CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 13 0000. ref SDS 12 0000.
040502 -
040503 -
040964 -
040966 -  ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Had a blood draw first thing after doing 10 laps.
041302 -
041304 -  ..
0414 -
0415 -
0416 - 1009
0417 -
041701 - Neil and a new member to the CT team, Doctor Nhan Nguyen, visited.
041702 -
041703 - Neil removed the wrap on the right leg, which KC had placed Friday
041704 - afternoon, reported on 091030 0810. ref SDS 12 Z29K
041706 -  ..
041707 - He noticed some slight seepage near the ankle, and asked Doctor Nguyen
041708 - to clean and dress it after the meeting (this was never done).
041710 -  ..
041711 - Neal said the labs this morning show that blood counts are within
041712 - target range, including albumin.  He further reported that WBC spiked
041713 - from 12 to 17, so there is a concern about another possible
041714 - infection of some kind.
041715 -
041716 -     [...below xray ordered for pneumonia. ref SDS 0 PR6Y
041718 -  ..
041719 - They have ordered another xray to check the lungs for pneumonia.
041721 -  ..
041722 - Vitals are excellent.
041724 -  ..
041725 - Discussed progress on discharge relative to meetings with Joe and
041726 - Elaine yesterday on 091031 0730. ref SDS 13 I15I
041728 -  ..
041729 - Reviewed background on correlation with low labs for albumin and
041730 - pre-albumin arising only because eating stopped for a few days to
041731 - facilitate tests and then heart surgery.
041733 -  ..
041734 - Neal said the CT team feels I have been a good sport on the feeding
041735 - tube project.  He indicated that everyone is on the same page to work
041736 - with the patient get things done as soon as possible.
041738 -  ..
0418 -
0419 -
0420 - 1026
0421 -
042101 - Joy arrives to tap another vein with a catheter, because the catheter
042102 - Kathi placed last Thursday has expired.  Joy said that catheters
042103 - created with IV's only last 4 days.  There is no blood draw nor drip
042104 - treatment ordered, but VA protocol requires replacing catheters every
042105 - 4 days to prevent infection and maintain viable medication injection
042106 - support while the patient is in TCU.
042107 -
042108 -        [On 091219 0600 4 days after Heller Myotomy surgery planning
042109 -        discharge next day; therefore standard protocol to replace IV
042110 -        catheter not followed to avoid expense and inconvenience to
042111 -        patient, and since the patient has been approved to get
042112 -        medication with pills orally. ref SDS 17 0L46
042114 -  ..
042115 - Millie arrived at this time, and she got to observe Rod get the
042116 - "treatment" she has been getting the past 8 years.
042118 -  ..
042119 - Joy was excellent.
042121 -  ..
042122 - Reviewed backgound on 091022 when Doctor Brezinzki and his team
042123 - including Sarah and Justin, had a lot of difficulty placing catheter
042124 - IV's in the left and right arms, 091022 0700, ref SDS 11 01F9,
042125 - continuing difficulties experienced the day before by Kevin on 091021
042126 - 0716, ref SDS 10 737P, and again by Susan and Steven. ref SDS 10 BU5I
042127 -
042128 -
042130 -  ..
042131 - Hot Towel Turnequet Solve Blood Draws Difficulty Finding Vein
042132 - Blood Draws Difficulty Finding Vein Solved with Hot Towel Turnequet
042133 -
042134 - Joy decided to use a trick, not previously applied.  She heated a wet
042135 - towel, and wrapped the right arm.  She said this allows blood to flow
042136 - more readily, and so with the tournequet, used previously by the
042137 - Brezinski team, this enabled Joy to place a catheter on the first try
042138 - finding a good vein about 2" above the right wrist on the outer
042139 - forearm.
042141 -  ..
042142 - Joy further noted that there is some luck in this process.
042143 -
042144 -            [On 110429 1230 case study on similar problems at VA in
042145 -            Martinez, getting adequate blood flow through IV catheter,
042146 -            related to dehydration from heavy exercise and low water
042147 -            intake hours before medical care; solved by getting another
042148 -            nurse to complete work. ref SDS 18 SR8M
042150 -  ..
