THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: November 12, 2009 09:30 AM Thursday; Rod Welch

Millie meeting at Kaiser evaluate next treatment for 9th relapse cance

1...Summary/Objective
........I.run my department how I run my department!
............Significant Improvement In Progression-Free Survival For
............Triple Negative Metastatic Breast Cancer Patients Treated
............With IXEMPRAT Plus Capecitabi
2...Medical Chart Received Weeks Later


..............
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CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 28 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 091027 Millie and Pam met with Doctor Johnson in the Oncology
040902 - Department at Kaiser in Walnut Creek. ref SDS 28 GN5I
040903 -
040904 -
040905 -
040907 -  ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - The doctor was about 20 minutes late, after completing examination
041302 - and consultation for another patient.
041304 -  ..
041305 - Doctor Johnson advised that he did not have enough time to review the
041306 - letter with the agenda for the meeting this morning, and which was
041307 - submitted earlier today on 091112 0752. ref SDS 29 IL8L  He therefore
041308 - left the examination room, and returned to his office to read the
041309 - letter.
041311 -  ..
041312 - About 20 minutes later, the doctor returned to the examination room.
041314 -  ..
041315 - Doctor Johnson commented that Millie's medical care at Kaiser and UCSF
041316 - benefits from thorough case management, illustrated by the letter
041317 - submitted through email to the medical team this morning, and which
041318 - analyses all communications for alignment with the record of
041319 - objectives, requirements, and commitments, reported on 091112 0752.
041320 - ref SDS 29 IL8L
041321 -
041322 -        [...below, after being unable to find an email which the doctor
041323 -        recalled showed Doctor Rugo approves Kaiser treating Millie
041324 -        with chemotherapy, and which conflicts with Millie's patient
041325 -        profile, Doctor Johnson relates being told today that HIPAA
041326 -        regulations deny patients access to communications on their
041327 -        health care, and which as well is in fact the opposite of the
041328 -        Federal rule which grants patients access. ref SDS 0 QN5G
041330 -  ..
041331 - Previously, on 090213 Doctor Johnson advised that other patients do
041332 - not have this support, which has enabled Millie to exceed survival for
041333 - disease trajectory.  This aligns with Doctor Rugo's comment that
041334 - Millie's records on patient history provide comprehensive case
041335 - management that supports Doctor Rugo's personal practice for tracking
041336 - critical details carefully, reported on 090514 0830. ref SDS 17 LS5M
041338 -  ..
041339 - During the meeting, Doctor Johnson sent a letter, using Kaiser's
041340 - internal Knowledge Management email system, to Paula Vannicola, who
041341 - manages the Chemotherapy Infusion Clinic.  The doctor's letter today
041342 - prescribes using Millie's Power Port with 1" high strength Lifeguard
041343 - Huber needles to perform blood draws and chemotherapy treatments as
041344 - standard of care for Millie's patient profile to recover from cancer.
041345 - Using the Power Port avoids the high risk of complications from
041346 - conventional needle penetrations that compound cancer and lymphedema
041347 - which now infect both of Millie's arms, and further avoids pain and
041348 - suffering which Millie and the nurses experience from difficulty
041349 - locating a vein that requires multiple penetrations, because Millie's
041350 - veins in the arms have been scarred by excessive needle penetrations
041351 - for prior care, reported on
041353 -  ..
041354 - The doctor's letter to Paula implements the agenda for the meeting
041355 - today, which was listed in Millie's letter to the medical team earlier
041356 - this morning on 091112. ref SDS 29 IL8L
041357 -
041358 -        [On 100104 1216 Chemotherapy Infusion Clinic at Kaiser in
041359 -        Walnut Creek refused to perform emergency blood draw ordered by
041360 -        Doctor Zhang to evaluate diagnosis of severe shingles,
041361 -        ref SDS 33 4W56, and using Millie's Power Port with a 1" Huber
041362 -        needle to prevent trauma from needle penetrations into Millie's
041363 -        arms infected with IBC and lymphedema, ordered by Doctor
041364 -        Johnson during the meeting at Kaiser on 091112 0930,
041365 -        ref SDS 0 UN8F; as a result, blood draw was performed in the
041366 -        Lab with conventional needle penetration contrary to the
041367 -        doctor's order. ref SDS 33 4Q40
041369 -         ..
041370 -        [On 100119 0830 Mary Beth in the Infusion Clinic at Kaiser in
041371 -        Martinez, CA reported a new policy to avoid using port catheter
041372 -        technology for blood draws because some may patients may have a
041373 -        small risk of complications caused by using Heperin to maintain
041374 -        the port catheter, ref SDS 35 X56L; Millie cited the record of
041375 -        having zero (0) risk since she never suffered complications
041376 -        from the medical team using Heperin to maintain her Power Port
041377 -        for hundreds of procedures over an 8-year period, and further
041378 -        explained Doctor Johnson's order for Kaiser to use Millie's
041379 -        Power Port for blood draws and infusion procedures in order to
041380 -        avoid the high risk of compounding Millie's cancer and
041381 -        lymphedema which now infect both arms, ref SDS 35 QR72; as a
041382 -        result, Kaiser's Infusion Clinic in Martinez used Millie's
041383 -        Power Port to perform blood draws to minimize the risk of
041384 -        complications. ref SDS 35 QR8G
041386 -         ..
