CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up
040502 -
040503 -
040504 -
040506 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 091103 Paula reported the VA has scheduled a meeting today with
040902 - Doctor Stewart for planning Heller Myotomy surgery to correct
040903 - achalasia problem. ref SDS 12 PS60  On 091104 0718 Medical Chart
040904 - discharge guidance lists meeting with Doctor Stewart 091117 1300,
040905 - which conflicts with patient history today. ref SDS 13 Q03J  On 091119
040906 - 1000 Erick confirmed visit with Doctor Stewart on 091208, and is
040907 - reviewing date of surgery scheduled for 091217. ref SDS 15 935H
040908 -
040909 -
040911 -  ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Parking Free in VA Garage for Patients
041302 -
041303 - We arrived OA 1100.  Had more trouble finding a parking spot.  We
041304 - tried the parking garage.  Could not find a place to purchase a
041305 - parking ticket.  We parked in an open spot.  Millie noticed other cars
041306 - seemed to have various forms of VA parking ID.  Millie went to find a
041307 - place to purchase a parking ticket.
041309 -  ..
041310 - Walked back to the Emergency Enterance, which is also where
041311 - outpatients are seen in two (2) Clinic Modules.  Talked to the
041312 - Information attendant.  She said patients park in the garage free of
041313 - charge.  Asked how patients are distinguished from paying customers
041314 - for parking purposes.  The Information attendant suggesting talking to
041315 - Security across the street in the main hospital building.
041317 -  ..
041318 - Walked to the next building.  Found a unit called "Police."  Asked if
041319 - this is also the "Security Department?"  The officer asked for a
041320 - question.
041322 -  ..
041323 - Explained having parked in the Parking Structure for a pre-surgery
041324 - meeting with Doctor Stewart in the General Surgery Department, and
041325 - could not find any place to purchase a parking ticket.
041327 -  ..
041328 - The officer said that patients are not charged for parking.
041330 -  ..
041331 - The officer said that Security Department checks license plates of
041332 - cars that do not have parking permits.  This list is checked against
041333 - the hospitcal patient list, and if they match, then a parking
041334 - violation ticket is not issued.
041336 -  ..
041337 - Advised that Millie owns the car, and she is the driver today, but
041338 - not the patient.
041340 -  ..
041341 - The office said he will make a note that Millie is driving Rod for his
041342 - meeting at the VA today.  This will clear the car for no-charge
041343 - parking.
041344 -
041345 -
041347 -  ..
0414 -
0415 -
0416 - 1146
0417 -
041701 - Information Release Ordered VA Records on Heart Surgery
041702 -
041703 - Found Module 2 for meeting with Doctor Stewart.
041704 -
041705 - The attendant said that check-in time is 1230 for meeting with the
041706 - Doctor.
041708 -  ..
041709 - Asked for the location of the Information Release office.
041711 -  ..
041712 - The Information Attendant at the entrance of the Emergency Department
041713 - explained it is on the 1st floor, room 176, and gave directions on
041714 - finding the location.
041716 -  ..
041717 - Visited patient Information Release office.
041719 -  ..
041720 - Ordered records from 091021 - 091104 and for 01117.
041721 -
041722 -        [On 100105 1300 ordered records on treatment from 091105 to
041723 -        present, 100105. ref SDS 20 PP8W
041725 -  ..
041726 - We went to the cafeteria.  Millie had a hamburger for lunch.
041727 -
041729 -  ..
0418 -
0419 -
0420 - 1247
0421 -
042101 - Checked in at Clinic Module #2.
042102 -
042104 -  ..
0422 -
0423 -
0424 - 1308
0425 -
042501 - Patient History on Achalasia Rendered for 10th Time
042502 -
042503 - Called for meeting with the doctor.
042505 -  ..
042506 - Vitals...
042507 -
042508 -             Weight,,,,,,,,,,,,,,,,, 176
042509 -             Blood pressure......... 126 70
042510 -             Pulse.................. 62
042511 -             Oxygen................. 97%
042513 -  ..
042514 - Met with Doctor Ranna Tabrizi.
042516 -  ..
042517 - The doctor had not received the agenda submitted with letter to the
042518 - medical team on 091201. ref SDS 17 M86X
042520 -  ..
