            related tests to evaluate regression of atherosclerosis                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081597 -            lesions based on labs showing elevated LDL-C, but also high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081598 -            HDL and low triglycerides (TG), which could signal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081599 -            discordance, i.e., low LDL-P, ref SDS 30 JZ4O, which is the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081600 -            healthiest condition for CVD patients, shown by research on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081601 -            131125 0005. ref SDS 29 FI3G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081603 -             ..
081604 -            [On 151019 0930 Radiology report on CCTA test performed on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081605 -            151019, indicates calcification in original bypassed                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081606 -            arteries has increased since CABG +4 surgery on 091022,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081607 -            ref SDS 31 J14N; seems conflicting with this research on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081608 -            131125, theorizing atherosclerosis plaques regress rapidly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081609 -            with elevated HDL and EPCs. ref SDS 29 RA7K                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081610 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081611 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081612 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081614 -  ..
081615 - CABG Successful Last 8 - 15 Years - CABG x4 Reduced Survival                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081616 - 
081617 - Research on CABG surgical procedures says...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081618 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081619 -              https://en.wikipedia.org/wiki/Coronary_artery_bypass_surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081620 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081621 -    1.  Prognosis following CABG depends on a variety of factors, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081622 -        successful grafts typically last 8-15 years.[citation needed]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081623 -        In general, CABG improves the chances of survival of patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081624 -        who are at high risk (generally triple or higher bypass),                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081625 -        though statistically after about five years the difference in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081626 -        survival rate between those who have had surgery and those                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081627 -        treated by drug therapy diminishes.  Age at the time of CABG is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081628 -        critical to the prognosis, younger patients with no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081629 -        complicating diseases doing better, while older patients can                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081630 -        usually be expected to suffer further blockage of the coronary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081631 -        arteries.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081632 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081633 -            [On 181102 1928 study in Denmark found 8-10 year survivors                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081634 -            after CABG surgery have an increased mortality of between                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081635 -            60 and 80 per cent when compared with the general                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081636 -            population.  This may be due to the fact that the disease                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081637 -            is progressive and that the atherosclerosis or hardening of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081638 -            the arteries increases, or that the implanted material                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081639 -            begins to fail. ref SDS 35 144J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081641 -             ..
081642 -            [On 190527 0857 letter asks Doctor Simpson's take on this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081643 -            article on Denmark study finding significantly increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081644 -            mortality 8-10 years after heart bypass, in relation to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081645 -            CABG x4 in this case 10 years ago on 091022, and 2-CCTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081646 -            studies which reported bypassed blood vessels contain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081647 -            significant plaque. ref SDS 37 NE56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081649 -             ..
081650 -            [On 200103 0700 treadmill stress test found no evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081651 -            blocked blood vessels, including coronary artery bypass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081652 -            grafts. ref SDS 39 TS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081654 -             ..
081655 -            [On 200124 0705 cardiac catheterization IVUS angiogram                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081656 -            found no evidence blocked coronary artery bypass grafts;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081657 -            found 1 branch vessel with 80-90% blockage; doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081658 -            described best condition every seen 10 years after CABG;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081659 -            told patient to keep doing whatever he is doing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081660 -            ref SDS 40 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081662 -         ..
081663 -    2.  A coronary artery may be unsuitable for bypass grafting if it                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081664 -        is small (< 1 mm or < 1.5 mm), heavily calcified, or located
081665 -        within the heart muscle rather than on the surface. A single                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081666 -        obstruction of the left main coronary artery is associated                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081667 -        with a higher risk for a cardiac death and usually receives a                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081668 -        double bypass.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081670 -         ..
081671 -    3.  The surgeon reviews the coronary angiogram prior to surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081672 -        and identifies the number of obstructions, the percent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081673 -        obstruction of each, and the suitability of the arteries                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081674 -        beyond the obstruction(s) as targets. The presumed number of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081675 -        bypass grafts needed as well as the location for graft                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081676 -        attachment is determined in a preliminary fashion prior to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081677 -        surgery, but the final decision as to number and location is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081678 -        made at surgery via direct examination of the heart.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081680 -         ..