041387 -        [On 100203 1410 Arlette called and advised she received
041388 -        Millie's letter notifying the medical team that Gloria ordered
041389 -        an interim blood draw to test INR on Friday, 100205, and in
041390 -        order to make timely adjustment to Millie's Coumadin
041391 -        prescription on Friday to reduce the risk of pulmonary
041392 -        embolism, ref SDS 36 QJ85; Arlette reported that Chemotherapy
041393 -        Infusion Clinic in Walnut Creek refuses to perform the doctor's
041394 -        order to use Millie's Power Port for blood draws, because of
041395 -        new general policy to reduce the risk of complications which
041396 -        some patients have from using Heperin to maintain port
041397 -        catheters. ref SDS 36 124J
041399 -         ..
041400 -        [On 100204 1325 Millie's letter to the medical team asks
041401 -        the primary care physician to enter in Millie's medical
041402 -        chart and notify the Chemotherapy Infusion Clinic that
041403 -        Millie's patient profile requires drawing blood from
041404 -        Millie's Power Port rather than use IV needle penetration
041405 -        balancing very low risks of Heprin contamination in the
041406 -        Power Port which has never occurred in Millie's case over 8
041407 -        years, against lymphedema recently diagnosed in the right
041408 -        arm which, has prevented IV needle penetrations in the left
041409 -        arm for 8 years. ref SDS 37 SB6S
041411 -         ..
041412 -        [On 100205 0938 Doctor Johnson did not have time to align
041413 -        Kaiser practices for Millie's blood draws, with Millie's
041414 -        patient profile, so Millie was forced to get the blood draw
041415 -        with an IV in her right arm despite rising IBC and lymphedema;
041416 -        fortunately, the lab was successful on the first needle
041417 -        penetration, ref SDS 38 IS6R, and the lab reported the test
041418 -        shows INR 3.2, significant improvement after pausing Coumadin
041419 -        for 2 days; Millie asks Gloria for guidance from Coagulation
041420 -        Control Clinic on adjusting Coumadin medicattion. ref SDS 38
041421 -        IS7Q
041423 -         ..
041424 -        [On 100427 0830 Doctor Johnson entered in medical chart
041425 -        another order for blood draws to be performed using only
041426 -        Millie's Power Port because both arms are infected with
041427 -        cancer, and needle punctures cause cancer to spread.
041428 -        ref SDS 42 X74Q
041430 -         ..
041431 -        [On 100529 0930 blood draw went smoothly correcting past
041432 -        problems, because nurse relied on instructions in
041433 -        medical chart on 100427, directing use of Millie's Power
041434 -        Port for blood draws, ref SDS 42 X74Q, and restating
041435 -        directions in the doctor's letter to the Kaiser Walnut
041436 -        Creek Infusion Clinic on 091112, ref SDS 30 UN8F, and so
041437 -        in Millie's case overrules the new policy change a few
041438 -        months ago that prevented nurses from drawing blood
041439 -        using Millie's port, thereby forcing Millie to get blood
041440 -        drawn from her arms infected with cancer, causing her
041441 -        cancer to spread, e.g., on 100104, ref SDS 33 4Q30, and
041442 -        which conflicted with the doctor's order to avoid blood
041443 -        draws and blood pressure procedures on Millie's arms
041444 -        infected with cancer. ref SDS 44 SK8M
041446 -  ..
041447 - Doctor Johnson said that even though he is Millie's primary care
041448 - physician, he cannot direct the work to implement orders for Millie's
041449 - care at Kaiser, by asking the Radiology Department to prepare a
041450 - protocol for using Huber needles to inject contrast medium for CT
041451 - tests, because he does not have political standing as a member of a
041452 - different department, i.e., he works in Oncology.  The doctor related
041453 - having talked informally to Doctor Davidson, former Chief of Radiology
041454 - about this issue.  He feels that Doctor Davidson is "on Millie's side"
041455 - with respect to publishing a protocol to avoid more mistakes, but
041456 - further feels that assisting the new Chief, Doctor Mates, would
041457 - undermine relations between Oncology and the Radiology Department, and
041458 - be regarded as "interference," rather than alerting Doctor Mates with
041459 - timely notice of critical requirements for Millie's care.
041461 -  ..
041462 - Doctor Johnson summarized the feeling by recalling that, when he was
041463 - Chief of Oncology for Kaiser's Diablo Service Region, he did not want
041464 - interference from outsiders telling him how to run his Department.  He
041465 - feels human nature resists improvement to save lives, time, and money.
041467 -  ..
041468 - This reminds of the line in the 1992 movie, "A Few Good Men." The
041469 - Comanding Officer at the Marine base in Guantanamo, Cuba objected to
041470 - "interference" from Navy headquarters ordering all commanders to end
041471 - the practice of "code red" extrajudicial punishment for perceived
041472 - minor offenses.  The commander at Guantanamo Bay said (in the
041473 - movie)...
041474 -         ..
041475 -        I run my department how I run my department!
041477 -  ..
041478 - Avoiding conflict in bureaucracy, rather than notify people in time to
041479 - be effective was reported at the VA on 060505 0830. ref SDS 2 P58H
041481 -  ..
041482 - Bureaucracy perogatives are helpful to maintain quality control, but
041483 - should not deny Millie the benefit of her bargain for the primary care
041484 - physician to direct the work for her care.  Referral orders must be
041485 - implemented with deferrance to doctor discretion.  Where a conflict is
041486 - preceived with local policy, then the doctor should be notified for
041487 - verification that the local policy was intended to be set aside.
041489 -  ..
041490 - Doctor Johnson examined Millie.
041492 -  ..
041493 - He advised that examination shows progression of IBC as reported in
041494 - Millie's letter to the medical team on 091019, ref SDS 26 0Z9S, and
041495 - discussed during the meeting at Kaiser the following week on 091027.