042521 - Doctor Tabrizi asked for patient history on achalasia?
042523 -  ..
042524 - Patient medical record on achalasia has been presented to VA Medical
042525 - Center in San Francisco more than 10-times since 091019, as listed in
042526 - the record on 091021, ref SDS 7 LJ7L, and including the meeting with
042527 - Doctor Stewart on 091030. ref SDS 10 025I
042529 -  ..
042530 - Despite the record on 091021, Doctor Tabrizi asked that this long,
042531 - complex history be presented again today.  She explained that finding
042532 - relevant records in the VA computer system is very difficult.
042534 -  ..
042535 - Fear of failure finding relevant medical history in time to be
042536 - effective, greatly increases redundancy in the record.  Reliance on
042537 - human memory rather than the medical record, accelerates chances of
042538 - error, conflict, and calamity for patients and providers.  Further,
042539 - redundancy retelling and entering patient history again and again
042540 - causes differences in eash record that creates confusion and takes
042541 - time to reconcile conflicting accounts, which increases mistakes,
042542 - doubt, frustration.  Doctor Tabrizi's report about slow access to
042543 - computer records further aligns with work last month meeting the CT
042544 - Surgery team on 091119 1000. ref SDS 15 9S5F
042546 -  ..
042547 - Management collapses into bumbling from negative synergy reducing
042548 - productivity to zero with redunancy that accelerates information
042549 - overload, explained in POIMS. ref OF 4 0476, and in NWO discussing
042550 - "meaning drift." ref OF 11 9449
042552 -             ..
042553 -            [On 100911 0800 VA credited for improving speed of access
042554 -            to computer records; discussed "Knowledge Management loop"
042555 -            that redundancy and ignoring the record collapses
042556 -            productivity and vitiates care because health care
042557 -            professionals do not have command and control of the record
042558 -            on patient history, ref SDS 21 OL50, citing case study of
042559 -            work at VA today on 091021. ref SDS 7 FB5N
042561 -  ..
042562 - As a result, presented the record of achalasia shown on 090908 1130.
042563 - ref SDS 6 FT6M
042565 -  ..
042566 - Doctor Tabrizi made examination, including inspection of incisions for
042567 - heart surgery performed on 091022 0700. ref SDS 8 LO3G
042569 -  ..
042570 - The doctor asked about medication history to avoid conflicts with
042571 - requirements for surgery, including issues like diabetes, asthma,
042572 - kidney problems, etc, history of smoking, alchohol, illicit drugs,
042573 - etc., which are all negative.
042574 -
042575 -        [On 091214 1100 Isagani, NP, asked similar questions for pre-op
042576 -        surgery review. ref SDS 19 5W9J
042578 -         ..
042579 -        [On 091214 1100 Karen, NP, asked similar questions for pre-op
042580 -        surgery review. ref SDS 19 OT6H
042582 -  ..
042583 - Doctor Tabrizi went into the hallway to wait for Doctor Stewart.
042584 -
042586 -  ..
0426 -
0427 -
0428 - 1350
0429 -
042901 - Doctor Stewart met with Doctor Tabrizi in the hallway.  Doctor Tabrizi
042902 - closed the door to the examination room while briefing Doctor Stewart
042903 - on findings from patient history and examination today, per above.
042904 - ref SDS 0 QB7H
042905 -
042906 -        [...below, pre-op scheduler orders another meeting to review
042907 -        patient history and make another examination tomorrow.
042908 -        ref SDS 0 6S50
042909 -
042911 -  ..
0430 -
0431 -
0432 - 1403
0433 -
043301 - Doctor Stewart and Doctor Tabrizi enter the examination room again to
043302 - continue the meeting.
043304 -  ..
043305 - Doctor Stewart asks how the patient is feeling?
043307 -  ..
043308 - The doctor proposes doing Heller Myotomy surgery to correct achalasia
043309 - a day earlier on 091216 0600, rather than wait until 091217, as
043310 - originally scheduled with Paula on 091103. ref SDS 12 PS60
043311 -
043312 -        [On 091211 1523 letter to medical team confirms schedule for
043313 -        Heller Myotomy surgery on 091216 to resolve achalasia
043314 -        ref SDS 18 PPXY
043316 -         ..