042151 - After setting the new catheter in the right arm, Joy removed the
042152 - catheter placed by Kathi with similar location on Thursday, except on
042153 - the inner arm, rather than the outer arm.  Removal was somehat
042154 - painful, because the catheter is taped to the arm, which has hair, so
042155 - removal pulls the hair.
042157 -  ..
042158 - Joy used another trick to place oil or vaseline of some kind in the
042159 - perimeter of the tape.  This was only marginally successuful reducing
042160 - pain of removing the tape to remove the catheter.
042162 -  ..
042163 - Reviewed background on 091021 when Remy in ICU shaved hair to provide
042164 - unimpeded access to treatment sites for tests and surgery.
042166 -  ..
042167 - Joy gave an explanation that was unclear when shaving a site for a
042168 - needle prick was more at risk from shaving skin, than doing the same
042169 - thing for a surgical incision.
042170 -
042171 -
042173 -  ..
0422 -
0423 -
0424 - 1106
0425 -
042501 - Gloria advises that Radiology wants the customer for an xray to test
042502 - for pneumonia.  This follows up report this morning of elevated WBC
042503 - from 12 - 17. ref SDS 0 QE8M
042505 -  ..
042506 - The nurses aide pushed the customer to Radiology in a wheelchair, even
042507 - though can walk fine.
042509 -  ..
042510 - The woman who has performed mobile xrays the past several days in a
042511 - row, pushed the wheelchair into the xray room.  Stood up and in front
042512 - of a target screen.  She took the xray.  A second xray was taken while
042513 - standing and turning 90 degrees for a side shot of the lungs.
042514 -
042515 -
042517 -  ..
0426 -
0427 -
0428 - 1126
0429 -
042901 - After returning, and visiting for awhile, took a walk to show Millie
042902 - the route hiking 5 miles or so the past few days.
042904 -  ..
042905 - Millie left for home wondering about what will happen tomorrow.
042906 -
042908 -  ..
0430 -
0431 -
0432 - 1412
0433 -
043301 - Asked Gloria to call and ask Neil to call the patient about a test
043302 - that evaluates benefits of Ensure in relation to ending treatment with
043303 - the feeding tube.
043305 -  ..
043306 - Also called the front desk and talked to Summer.  Since don't know
043307 - Neil's last name, Summer tried to find Neil's number.  Had trouble, so
043308 - gave her Doctor Ngugyen's name.
043309 -
043311 -  ..
0434 -
0435 -
0436 - 1423
0437 -
043701 - Doctor Nguyen called.
043702 -
043703 - Explained idea to not use the feeding tube tonight in order to
043704 - experiment with trade-offs between taking more Ensure, based on
043705 - Hellen's calculations a few days ago.  A blood test in the morning
043706 - will show the effects of the trade-off to guide adding Ensure to the
043707 - home diet.
043709 -  ..
043710 - Nguyen asked about the diet at home.
043712 -  ..
043713 - Explained plans to eat some of prior diet with emphasis on liquid
043714 - digestion.  So for example, I can make a salad consisting of avacado,
043715 - onion and cellary cut into fine bits, cottage, and brockley and
043716 - sometimes cawleflower.  With condiments of mayonaize and ranch
043717 - dressing, this is nearly a liquid diet.
043719 -  ..
043720 - Small bites chased with liquid like water, lemmon mixed with grade
043721 - juice and Squirt or Doctor Peper should allow this combination to
043722 - seep through into the stomach, similar to Ensure.
043724 -  ..
043725 - Will have clam chowder similar soup.
043727 -  ..
043728 - Breakfast will be Cherios with fruit well cut up with plenty of milk
043729 - that largely liquifies the cereal.
043731 -  ..
043732 - This will be supplemented with 4 - 6 Ensure per day.
043734 -  ..
043735 - Doctor Nguyen said he would order removal of the feeding tube this
043736 - afternoon.
043738 -  ..
043739 - Thanked the doctor for support.
043740 -
043741 -        [On 091102 0642 Joe reports CT test finds aspiration pneumonia,
043742 -        which accounts for elevated WBC; treatment requires avoiding
043743 -        risk of further aspirating food and liquid into the lungs while
043744 -        eating, and so the team wants to reinstall the feeding tube.