081681 -    4.  Grafts can become diseased and may partially or completely                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081682 -        occlude - that is, lose their patency - in the months to years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081683 -        after bypass surgery is performed. A graft is considered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081684 -        patent if there is normal flow through the graft: flow begins                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081685 -        to diminish with around a 70 percent stenosis in the graft.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081686 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081687 -            [On 151019 0930 CCTA study was performed at the VA Medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081688 -            Center in San Francisco, for the purpose of testing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081689 -            response to treatment hiking 10K miles in prior 4 years                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081690 -            that raised HDL 30 to HDL 70, and where favorable response                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081691 -            could support reducing line of care with statin medication                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081692 -            and hiking in order to reduce debilitating side effects;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081693 -            CCTA test found "All the bypass grafts are patent," with no                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081694 -            affirmative findings of blockages of any kind 6 years after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081695 -            CABG +4 due to severe atherosclerosis caused by HDL 30;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081696 -            this left a question whether there could be blockages of up                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081697 -            to 70% anywhere in the active circulatory system,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081698 -            consistent with the finding of "patent." ref SDS 32 JW8O                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081700 -             ..
081701 -            [On 160104 0855 Doctor Jha, attending physician for this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
081702 -            CCTA imaging study, advised that standard of practice for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081703 -            radiology reporting is to present any and all blockages of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081704 -            any kind observable in CCTA scan imaging; so, in this case,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081705 -            since none are reported, the CCTA test on 151019, can                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081706 -            correctely be interpretted to mean there are no blockages,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081707 -            plaques, stenosis of any kind evident from the scan file                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081708 -            record. ref SDS 34 054G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081710 -             ..
081711 -            [On 200103 0700 treadmill stress test found no evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081712 -            blocked blood vessels, including coronary artery bypass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081713 -            grafts. ref SDS 39 TS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081715 -             ..
081716 -            [On 200124 0705 cardiac catheterization IVUS angiogram                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081717 -            found no evidence blocked coronary artery bypass grafts;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081718 -            found 1 branch vessel with 80-90% blockage; doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081719 -            described best condition every seen 10 years after CABG;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081720 -            told patient to keep doing whatever he is doing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081721 -            ref SDS 40 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081722 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081724 -  ..
081725 - Another article...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081726 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081727 -        PMC                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081728 -        Outcomes of coronary artery bypass graft surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
081729 -        Date........................ December 2006                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081730 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081731 -              https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1994021/                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081733 -         ..
081734 -        The study revealed no significant difference in mortality 4                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081735 -        years after CABG in patients with one-, two- or three-vessel                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081736 -        disease, although a highly significant increase in survival                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081737 -        rate was observed in a subset of patients who underwent CABG                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081738 -        for left main coronary artery obstruction.  The 4-year                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081739 -        mortality for CABG patients was 7% (n = 46), compared with 33%                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081740 -        for medical treatment (n = 44) (Hampton 1984).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081741 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081742 -        10 years after CABG three quarters of vein conduits are                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081743 -        blocked or severely diseased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081745 -         ..
081746 -        Vein graft failure leads to reduced survival, recurrent                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081747 -        angina, late myocardial infarction, and the need for further                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081748 -        intervention (Eagle et al 1999), so that by 10?15 years after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081749 -        the initial operation up to 40% of patients may require redo                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081750 -        CABG at increased risk and cost                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081751 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081752 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081754 -  ..
081755 - There is an impression that >3-vessel disease CABG is less frequently                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081756 - recommended in 21st century, compared to prior practice.  Mortality                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081757 - seems to increase significantly, i.e., survival declines, for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081758 - patients having CABG with >3-vessel disease.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081760 -  ..
081761 - In this case, cardiology recommended CABG, based on Doctor Shunk                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081762 - diagnosing 2-vessel disease, and only possibly a 3rd, reported on for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081763 - cardiac catheritization for angiogram test, performed on 091021 0716.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081764 - ref SDS 12 AL9O  If 4-vessel disease had been identified, would this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081765 - have resulted in not getting CABG surgery?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
081766 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081767 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081769 -  ..