043317 -        [On 091214 1100 pre-op meeting with Isagani shows patient "good
043318 -        to go" for Heller Myotomy surgery on 091216. ref SDS 19 GG66
043320 -  ..
043321 - We reviewed conflict with Millie starting 2nd cycle of Navelbine
043322 - chemotherapy at Kaiser in Walnut Creek, and to recover from 9th
043323 - relapse of cancer.  So, this timing seems problematic.
043325 -  ..
043326 - Doctor Stewart explained that, if surgery to correct achalasia is not
043327 - performed on 091216, then the next available date will be in late
043328 - January.  At that time, there could be further conflicts with Millie's
043329 - care at Kaiser.
043331 -  ..
043332 - Decided to do surgery on 091216 0600.  Can take BART and a cab to get
043333 - to the VA on time.  Mille's recalls that BARt starts running at 0430
043334 - in the mornings.  Leaving at 0430, would arrive in San Francisco, OA
043335 - 0530.  That leaves 30 minutes for a cab ride to the VA across town.
043336 - This is a tight schedule.
043338 -  ..
043339 - Another option would be to take the last BART train around 0100.  Take
043340 - a cab, and arrive at the VA OA 0300; then work a few hours in the
043341 - Emergency Waiting area.  Might be able to report to ASU, and find a
043342 - place to sleep or work for a few hours.
043344 -  ..
043345 - Could also drive from Concord at 0400, and arrive at the VA OA 0530;
043346 - this would give Millie plenty of time to drive back to Kaiser in
043347 - Walnut Creek in time for 0730 treatment.  Since she is tolerating
043348 - Navelbine well, and there are no support meds, she should be okay
043349 - driving home after treatment.  One problem is taking percocet for
043350 - rising pain from progression of cancer, which hopefully Navelbine will
043351 - slow or reverse.  Taking percocet could present driving risk getting
043352 - home.  Will monitor situation, and decide the best course from
043353 - circumstances that evolve until 091216.
043355 -  ..
043356 - Doctor Stewart reported consultations with Doctor Tseng on risks
043357 - performing Heller Myotomy surgery to resolve achalasia, following
043358 - heart surgery on 091022, and as planned in the meeting with Doctor
043359 - Stewart on 091031. ref SDS 10 OY77  Doctor Stewart indicated that
043360 - Doctor Tseng has cleared the patient for this additional surgery based
043361 - on significant recovery from heart surgery on 091022.  This aligns
043362 - with meeting the CT surgery team on 091117.  At that time, Neil cited
043363 - strong recovery from heart surgery on 091022, supports proceeding with
043364 - surgery to recover from achalasia on 091217, and scheduled follow up
043365 - examination the day of surgery for achalasia, ref SDS 15 936G, which
043366 - at that time was planned for 091217.
043368 -  ..
043369 - Doctor Tabrizi presented a surgery consent document for online
043370 - signature.
043372 -  ..
043373 - Based on understandings that the CT surgery team approves recovery
043374 - from heart surgery sufficient to enable safely performing Heller
043375 - Myotomy surgery on 091217, signed a consent document online for doing
043376 - surgery to resolve achalasia a day earlier on 091216.
043377 -
043378 -     [...below Doctor Joe Enayati indicates he will provide post-op
043379 -     care for Heller Myotomy surgery on 091216, to resolve achalasia;
043380 -     continuity of care with the CT Surgery team redues risks of
043381 -     near-term surgery following heart surgery on 091022. ref SDS 0
043382 -     QB66
043384 -  ..
043385 - Doctor Stewart asked again about patient history.  The doctor wanted
043386 - to know dates of endoscopy that checked the throat and stomach for
043387 - cancer, and for results of manometry test.
043389 -  ..
043390 - Reviewed the record on 091030, when this information was presented to
043391 - Doctor Stewart during a meeting in the TCU (Telemetry) Department.
043392 - ref SDS 10 6H9J   An hour or so later, Doctor Ratcliffe reviewed
043393 - patient history and seemed satisfied the record is sufficiently clear
043394 - showing these pre-op tests have been satisfactorily performed.
043395 - ref SDS 10 V16J
043397 -  ..
043398 - Offered to get this information from the computer, c16, which was
043399 - brought to the meeting for access to patient history.
043401 -  ..