041496 - ref SDS 28 DR6M
041498 -  ..
041499 - Bad news is new, strong evident IBC lesions on the right breast and
041500 - upper chest.  Until now, and for the past 4 years, Millie's right
041501 - breast only had a very small area of skin infected from time to time
041502 - with IBC rash, extending about .5 inches from intense IBC in the
041503 - breastbone area onto the right breast.  This was originally observed
041504 - on 061204, ref SDS 4 I93X, and has never progressed until now due to
041505 - rising cancer in Millie's breastbone that was untreated for 6 months
041506 - because of medical mistakes getting radiation treatments at UCSF on
041507 - referral from Kaiesr, reported by Doctor Hsu on 090609. ref SDS 19
041508 - W65W
041509 -        [...below, medical chart reports cancer spread to righ side.
041510 -        ref SDS 0 EZ4R
041512 -         ..
041513 -        [On 091203 1017 Millie's letter confirms progression of IBC
041514 -        onto the entire right side, caused by untreated cancer in the
041515 -        breastbone area due medical mistakes getting radiation from
041516 -        UCSF. ref SDS 32 A98Y
041518 -  ..
041519 - Doctor Johnson further advised that he and Doctor Rugo have not had
041520 - time to review treatments for Millie submitted to the medical team on
041521 - 090326 0058. ref SDS 14 DW5S, and cited again for reminder in a follow
041522 - up letter later that morning on 090326 0947, ref SDS 15 QM3V, similar
041523 - to Doctor Rugo's report on 090716 submitted by Tara Lacey at that time
041524 - on 090716.  As a result, the only treament Doctor Johnson can
041525 - prescribe today is Navelbine, which he previously reported on 090515,
041526 - would not likely be effective for Millie's patient profile.
041527 -
041528 -        [...below the doctor recalls there has been collaboration with
041529 -        UCSF through email correspondence, and that Doctor Rugo
041530 -        approves Kaiser treating Millie with chemotherapy. ref SDS 0
041531 -        QN5G; today, the doctor cannot find a record of any
041532 -        correspondence with Doctor Rugo on Millie's care. ref SDS 0
041533 -        LQ5N
041535 -  ..
041536 - The doctor orders Navelbine treatment to start with the next cycle on
041537 - 091118.
041539 -  ..
041540 - Doctor Johnson advised that Navelbine treatments are every week for 4
041541 - weeks, then start a new 4 week cycle.  The patient does not get a week
041542 - of rest between cycles.
041543 -
041544 -            [On 091118 0730 Barbara the nurse for Millie's 1st
041545 -            treatment of the 1st cycle with Navelbine clarified that
041546 -            cycles are only for 3 weeks with Navelbine, and then the
041547 -            patient has a week of rest. ref SDS 31 6263
041549 -  ..
041550 - Doctor Johnson today said that, if Doctor Rugo suffers further delays
041551 - starting Millie on PARP for "targeted" treatemnt planned on 090616,
041552 - and confirmed in the letter on 090716, ref SDS 22 EE5W, then Kaiser
041553 - will provide chemotherapy treatments until PARP is ready at UCSF for
041554 - Millie's 10th relapse, after Navelbine, and with...
041555 -
041556 -        a.  Abraxane
041557 -        b.  Ixempra
041558 -
041559 -               [...below, medical chart lists Abraxane and Ixempra for
041560 -               consideration in Doctor Johnson's work plan. ref SDS 0
041561 -               RV60
041563 -  ..
041564 - Ixempra was not discussed during the meeting today.  After the
041565 - meeting, research shows...
041566 -
041567 -            Medical News Today
041568 -
041569 -            Breast Cancer News
041571 -             ..
041572 -            Significant Improvement In Progression-Free Survival For
041573 -            Triple Negative Metastatic Breast Cancer Patients Treated
041574 -            With IXEMPRAT Plus Capecitabi
041575 -
041576 -              http://www.medicalnewstoday.com/articles/133039.php
041578 -             ..
041579 -            Article Date: 15 Dec 2008 - 4:00 PDT
041581 -             ..
041582 -            Bristol-Myers Squibb Company (NYSE:BMY) today announced new
041583 -            data from studies of IXEMPRAT (ixabepilone) plus
041584 -            capecitabine compared to capectabine alone, including a
041585 -            pre-specified sub set analysis demonstrating a significant
041586 -            increase in progression free survival (PFS) in patients
041587 -            with triple negative breast cancer.
041589 -             ..
041590 -            The study results - which are from a pooled analysis of
041591 -            approximately 2,000 patients enrolled in two Phase III
041592 -            clinical trials of IXEMPRA (046 and 048) - were presented
041593 -            today at the 2008 San Antonio Breast Cancer Symposium
041594 -            (SABCS). Patients studied were either resistant to or
041595 -            pretreated with anthracyclines and taxanes. In the pooled
041596 -            analysis of the subset of 443 patients with triple
041597 -            negative breast cancer, data show that IXEMPRA plus
041598 -            capecitabine (n = 191 patients) is the first combination
041599 -            regimen to demonstrate statistically significant
041600 -            (p<0.0001) PFS compared to capecitabine (n = 208 patients)
041601 -            alone.
041602 -
041603 -            "Patients with advanced, triple negative breast cancer
041604 -            have limited treatment options and a poor prognosis," said
041605 -            Hope S. Rugo, M.D., Clinical Professor of Medicine and
041606 -            Director, Breast Oncology Clinical Trials Program,
041607 -            University of California San Francisco Helen Diller Family
041608 -            Comprehensive Cancer Center. "For this reason, it is
041609 -            important to explore the potential of other current and
041610 -            developmental therapies to discover more and effective
041611 -            treatment options for patients with this specific type of
041612 -            breast cancer."