081770 - Complications CABG Surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081771 - 
081772 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081773 -    1.  Postperfusion syndrome (pumphead), a transient neurocognitive                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081774 -        impairment associated with cardiopulmonary bypass. Some                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081775 -        research shows the incidence is initially decreased by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081776 -        off-pump coronary artery bypass, but with no difference beyond                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081777 -        three months after surgery. A neurocognitive decline over time                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081778 -        has been demonstrated in people with coronary artery disease                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081779 -        regardless of treatment (OPCAB, conventional CABG or medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081780 -        management). However, a 2009 research study suggests that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081781 -        longer term (over 5 years) cognitive decline is not caused by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081782 -        CABG but is rather a consequence of vascular disease.[5] Loss                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081783 -        of mental function is a complication of bypass surgery in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081784 -        elderly people, and might influence procedure cost benefit                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081785 -        considerations.[15] Several factors may contribute to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081786 -        immediate cognitive decline. The heart-lung blood circulation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081787 -        system and the surgery itself release a variety of debris,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081788 -        including bits of blood cells, tubing, and plaques. For                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081789 -        example, when surgeons clamp and connect the aorta to tubing,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081790 -        resulting emboli block blood flow and cause mini strokes.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081791 -        Other heart surgery factors related to mental damage may be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081792 -        events of hypoxia, high or low body temperature, abnormal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081793 -        blood pressure, irregular heart rhythms, and fever after                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081794 -        surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
081796 -         ..
081797 -    2.  Myocardial infarction due to embolism, hypoperfusion, or graft                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081798 -        failure.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081800 -         ..
081801 -    3.  Late graft stenosis, particularly of saphenous vein grafts due                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081802 -        to atherosclerosis causing recurrent angina or myocardial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081803 -        infarction.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081805 -         ..
081806 -    4.  Graft failure: grafts last 8-15 years, and then need to be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081807 -        replaced.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081808 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081809 -            [On 151028 1000 Doctor Simpson comments in Progress Notes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081810 -            that CCTA results on 151019 "... could be read as showing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081811 -            some early changes in the [...saphenous vein grafts...]                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081812 -            SVGs.  This is about what I had predicted." ref SDS 33 5Y6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081814 -             ..
081815 -            [On 181102 1928 study in Denmark found 8-10 year survivors                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081816 -            after CABG surgery have an increased mortality of between                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081817 -            60 and 80 per cent when compared with the general                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
081818 -            population.  This may be due to the fact that the disease                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081819 -            is progressive and that the atherosclerosis or hardening of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
081820 -            the arteries increases, or that the implanted material                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
081821 -            begins to fail. ref SDS 35 144J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081823 -             ..
081824 -            [On 190527 0857 letter asks Doctor Simpson's take on this                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081825 -            article on Denmark study finding significantly increased                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081826 -            mortality 8-10 years after heart bypass, in relation to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081827 -            CABG x4 in this case 10 years ago on 091022, and 2-CCTA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081828 -            studies which reported bypassed blood vessels contain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081829 -            significant plaque. ref SDS 37 NE56                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
081831 -             ..
081832 -            [On 200103 0700 treadmill stress test found no evidence of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
081833 -            blocked blood vessels, including coronary artery bypass                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
081834 -            grafts. ref SDS 39 TS6L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
081836 -             ..
081837 -            [On 200124 0705 cardiac catheterization IVUS angiogram                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
081838 -            found no evidence blocked coronary artery bypass grafts;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081839 -            found 1 branch vessel with 80-90% blockage; doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
081840 -            described best condition every seen 10 years after CABG;                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
081841 -            told patient to keep doing whatever he is doing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
081842 -            ref SDS 40 ME8G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
081843 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081844 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081845 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081846 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081847 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081848 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081849 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081850 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
081851 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
0819 -