043402 - Doctor Stewart indicated that using the patient's computer is not
043403 - necessary; she asked for dates of procedures, so that Doctor Tabrizi
043404 - could find Doctor Lee's reports on the VA computer for the endoscopy
043405 - and menometry tests?
043407 -  ..
043408 - Recalled endoscopy procedure may have been done in December 2006, and
043409 - that manomtry test was in March 2007.
043411 -  ..
043412 - Doctor Tabrizi used the VA computer to check patient records, but
043413 - could not find the specific results of endoscopy and manometry tests.
043415 -  ..
043416 - Since records on patient history could not be located on the VA's
043417 - computer system during the meeting, Doctor Stewart discussed delaying
043418 - Heller Myotemy surgery to resolve achalasia, and in order to perform
043419 - another manometry test to verify achalaasia, and also perform another
043420 - endoscopy to evaluate for throat cancer.
043422 -  ..
043423 - Reviewed understandings again that on 091030 Doctor Ratcliffe approved
043424 - surgery to correct achalasia based on patient history, ref SDS 10 V16J,
043425 - which shows...
043427 -             ..
043428 -        1.  Endoscopy performed by Doctor Lee at the VA in Martinez on
043429 -            051209, and finding no evidence of throat nor stomach
043430 -            cancer. ref SDS 3 PRRT
043432 -             ..
043433 -            Four (4) photographs were taken of the throat and stomach,
043434 -            showing no evidence of cancer. ref SDS 3 CZ6M
043436 -             ..
043437 -            Biopsy was taken at that time, and on 051222 pathology
043438 -            report presented negative findings for cancer, that
043439 -            condition consistent with achalasia. ref SDS 4 FT6M
043441 -             ..
043442 -        2.  Endoscopy performed again at VA in Sacramento on 060330,
043443 -            ref SDS 5 VX4G, and again finding no evidence of cancer in
043444 -            the throat nor stomach. ref SDS 5 CX8J
043446 -             ..
043447 -        3.  Manometry test was also performed at VA in Sacramento on
043448 -            060330, ref SDS 5 MC6K, and Doctor Lee observed findings
043449 -            that support diagnosis of achalasia. ref SDS 5 MD4N
043451 -  ..
043452 - Further, reviewed today,,for Doctor Stewart and Doctor Tabrizi, work
043453 - here at the VA in San Francisco on 091030 0810 at 1643.  At that time,
043454 - Doctor Sawhney performed a procedure in the Radiology Department to
043455 - place a feeding tube ordered by Doctor Ratcliffe. ref SDS 10 05GB
043456 - Doctor Swahney examined the throat and the stomach with a camera and
043457 - found no evidence of throat nor stomach cancer. ref SDS 10 AS6M
043459 -  ..
043460 - Doctor Stewart advised that the record of patient history supports
043461 - performing Heller Myotomy surgery to relieve achalasia, and without
043462 - further endoscopy and manometry tests.
043464 -  ..
043465 - Scheduled pre-op procedures for tomorrow.  This requires coming back
043466 - to San Francisco.  For some reason cannot do it today.
043468 -  ..
043469 - Doctor Stewart advised that Xray and EKG tests performed on 091117 at
043470 - VA in Martinez, ref SDS 14 TD6M, for meeting with the CT surgery team
043471 - on 091119, ref SDS 15 938N, are also within the time frame required to
043472 - evaluate safety getting Heller Myotomy surgery on 091216.  Therefore
043473 - these tests are not needed again for pre-op.
043475 -  ..
043476 - Doctor Stewart further explained that since endoscopy and manometry
043477 - tests are not needed, based on patient history reviewed today, per
043478 - above, ref SDS 0 U46G, pre-op scope in this case is reduced to only
043479 - doing a lab blood draw.
043481 -  ..
043482 - Asked about adding test for cholesterol to the lab, in order to
043483 - evaluate effect of medication started in September.
043485 -  ..
043486 - Doctor Stewart approved this test with the pre-op lab.
043487 -
043488 -        [...below, Mike schedules pre-op lab on 091209, ref SDS 0 6S50;
043489 -        this is changed to 091214 to evaluate INR nearer to the date of
043490 -        surgery. ref SDS 0 PUQT
043492 -  ..