041614 -  ..
041615 - Abraxane was presented during the meeting based on treatments listed
041616 - in the record on 090121. ref SDS 10 EV53  Previously, Kaiser maintained
041617 - they had no additional treatments for Millie, and so Millie should ask
041618 - Doctor Rugo to do the research to identify agents for treating
041619 - Millie's cancer as a chronic disease, see case study on 090213.
041620 - ref SDS 11 PT3N
041622 -  ..
041623 - UCSF 2nd opinion received on 060929 lists Abraxane with lapitinib,
041624 - ref SDS 3 UI9K, but also says that Millie is not likely to benefit
041625 - from Abraxane, because of prior treatment with taxanes. ref SDS 3
041626 - SX3J
041627 -
041628 -            [On 100218 1000 Doctor Johnson disgnosed relapse with
041629 -            Navelbine, and prescribed Abraxane for 10th relapse.
041630 -            ref SDS 39 MD4H
041632 -             ..
041633 -            [On 100303 0730 Millie at Kaiser for 1st treatment of 1st
041634 -            cycle with Abraxane to recover from 10th relapse of cancer.
041635 -            ref SDS 41 625I
041637 -             ..
041638 -            [On 100501 1037 Millie notifies the medical team that
041639 -            treatment with Abraxane seems to have failed after 2
041640 -            cycles. ref SDS 43 U44U
041642 -  ..
041643 - Doctor Johnson seemed to indicate today that Abraxane is a stronger
041644 - form of Carboplatin chemotherapy, which Millie received with cetuximab
041645 - at UCSF during 2008, and beginning on 080313, ref SDS 8 TZ8I, and
041646 - which would therefore seem to preclude using again, following
041647 - progression and ending treatment with Carboplatin on 081016.
041648 - ref SDS 9 J34U
041650 -  ..
041651 - After the meeting research indicates Abraxane is prescribed to treat
041652 - patients in combination with Carboplatin; typical reporting shows...
041653 -
041654 -            CancerConsultants.com
041655 -
041656 -            Developments in the Treatment of Non-Small Cell Lung
041657 -            Cancer with Abraxane
041659 -               ..
041660 -              http://professional.cancerconsultants.com/conferencecoverage.aspx?id=38966
041662 -             ..
041663 -            Chandra Belani, MD, Co-Director, Lung and Thoracic
041664 -            Malignancies Program, University of Pittsburgh Cancer
041665 -            Institute
041667 -             ..
041668 -            Date: November 5-9, 2006
041669 -            Location: New York, New York
041670 -            Author: Chandra Belani, MD, Co-Director, Lung and Thoracic
041671 -            Malignancies Program, University of Pittsburgh Cancer
041672 -            Institute
041674 -             ..
041675 -            Combination Regimens
041677 -             ..
041678 -            Encouraged with the single agent activity of Abraxane, the
041679 -            combination with carboplatin was then evaluated in NSCLC.
041680 -            The efficacy of the combination of Abraxane and carboplatin
041681 -            appears to be comparable to that reported for solvent-based
041682 -            paclitaxel and carboplatin in patients with advanced
041683 -            NSCLC.[8]
041685 -  ..
041686 - Research indicates that Abraxane is is a stronger form of Taxol
041687 - chemotherapy...
041688 -
041689 -            Paclitaxel
041690 -
041691 -            From Wikipedia, the free encyclopedia
041693 -               ..
041694 -              http://en.wikipedia.org/wiki/Paclitaxel
041696 -             ..
041697 -            A newer formulation, in which paclitaxel [Taxol] is bound
041698 -            to albumin, is sold under the trademark Abraxane.
041700 -  ..
041701 - Millie also received Taxol previously with bevacizumab (Avastin) at
041702 - Kaiser to treat the first relapse of cancer, diagnosed as secondary
041703 - IBC, and beginning on 040420. ref SDS 1 9Z5J  Millie had good success
041704 - with another taxane, Taxotere, except on the 3rd relapse her cancer
041705 - progressed and this treatment was ended, reported on 061208.
041706 - ref SDS 5 3B4N
041708 -  ..
041709 - Doctor Johnson has previously reported chemotherapy is not effective
041710 - for Millie's patient profile, because Millie's cancer has mutated to
041711 - resist chemotherapy - see again case study on 090213. ref SDS 11 PT3N
041713 -  ..
041714 - Doctor Johnson did not discuss the UCSF 2nd opinion prepared by Doctor
041715 - Benz, and received in the record on 060929, and which says in part...
041717 -  ..
041718 - He feels today, that since the medical team has not had time to review
041719 - treatments targeted to Millie's cancer, then doctor discretion can
041720 - prescibe Abraxane for medical necessity, i.e., Abraxane is the best
041721 - treatment available at the moment, becasue nobody has had enough time
041722 - to compare trade-offs for the list of targeted treatments submitted to
041723 - the medical team on 090326. ref SDS 14 DW5S
041724 -
041725 -            [...below CT test on 090919, shows no pulmonary embolism,
041726 -            which indicates ending Millie's treatment with MPA, may not
041727 -            have been necessary, and so resuming treatment may expand
041728 -            her treatment options. ref SDS 0 RU68
041730 -             ..