043745 -        ref SDS 14 PB6Y
043747 -         ..
043748 -        [On 091102 0642 Joe reports that Doctor Tseng is disappointed
043749 -        about order to remove the feeding tube, and she prescribes
043750 -        replacing the feeding tube again as a condition for discharging
043751 -        the patient. ref SDS 14 WC77
043753 -         ..
043754 -        [On 091103 0347 Neil advised CT Surgery Team discussed
043755 -        replacing feeding tube; this is patient's call based on history
043756 -        since 2005 adapting to achalasia and maintaining sufficient
043757 -        nutrition for lifestyle of vigorous exercise. ref SDS 15 U66G
043759 -         ..
043760 -        [On 091103 0347 Paula reports diagnosis of aspiration pneumonia
043761 -        has been withdrawn. ref SDS 15 HA5L
043763 -         ..
043764 -        [On 091214 1100 lab shows albumin 4.2, increased well above 3.6
043765 -        nutrition target criteria set by CT Surgery Team on 091030,
043766 -        ref SDS 12 MU5N, and was achieved without reliance on feeding
043767 -        tube, and by drinking 6 cans of Ensure per day, and minimal
043768 -        normal food digestion, pending resolution of achalasia.
043769 -        ref SDS 16 GI65
043770 -
043771 -
043773 -  ..
0438 -
0439 -
0440 - 1431
0441 -
044101 - Gloria came into the room and related she was called by the doctor
044102 - and told to remove the feeding tube.
044104 -  ..
044105 - Karina was with Gloria.
044107 -  ..
044108 - Gloria asked Karina if the nurse can remove the feeding tube, since
044109 - it was placed by a doctor.
044111 -  ..
044112 - Karina assured Gloria that nurses in Telemtry unit remove feeding
044113 - tubes under doctor's oders.
044115 -  ..
044116 - Gloria said she wants a doctor's order signed on the computer before
044117 - she removes the feeding tube.
044118 -
044120 -  ..
0442 -
0443 -
0444 - 1441
0445 -
044501 - Gloria came into the room.  She has the doctor's order to remove the
044502 - feeding tube.
044504 -  ..
044505 - Based on prior discussion with Karina, asked Gloria if she has done
044506 - this previously, and if not, should Karina be asked to do the task
044507 - with Gloria observing.
044509 -  ..
044510 - Gloria said she has done this procedure many, many times.  It is very
044511 - simple.  Her only question to Karina earlier was whether the nurse can
044512 - do this on the doctor's verbal order.  Since she now has a written
044513 - order, she can easily remove the feeding tube.
044515 -  ..
044516 - Take a deep breath and hold it.
044518 -  ..
044519 - Gloria removes the feeding in about 2 seconds with a long continuous
044520 - pull.  She showed the full tube.  Looks 2.5 to 3 feet.
044522 -  ..
044523 - Didn't feel a thing.
044525 -  ..
044526 - Thanked Gloria.
044527 -
044529 -  ..
0446 -
0447 -
0448 - 1512
0449 -
044901 - Doctor Nguyen came into the room and noticed that Gloria had already
044902 - executed his order to remove the feeding tube.
044904 -  ..
044905 - The doctor related having just talked to Neal on the telephone.  Neal
044906 - evidently indicated the team had not yet decided to remove the feeding
044907 - tube, because they wanted to give Doctor Stewart an opportunity to
044908 - comment tomorrow on Monday, before taking action today.
044910 -  ..
044911 - Doctor Nguyen said he is none-the-less comfortable with the decision.
044913 -  ..
044914 - Discussed goals to maintain pressure on the medical team to schedule
044915 - surgery for achalasia as soon as possible, i.e., next Friday, the
044916 - following week, etc.  Knowing the patient needs to swallow in order to
044917 - recover from heart surgery, keeps pressure from the CT team for the
044918 - general surgery to expedite the work.
044919 -
044920 -
044921 -
044922 -
044923 -
044924 -
044925 -
044926 -
044927 -
0450 -