043493 - Asked about post-op recovery?
043495 -  ..
043496 - Doctor Stewart advised patients who have Heller Myotomy surgery for
043497 - achalasia typically stay in the hospital for several days to enable
043498 - observation and recovery support.
043500 -  ..
043501 - As a result, will be in the hospital on 091217 1000 when the CT
043502 - surgery team has scheduled a meeting to review progress for for
043503 - post-op recovery from heart surgery on 091022, as discussed with Neil
043504 - and Erick on 091119. ref SDS 15 FW6W
043506 -  ..
043507 - Asked about sonogram test to evaluate DVT problem, requested during
043508 - the meeting with the CT surgery team on 091119, ref SDS 15 K24M, and
043509 - presented in the letter to the team on 091201? ref SDS 17 M88R
043511 -  ..
043512 - Doctor Stewart agreed to order a sonogram today to evaluate resolution
043513 - of DVT.  The doctor explained that if the sonogram test shows DVT is
043514 - no longer visible, then Coumadin (warfarin) can stop today.  If not.
043515 - then Coumadin should be paused in 2-days on 091210 in order to provide
043516 - enough time for the blood to thicken sufficient for surgery on 091216.
043517 - Coumadin would then be resumed after surgery, if the sonogram test
043518 - today finds continuing evidence of DVT problems.
043519 -
043520 -        [...below, sonogram test finds DVT problems resolved, so
043521 -        Coumadin treatments end today. ref SDS 0 D24G
043523 -  ..
043524 - Doctor Stewart called Radiology.  She consulted with a doctor on
043525 - adding an unscheduled sonogram to the work this afternoon, and in
043526 - order to assess criteria for approving surgery next week on 091216.
043527 - Radiology agreed to perform the sonogram this afternoon.  Doctor
043528 - Stewart indicated the sonogram test can be done in about 30 minutes,
043529 - after the Pre-op Scheduler provides instructions to the patient.
043531 -  ..
043532 - Doctor Stewart ended the meeting, saying to wait in the hallway for a
043533 - few minutes to meet with Mike, the scheduling manager, who will
043534 - provide specific steps for pre-op tomorrow leading to surgery on
043535 - 091216.  After getting instructions from the Pre-op scheduler, go to
043536 - Radiology Department for the sonogram, and then everything will be
043537 - done for today.
043539 -  ..
043540 - Asked about submitting a letter to confirm understandings from the
043541 - meeting today which seem very complex.
043543 -  ..
043544 - Doctor Stewart explained that email is not an efficient way for
043545 - patients to expedite the work by verifing accuracy of communications
043546 - that avoid medical mistakes.  She noted that email from a patient may
043547 - take several weeks for response due to such a large volume of
043548 - correspondence.  Doctor Stewart proposed expediting work by calling
043549 - the General Surgery Department.  This aligns with Doctor Moini at Mt
043550 - Diablo hospital, reported on 020708. ref SDS 2 EY9N  This further
043551 - aligns with Dave Vannier's report on 950927 that email is the least
043552 - effective business system at Intel. ref SDS 1 4939
043553 -
043554 -
043555 -
043557 -  ..
0436 -
0437 -
0438 - 1344
0439 -
043901 - Waiting in the hallway to meet with Mike for pre-op schedule.  We can
043902 - see he has another patient in the office.  The scheduler says we will
043903 - be next in about 20 minutes.
043905 -  ..
043906 - Met Doctor Joe Enayati working at a desk in the hallway around the
043907 - corner from where we are waiting to see the pre-op scheduler.  Joe has
043908 - been transferred to General Surgery from Cardiothoracic (CT) surgery
043909 - team.  Joe seemed to indicate that he will be supporting surgery in
043910 - this case beginning on 091216, similar to his excellent work
043911 - recovering from heart surgery, as reported on 091031. ref SDS 11 I15I
043913 -  ..
043914 - This provides continuity of care between concerns presented during
043915 - recovery from heart surgery on 091022, and the new surgery on 091216.
043916 - There will also be good communication between surgery teams with Joe
043917 - facilitating the work in this case.  Joe's role reduces risks of
043918 - near-term complications following heart surgery on 091022, and so
043919 - supports signing the consent for this work, per above. ref SDS 0 DZ64
043920 -
043921 -
043922 -
043924 -  ..