041731 -            [On 100108 1618 UCSF notifies Kaiser that Millie cannot get
041732 -            treatment for cancer with PARP that includes a protocol for
041733 -            Carboplatin, because Millie's was previously treated with
041734 -            Carboplatin chemotherapy, and UCSF fails to compare
041735 -            trade-offs exercising discretion balancing Millie's medical
041736 -            necessity for life-saving treatment with PARP, which UCSF
041737 -            and Kaiser indicated on 090616 was the best choice for
041738 -            Millie to recover from life-threatening medical mistakes
041739 -            made by UCSF. ref SDS 34 FM5I
041741 -  ..
041742 - Millie has had severe problems holding blood counts with chemotherapy
041743 - getting Taxotere, Taxol, capeticabine, Carboplatin.  In 2008, UCSF
041744 - exercised discretion for medical necessity ordering Millie to miss
041745 - treatments, and the dose was ultimately reduced (evidently in error).
041746 - This combination of missing and reduced treatment dose caused Millie
041747 - to suffer progression with 5th relapse of cancer reported on 081016
041748 - 2342. ref SDS 9 J34U
041750 -  ..
041751 - There is a question that if Abraxane is stronger form of chemotherapy
041752 - that caused reduced blood counts that prevented getting regular
041753 - treatments, will this occur with Abraxane as well?
041755 -  ..
041756 - Doctor Johnson advised that he has collaborated with Doctor Rugo on
041757 - finding Millie's next treatment to mitigate damages caused by medical
041758 - mistakes UCSF made.  Doctor Johnson related today that communication
041759 - with Doctor Rugo has occurred through email rather than telephone
041760 - calls, and that Doctor Rugo approves Kaiser treating Millie with
041761 - Navelbine and then Abraxane, discussed above, ref SDS 0 KB4F, if
041762 - necessary, and because Doctor Rugo has reported to Kaiser that
041763 - "targeted" treatment with PARP is still not ready for Millie at UCSF.
041765 -  ..
041766 - This seems to clarify and revise initial understandings starting the
041767 - meeting, per above, ref SDS 0 A94I, aligns in part with the meeting at
041768 - Kaiser on 090909, when Doctor Johnson was worried that Millie's cancer
041769 - was worse, and she needed to change treatments.  At that time, the
041770 - doctor reported his schedule had finally cleared after 6 months, so he
041771 - had time to collaborate with Doctor Rugo at UCSF on providing standard
041772 - of care comparing trade-offs on results and costs for the 20 or so
041773 - treatments submitted to the medical team, ref SDS 24 VF60, with
041774 - Millie's letter on 090326. ref SDS 14 DW5S
041776 -  ..
041777 - Doctor Johnson was asked during the meeting today for a copy the
041778 - letter sent with email showing UCSF ordering or agreeing on Kaiser
041779 - treating Millie with Navelbine, pending starting treatment with PARP,
041780 - and for all other communications in email and otherwise with Doctor
041781 - Rugo and UCSF on Millie's case.
041783 -  ..
041784 - The doctor left the meeting to check the files in his personal office
041785 - down the hall.
041787 -  ..
041788 - Doctor Johnson returned about 15 minutes later, and said he cannot
041789 - find any communication with Doctor Rugo on Millie's case in Kaiser's
041790 - records.  Sounded like he mainly checked email program on his office
041791 - computer.  Aligns with initial understanding starting the meeting that
041792 - Kaiser and UCSF have not done anything to plan Millie's care with
041793 - targeted treatments, per above. ref SDS 0 A94I
041795 -             ..
041796 -            [On 091203 1017 Millie confirmed in a letter to the medical
041797 -            team that Kaiser and UCSF owe a duty to provide standard of
041798 -            care to evaluate treatments targeted to Millie's patient
041799 -            profile, based on represnetation of intent to collaborate
041800 -            through email on Millie's care, ref SDS 32 A99R, and Doctor
041801 -            Johnson was unable to fined evidence of email showing
041802 -            performance of collaboration and coordiantion between
041803 -            Kaiser and UCSF. ref SDS 32 A99U
041805 -  ..
041806 - Doctor Johnson further said that he was just told (didn't say by whom
041807 - -- a colleague, the boss, nurse, someone in the business office, Chief
041808 - of Oncology??) that HIPAA prohibits distribution of communications on
041809 - Millie's health care to Millie.  He feels Kaiser and UCSF therefore
041810 - need not spend time submitting communications to Millie that pertain
041811 - to her care.
041813 -  ..
041814 - The medical team has distributed communications the past 8 years, with
041815 - Millie facilitating collaboration between Kaiser and UCSF to
041816 - coordinate case management.
041818 -  ..
041819 - Discussed  review on 071009, showing HIPAA entitles patients to any
041820 - and all communications among health care provides, doctors, nurses,
041821 - administrators, managers, accountants, etc., that pertains to patient
041822 - care. ref SDS 7 TG3K  Patient access to health records, including
041823 - communications among providers pertaining to patient care provides
041824 - transparency that encourages timely, accurate work that prevents small
041825 - mistakes from escalating into major catastrophies.
041827 -  ..
041828 - Doctor Johnson reported this morning that Millie benefits with
041829 - extended survival and quality of life from Millie's access to
041830 - communications that enables effective support for case management,
041831 - citing Millie's letter today submitting the agenda for this meeting,
041832 - per above. ref SDS 0 4W8K
041834 -  ..
041835 - This is the 3rd major correspondence affecting Millie's care that is
041836 - reported to have occurred, and cannot be produced, and was witheld
041837 - from Millie.
041839 -  ..
041840 - Previously, on 090616, Doctor Rugo cited agreement between Kaiser and
041841 - UCSF in an email, and to treat Millie's cancer as a chronic disease
041842 - initially with MPA, and then with PARP. ref SDS 20 KD6L  At that time,
041843 - Doctor Rugo said the letter could not be given to Millie, because it
041844 - also pertained to other patients.  On 090716, Tara said Doctor Rugo
041845 - sent a letter to Doctor Johnson with email that amended the agreement
041846 - on 090616, to treat Millie with Gemzar until PARP was ready in
041847 - September. ref SDS 22 EE5W  Millie has asked for the 090716 letter
041848 - numerous times, and it has never been produced.
041849 -
041850 -
041851 -
041852 -
0419 -

SUBJECTS
Default Null Subject Account for Blank Record

0503 -
050401 -  ..
050402 - Medical Chart Received Weeks Later
050403 -
050404 - Doctor Johnson distributed the medical chart for the meeting today at
050405 - Kaiser, however, it was not received until weeks later due to a
050406 - combination of problems with Kaiser's electronic business system being
050407 - of -line and denying access at varous times, and that Rod was
050408 - recuperating from heart surgery on 091022. ref SDS 27 PQWU  After
050409 - release from the hospital on 091104, support for case management on
050410 - Millie's care was slowed.
050412 -             ..
050413 -            [On 100301 0005 Millie's letter notified the medical team
050414 -            that Doctor Johnson's medical chart for the meeting today
050415 -            on 090912 was reviewed, and shows critical errors reporting
050416 -            that during this meeting the doctor disucssed potential
050417 -            risks (side effects and complications) and benefits of
050418 -            recommended alternative oncologic treatment(s), and
050419 -            answered the patient's question, and that the patient is
050420 -            competent to understand recommendations, and agrees with
050421 -            recommendations, in that this discussion did not occur, and
050422 -            Millie asked Kaiser to submit what recommendations were
050423 -            presented, what side effect risks and complications were
050424 -            presented, and what questions were asked and what answeres
050425 -            were given. ref SDS 40 OO9S
050427 -         ..
050428 -        Subject:  Visit 11/12/09
050429 -        Received: 11/12/09 11:00 AM
050430 -        To: Mildred A Buck
050431 -        From: ROBERT ALLSTON JOHNSON MD
050433 -         ..
050434 -        Patient presents with: RECHECK
050436 -         ..
050437 -        History of Present Illness:
050439 -         ..
050440 -        Mildred A Buck is a 73 Y female with a history of IBC of left
050441 -        breast who was initially diagnosed 03/04/02.  S/P AC x's 4 from
050442 -        04/23/02 through 07/01/02 followed by Taxotere ending 12/04/02.
050443 -        She had recurrent disease noted initially in the cervical LN's
050444 -        03/03/04.  On E2100 Study with Taxol/Avastin, but she had a PE
050445 -        noted on CT 11/03/2004.  Then, because of progression of
050446 -        disease, the patient was started on Taxotere and Xeloda
050447 -        4/15/05.  She had a total of 8 cycles ending 9/16/05.  She had
050448 -        a palliative left mastectomy performed 10/21/05.  Then her left
050449 -        chest lesions began expanding again.  The patient started
050450 -        Taxotere and Xeloda again 07/21/06 for 7 cycles.  She was
050451 -        started on a Clinical Trial 02/01/07 at UCSF and was randomized
050452 -        to the Erbitux only (no Carbo) Arm.  She had weekly Carboplatin
050453 -        added 03/13/08 because of progression of disease.  Her disease
050454 -        progressed again and she began a Phase I/II Study of Sunitinib
050455 -        (SU11248) at UCSF 11/14/08.  Lengthy discussion about current
050456 -        status and response to therapy. Because of cytopenia, MTX to be
050457 -        D/C'd and Sutent and CTX held and then dose reduced.  The
050458 -        patient started hyperthermia/XRT at UCSF 02/19/09 and completed
050459 -        it 03/17/09.  She has started the MPA Clinical Trial at UCSF
050460 -        06/16/09 but this has been D/C'd.
050462 -         ..
050463 -        She started Gemzar 07/28/09 and started Cycle #4 11/05/09.  She
050464 -        is here for FU.  She is concerned that there is continued
050465 -        evidence of progression.
050467 -         ..
050468 -        Current medications:
050470 -         ..
050471 -        HYDROCODONE/ACETAMINOPH 5-5
050472 -        WARFARIN 4 MG TABLETS
050473 -        LUMIGAN 0.03% EYE DROPS (2.
050474 -        TIMOLOL MALEATE 0.5% EYE DR
050475 -        OXYCODONE W/APAP 5-325 MG T
050476 -        AEROCHAMBER Z-STAT/PLUS W/O
050477 -        QVAR 80 MCG ORAL INHALER
050478 -        ALBUTEROL HFA 90MCG ORAL IN
050479 -        GUAIFEN/CODEIN 100-10MG/5ML
050480 -        LORAZEPAM 1 MG TABLETS
050482 -         ..
050483 -        Review of systems:
050485 -         ..
050486 -        Constitutional: Appetite and energy level are stable still
050487 -        able to walk Lafayette Reservoir.
050489 -  ..
050490 - This report is incorret, and ignores reporting since April, that
050491 - Millie cannot walk a lap at Lafayette, and can barely walk from the
050492 - parking lot to the store.  Millie's letter this morning submitting the
050493 - agenda for the meeting, and which Doctor Johnson took 20 minutes to
050494 - read prior the the meeting, ref SDS 0 4W8K, states that Millie can
050495 - barely function; she cannot hike even 1 lap (3 miles) at Lafayette
050496 - reservoir, and can barely walk from the paring lot into the hospital
050497 - for meeting with the doctor. reporting on 091112 0752. ref SDS 29 L65W
050499 -             ..