0440 -
0441 -
0442 - 1415
0443 -
044301 - Mike, the Pre-op scheduler, walked by in the hallway checking on
044302 - something for the patient ahead of us.
044304 -  ..
044305 - Asked about going to Radiology for the sonogram test, since Doctor
044306 - Stewart negotiated getting the test done today at about this time, per
044307 - above. ref SDS 0 6F75
044309 -  ..
044310 - Mike apologized for delays, and said he expects to complete the
044311 - current patient in a few minutes, and can then do planning for the
044312 - surgery on 091216.  He feels therefore the patient should continue
044313 - waiting, rather than go get the sonogram test.
044314 -
044315 -
044317 -  ..
0444 -
0445 -
0446 - 1450
0447 -
044701 - Mike completes pre-op schedule work for the other patient.
044702 -
044703 - Begin meeting on pre-op schedule for surgery on 091216.
044705 -  ..
044706 - Mike reviews the record discussed with Doctor Stewart that the patient
044707 - does not need endoscopy test, manometry test, nor xray and EKG tests,
044708 - since these have already been done, per above. ref SDS 0 ED6F
044710 -  ..
044711 - The Pre-op scheduler advised that the patient must drive back to the
044712 - VA in San Francisco tomorrow for a lab, because the General Surgery
044713 - Department will not accept results of blood tests performed at other
044714 - VA facilities, at least for pre-op surgery evaluation.
044716 -  ..
044717 - Received a document...
044719 -         ..
044720 -        Preparing for Your Operation or Procedure
044721 -
044722 -
044723 -        1.  Patient history and physical examination, that supplments
044724 -            the work done today by Doctor Tabrizi and Doctor Stewart,
044725 -            per above. ref SDS 0 QB7H
044727 -             ..
044728 -        2.  Anesthesia pre-op clinic examination and orientation.
044730 -             ..
044731 -        3.  Ambulatory Surgical Unit (ASU) meeting for orientation
044732 -            with nurses.
044734 -             ..
044735 -        4.  Laboratory blood draw.
044736 -
044738 -  ..
0448 -
0449 -
0450 - 1514
0451 -
045101 - Completed work on pre-op schedule.
045102 -
045103 - Walked to Radiology on the 3rd floor.
045105 -  ..
045106 - Met with Irene.  She recalled work on 091030 performing sonogoram that
045107 - found DVT. ref SDS 10 1N5P
045109 -  ..
045110 - Irene said she expected to do this work an hour ago, based on telecon
045111 - with Doctor Stewart, per above. ref SDS 0 6F75
045113 -  ..
045114 - Explained delay getting Pre-op schedule, per above. ref SDS 0 D17F
045116 -  ..
045117 - Irene was busy with another patient, so Ping started the sonogram
045118 - test.
045120 -  ..
045121 - This took about 30 minutes.  Ping said that Doctor Stewart or Doctor
045122 - Tabrizi called and said they want to include the right arm in addition
045123 - to the right side of the neck where the DVT was found at the location
045124 - of the cordis catheter, reported on 091030. ref SDS 10 U24G
045126 -  ..
045127 - About half way through the test, Irene came back to assist Ping.
045129 -  ..
045130 - Irene advised that Doctor Tabrizi called again and said that pre-op
045131 - tasks scheduled by Mike for tomorrow, per above, ref SDS 0 6S50, have
045132 - been cancelled, and rescheduled to next Monday on 091214.  Rather than
045133 - go home, the patient must return to Module #2 General Surgery Clinic
045134 - to get the revised pre-op schedule.
045135 -
045137 -  ..
0452 -
0453 -
0454 - 1549
0455 -
045501 - When the sonogram test was completed, Ping indicated that the DVT
045502 - discovered in the test on 091030, ref SDS 10 KF5W, is no longer
045503 - visualized today.  The test finds no evidence of blood clots nor DVT
045504 - problems of any kind either in the neck, nor the expanded test area of
045505 - the right arm.
045507 -  ..
045508 - Irene called Doctor Tabrizi to report finings, which will be confirmed
045509 - in a written report from the Radiology Department.
045511 -  ..
045512 - Irene then said the doctor wants to speak with the patient.
045514 -  ..