050500 -            [...below representation that the doctor performed standard
050501 -            of care comparing trade-offs of oncology treatments also
050502 -            did not occur, and conflicts with the record. ref SDS 0
050503 -            M86O
050505 -  ..
050506 - Medical Chart Review of Systems continues...
050507 -
050508 -        Eyes: Vision is OK.
050509 -        ENT: No nose bleeds.
050510 -        Cardiovascular: No SOB, palpitations or chest pain
050511 -        Respiratory: No hemoptysis or cough. Some DOE noted
050512 -        GI: Diarrhea resolved
050513 -        GU: No hematuria or dysuria
050515 -         ..
050516 -        Musculoskeletal: Left neck spasm and right shoulder pain
050517 -        improved with Robaxin
050519 -         ..
050520 -        Skin: Pruritis of chest wall
050521 -        Neurological: No confusion, sensory changes or motor weakness
050522 -        Psychiatric: Anxious
050524 -         ..
050525 -        Physical Exam:
050526 -        ECOG Performance Score 0
050527 -        BP 126/74 | Pulse 75 | Temp (Src) 98.2 F (36.8 C) (Oral) |
050528 -        Wt 143 lb (64.864
050529 -        kg) | SpO2 93%
050530 -        Head: alopecia
050531 -        Eyes: normal conjunctiva
050532 -        Mouth: normal mucosa
050533 -        Lymph: no nodes palpable in neck, axillae or groin
050535 -         ..
050536 -        Breasts: evidence of progression of erythema to other breast
050538 -  ..
050539 - Cancer spreading to right breast, actually the right side, per
050540 - examination above, ref SDS 0 8G6O, is major progression of Millie's
050541 - patient profile, since the right side has been mostly free of IBC for
050542 - 8 years.
050543 -
050544 -               [On 091203 1017 Millie's letter confirms progression of
050545 -               IBC onto the entire right side, caused by untreated
050546 -               cancer in the breastbone area due medical mistakes
050547 -               getting radiation from UCSF. ref SDS 32 A98Y
050549 -  ..
050550 - Medical Chart Review of Systems continues...
050551 -
050552 -        Lungs: clear to percussion and auscultation
050553 -        Heart: regular without murmur or gallop
050554 -        Abd: soft with normal bowel sounds. No masses or organomegaly
050555 -        Ext: no edema
050556 -        Skin: no rashes or palpable masses
050557 -        Bones: no tenderness
050558 -        Neuro: awake, alert, and oriented. Moves all extremities well. Normal gait.
050560 -         ..
050561 -        Lab:
050562 -        WBC 9.4 K/uL
050563 -        RBC L 2.90 M/uL
050564 -        Hemoglobin L 8.9 g/dL
050565 -        Hematocrit L 27.8 %
050566 -        MCV 96 fL
050567 -        RDW H 19.1 %
050568 -        Plt 174 K/uL
050570 -         ..
050571 -        PT, Patient H 31.3 Sec
050572 -        PT INR 3.0 Ratio
050574 -         ..
050575 -        CA 15-3
050576 -        -----------
050577 -        299 H
050578 -        299 H
050579 -        343 H
050580 -        297 H
050581 -        302 H
050582 -        346 H
050583 -        335 H
050584 -        350 ?
050585 -        389 H
050587 -         ..
050588 -        PFT's 08/31/09
050589 -        - No obstruction
050590 -        - Good response to bronchodilators
050591 -        - Moderate decrease in diffusion capacity
050593 -         ..
050594 -        Imaging:
050596 -         ..
050597 -        09/19/09 CT THORAX W CONTRAST -
050599 -         ..
050600 -        No pulmonary emboli on a technically good study.
050602 -  ..
050603 - This CT test was ordered for Millie's treatment in the Emergency Room
050604 - on 090919, and to treat painful breathing. ref SDS 25 DA6Q
050606 -  ..
050607 - UCSF called on 090716, and ended Millie's treatment targeted to her
050608 - patient profile with MPA, because of concerns that MPA had caused
050609 - Millie to get another pulmonary embolism that is life threatening, and
050610 - based on Millie suffering compromised breathing, and MPA protocol
050611 - lists blood clots as a rare side effect, which can cause pulmonary
050612 - embolism which causes diminished breathing, heavy chest, cough.
050613 - ref SDS 22 EE6P
050615 -  ..
050616 - This report finding no evidence of PE demonstrates that UCSF's reason
050617 - for ending Millie's treatment with MPA on 090716, may have been
050618 - premature, and further that Millie can be treated again with MPA, in
050619 - the same way Kaiser treated Millie with AC on 050104, and prior
050620 - treatment in July 2002, and similarly, Kaiser planning today to
050621 - prescribe Abraxane that is a stronger form of Taxol, shows resuming
050622 - prior discontinued treatments may be appropriate in some cases,
050623 - ref SDS 0 NA3O,
050625 -  ..
050626 - Medical Chart report on CT test 090919 continues...
050627 -
050628 -        The lungs show multiple areas of ground glass opacity and
050629 -        multiple small areas of more confluent density.  Tiny left
050630 -        pleural effusion.  S/P left mastectomy.  A few additional minor
050631 -        findings, as described above.  Since July 20, 2009 CT scan of
050632 -        the chest, there has been resolution of many of the pulmonary
050633 -        opacities but there are now many new ones, especially in the
050634 -        left lower lobe and in the right upper lobe.  The left pleural
050635 -        effusion is much smaller.  Otherwise, no change.
050637 -  ..
050638 - This report that some ground glass opacity nodules are resolved in
050639 - some areas, and new ones appear in other areas, aligns with Doctor
050640 - Hsu's report on 090312, that radiation continues to affect tissue,
050641 - enabling recovery for months after ending treatments. ref SDS 12 F860
050642 - Doctor Hsu repeated this prognosis again during a follow up meeting at
050643 - UCSF on 090423 0830. ref SDS 16 YN5N
050645 -  ..
050646 - Doctor Mates, Chief Radiology at Kaiser in Walnut Creek, seemed to
050647 - indicate in a call on 090625, that ground glass opaciteis shown in
050648 - Millie's CT test at Kaiser on 090612, and which caused Millie severe
050649 - resperatory compromise, shown by treatment for painful breathing taht
050650 - required care in the Emergency Department on 090720, ref SDS 23 GE5H,
050651 - and again on 090919, ref SDS 25 L78M, Millie was hospitalized for a
050652 - week, might eventually resolve and heal without treatment. ref SDS 21
050653 - IJ4W
050655 -  ..
050656 - Medical Chart Image Tests continues...
050658 -         ..
050659 -        09/19/09 CHEST, SINGLE
050661 -         ..
050662 -        07/31/09 RIBS, UNILATERAL, 2 VIEWS - Right ribs appear intact
050664 -         ..
050665 -        07/20/09 CT THORAX W CONTRAST - 1. Negative for pulmonary embolus. 2. New
050666 -        small left pleural effusion. No pleural enhancement or evidence of loculation.
050667 -        3. Otherwise stable chest CT compared with recent examination from one month
050668 -        earlier.
050670 -         ..
050671 -        06/12/09 CT THORAX, ABDOMEN, PELVIS W CONTRAST
050673 -         ..
050674 -        06/12/09 CT NECK W CONTRAST
050676 -         ..
050677 -        03/17/09 DXA BONE DENSITY, AXIAL - 1. Bone mineral density calculated for the
050678 -        LUMBAR SPINE is statistically consistent with osteopenia. 2. Bone mineral
050679 -        density calculated for the TOTAL HIP is statistically consistent with
050680 -        osteopenia.
050682 -         ..
050683 -        01/29/09 SHOULDER, COMPLETE 2+ VIEWS
050685 -         ..
050686 -        01/22/09 SHOULDER, COMPLETE 2+ VIEWS - Orthopedic follow up. See Orthopedic
050687 -        note for details. S/P reduction of anterior shoulder dislocation.
050689 -         ..
050690 -        01/22/09 SHOULDER, ONE VIEW - Dislocation, right shoulder. Fracture right
050691 -        humeral head
050693 -         ..
050694 -        01/22/09 CT CERV SPINE W/O CONTRAST - Degenerative changes of the cervical
050695 -        spine without evidence of acute C spine fracture or loss in alignment.
050697 -         ..
050698 -        01/22/09 CT HEAD W/O CONTRAST - 1. No evidence of acute infarct or hemorrhage.
050699 -        2. Sinus disease. Mild nasal septal deviation to the right.
050701 -         ..
050702 -        Assessment:
050703 -
050704 -        1.  Metastatic breast cancer (IBC) lung, lymph node and chest
050705 -            wall; progression?
050706 -        2.  ACD
050707 -        3.  DOE; due to radiation injury vs lymphangitic spread; stable
050708 -        4.  Neck spasm resolved
050710 -         ..
050711 -        Plan:
050712 -
050713 -        1.  D/C Gemzar because of progression
050714 -        2.  Start Vinorelbine (Navelbine) 20 mg/m2 iv weekly
050716 -             ..
050717 -        3.  I have discussed the potential risks (side effects and
050718 -            complications) and benefits of the recommended and
050719 -            alternative oncologic treatment(s).  I have answered the
050720 -            patient's questions.  I believe the patient is competent
050721 -            and can understand the recommendations that I have made.
050722 -            The patient agrees with these recommendations.
050724 -  ..
050725 - This part of the medical chart sounds like the Legal Department asked
050726 - the doctor to add this language responding to Millie's continuing
050727 - request for standard of care comparing trade-offs to evaluate
050728 - treatments targeted to her patient profile, and asked again in
050729 - Millie's letter this morning submitting the agenda for the meeting.
050730 - ref SDS 29 L66S, and further requesting review of 20 or so treatments
050731 - submitted to the team and which have not been compared for trade-offs.
050732 - ref SDS 29 LE3R
050734 -  ..
050735 - This representation of discussion, like erroneous representation that
050736 - Millie is still hiking laps at Lafayette reservoir, per above,
050737 - ref SDS 0 RT94, did not take place; Doctor Johnson said the only
050738 - treatments he has left at Kaiser are Abraxane and Ixempra; he
050739 - prescribed Abraxane and said it is a stronger form of Careboplatin;
050740 - nothing else was presented, and nothing was said about Ixempra.  After
050741 - the meeting research indicates Abraxane may be another form of Taxol,
050742 - per above. ref SDS 0 KB4F
050744 -  ..
050745 - Medical Chart Image Tests continues...
050746 -
050747 -        4.  Neupogen as needed
050748 -        5.  Continue serial CA 15-3's
050749 -        6.  Continue Robaxin
050750 -        7.  Consider ABRAXANE or IXEMPRA next
050751 -        8.  RTC monthly prior to chemotherapy
050753 -         ..
050756 -
050757 -
050758 -
050759 -
050760 -
050761 -
0508 -