045515 - Doctor Tabrizi explained that effective pre-op labs should show
045516 - findings of sufficient INR to enable surgery on 091216.  Since the
045517 - sonogram test today shows no evidence of DVT nor other blood clot
045518 - issues, Coumadin (warfarin) treatments can end today, per planning
045519 - with Doctor Stewart during the meeting earlier today, above.
045520 - ref SDS 0 C46I  However, stopping Coumadin today will take several
045521 - days for the blood to return to normal thickness needed for surgery.
045523 -  ..
045524 - Pre-op requires a lab showing INR in the range below 1.5.  Assuming
045525 - INR is currently above 2.0, which was the goal of Coumadin treatment
045526 - to prevent further blood clot issues, doing a lab tomorrow will not
045527 - provide an accurate evaluation of the condition on the day of surgery.
045528 - Therefore, Doctor Stewart wants to change pre-op labs from tomorrow to
045529 - 091214, to provide time for the effects of ending Coumadin today to
045530 - take effect.
045532 -  ..
045533 - Thanked Irene and Ping for doing the sonogram on short notice today,
045534 - and especally for the results that show the problem on 091030 is now
045535 - resolved.
045537 -  ..
045538 - Ending Coumadin today, eliminates the need for meeting with Diana at
045539 - the VA Coagulation Control Clinic in Martinez on 091214, which was
045540 - planned during the meeting with Diana on 091201. ref SDS 16 OS3N
045541 -
045542 -        [On 091211 1523 letter notifies medical team Coumadin is ended
045543 -        based on sonogram test finding no evidence of DVT nor blood
045544 -        clot problems of any kind, ref SDS 18 445Y; by copy notify
045545 -        Diana that meeting scheduled for 091214 to check INR and adjust
045546 -        Coumadin is not longer needed, and so can be cancelled.
045547 -        ref SDS 18 446W
045548 -
045549 -
045550 -
045552 -  ..
0456 -
0457 -
0458 - 1610
0459 -
045901 - Walked back to the General Surgery Clinic Module #2.  Met briefly with
045902 - Doctor Stewart and Doctor Tabrizi.  Mike submitted a corrected copy of
045903 - the following document, and showing all tasks scheduled on 091214...
045905 -         ..
045906 -        Preparing for Your Operation or Procedure
045907 -
045908 -
045909 -        1.  Patient history and physical examination, that supplments
045910 -            the work done today by Doctor Tabrizi and Doctor Stewart,
045911 -            per above. ref SDS 0 QB7H
045913 -             ..
045914 -            091214 1300................. Building 200 Clinic Module 2
045916 -             ..
045917 -        2.  Anesthesia pre-op clinic examination and orientation.
045918 -
045919 -            091214 1400................. Building 200 3rd floor 3A-122
045921 -             ..
045922 -        3.  Ambulatory Surgical Unit (ASU) meeting for orientation
045923 -            with nurses.
045925 -             ..
045926 -            091214 1400................. Building 200 3rd floor 3A-122
045927 -            (included with Anesthesia pre-op clinic visit)
045929 -             ..
045930 -        4.  Laboratory blood draw.
045931 -
045932 -            091214 1400................. Building 200 2nd floor 2B-113A
045934 -             ..
045935 -            Mike said to come early and get this done before coming to
045936 -            Module #2 Clinic at 1300; no specific time required.
045938 -  ..
045939 - Thanked Doctor Stewart and Doctor Tabrizi for expediting surgery on
045940 - 091216, for excellent coordination today getting everything scheduled,
045941 - and for waiting after-hours to complete schedule revisions.
045943 -  ..
045944 - Everything now seems lined up for a successful surgery project to
045945 - recover from achalasia on 091216.  This will transform negative
045946 - synergy to make nutrition a positive factor recovering from heart
045947 - surgery on 091022, and as planned by Doctor Ratcliffe on 091029.
045948 - ref SDS 9 RE7I
045950 -  ..
045951 - At this time there were no other patients nor attendants in either
045952 - Clinic Module #1 nor #2.  It was great working with a team dedicated
045953 - to the job rather than the clock.
045954 -
045955 -
045956 -
045957 -
045958 -
045959 -
045960 -
045961 -
045962 -
045963 -
0460 -