Welch Company
San Francisco, CA


S U M M A R Y


DIARY: December 19, 2009 06:00 AM Saturday; Rod Welch

Recovery at VA from Heller Myotomy surgery correct achalasia.

1...Summary/Objective


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CONTACTS 

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 36 0000. ref SDS 35 0000.
040502 -
040503 -
040504 -
040505 -
040506 -
040508 -  ..
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 24 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 25 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 27 935H
040909 -  ..
040910 - On 091208 Doctor Stewart advanced the schedule for surgery one day to
040911 - 091216. ref SDS 29 6E41
040913 -  ..
040914 - On 091216 0600 meeting Doctor Stewart for Heller Myotomy surgery to
040915 - correct achalasia; check in at ASU. ref SDS 34 PP8W
040917 -  ..
040918 - On 091217 0600 meeting with Joe and Jon on recovring from Heller
040919 - Myotomy surgery; report of complication during surgery on 091216,
040920 - which was repaired, with plan for test to evaluate recovery. reported
040921 - on 091217 0600, ref SDS 35 0042  Doctor Stewart visited and expects
040922 - can start eating after favorable test. ref SDS 35 027A
040924 -  ..
040925 - On 091218 0600 xray with gastrogafin to evaluate repair for
040926 - complicaiton during Heller Myotomoy surgery Wednesday, ref SDS 36 PP8W,
040928 -  ..
040929 - On 091219 0600 doctor plans discharge tomorrow after evaluating
040930 - progress eating solid food today. ref SDS 0 PP5V  Since now eating
040931 - solid food, switched to oral pill medication to replace IV injections;
040932 - this relieved pain that has been increasing using IV catheters set on
040933 - Wednesday, ref SDS 0 PQPX, and also eliminated need to replace IV
040934 - catheters per TCU protocol. ref SDS 0 7Q55  Doctors prescribed hiking
040935 - to recover from Heller Myotomy surgery resolving achalasia.
040936 - ref SDS 0 7Q6P   Doctor Ratcliffe and Neil visit and discussing doing
040937 - a small business trial to apply SDS technology for upgrading VA and
040938 - UCSF case management. ref SDS 0 0M6S  Nurse advises that patient
040939 - approved for moving to a ward for non-critical care, as a predicate to
040940 - discharge, but since there are no rooms available, patient will remain
040941 - in TCU untill a room is available. ref SDS 0 0M8S
040942 -
040943 -
040944 -
040946 -  ..
0410 -
0411 -
0412 - Progess
0413 -
041301 - Pain recovering from surgery, reported on 091217 0600. ref SDS 35
041302 - VX54, has been controlled with hourly medication, ref SDS 35 FT58, and
041303 - hiking.  Usually do 10 laps around the TCU ward, making about a mile.
041304 - Start slow, and by 2nd or 3rd lap pain subsides, and can hike faster.
041305 - Hiking 3 - 5 times per day, doing 10 laps, makes a total of 3 - 5
041306 - miles per day, based on experience following heart bypass surgery,
041307 - reported on 091029 0700. ref SDS 20 01F9
041309 -  ..
041310 - This morning things have improved enough to stop pain medication.  The
041311 - last treatment for pain was prior to hiking at about 0300.
041313 -  ..
041314 - Rose, the nurse, visits to take vitals and blood sugar.
041316 -  ..
041317 - She says everything looks excellent for strong recovery from surgery
041318 - on 091216.
041319 -
041321 -  ..
0414 -
0415 -
0416 - 0623
0417 -
041701 - Blood draw.
041702 -
041704 -  ..
0418 -
0419 -
0420 - 0745
0421 -
042101 - Two-person medical team arrives.  One is Steven.
042102 -
042103 - Lab results not yet available, from blood draw this morning.
042104 - ref SDS 0 0K5M
042106 -  ..
042107 - They seemed to say discharge is scheduled for tomorrow after a day
042108 - eating solid food today testing recovery from surgery, and following
042109 - favorable test showing patient can now eat solid food, reported on
042110 - 091218 0541. ref SDS 36 ER4F
042111 -
042112 -     [...below, follow up meeting doctors advise that since patient can
042113 -     eat solid food, medication can be taken with pills orally, rather
042114 -     through IV injections. ref SDS 0 0L90
042115 -
042117 -  ..
0422 -
0423 -
0424 - 0810
0425 -
042501 - Breakfast arrives.
042502 -
042503 - The two cans of Ensure ordered by Doctor Stewart yesterday were not
042504 - included.
042506 -  ..
042507 - Ate most of cream of wheat.
042509 -  ..
042510 - Drank a carton of apple juice.
042512 -  ..
042513 - Drank most of a cup of hot chocolate.
042514 -
042515 -
042517 -  ..
0426 -
0427 -
0428 - 0815
0429 -
042901 - After shift change, nursing team, Elizabeth and Danny, visit to take
042902 - vitals again.  Received simvistatin pill for chelosterol; switch to
042903 - oral treatment aligns with Doctor Stewart's order yesterday to end NPO
042904 - status, medications do not require IV injection, reported on 091218
042905 - 0541. ref SDS 36 FU5O
042907 -  ..
042908 - Elizabeth indicated she would be back later to give Metoprolol through
042909 - the IV catheter, and specified in the medication list received on
042910 - 091104 0718. ref SDS 25 UN6L
042912 -  ..
042913 - Discussed understandings with Doctor Stewart, attending physician for
042914 - Heller Myotomy surgery on 091216, that the patient can now consume
042915 - solid food, and so medications can be given orally, reported yesterday
042916 - on 091218 0541. ref SDS 36 ER4F
042918 -  ..
042919 - Elizabeth said this requires a doctor's order.  She asked why
042920 - Metoprolol should not be given through the IV?
042921 -
042922 -        [...below doctors confirm pill for oral medication can replace
042923 -        IV injection for giving Metoprolol. ref SDS 0 0L40
042925 -  ..
042926 - Reported rising pain getting injections of medication in both IV
042927 - catheters.  Since Thursday, all injections have been in the IV on the
042928 - inner right wrist, because the IV catheter on the left arm had become
042929 - problematic.  The next day, the same problem occurred with the IV in
042930 - the right wrist.  The IV in the right wrist has become increasingly
042931 - painful even when not getting injections.  Bending the wrist under
042932 - stress to lift, for example, the keyboard, using the keyboard and
042933 - mouse for daily work, getting out of bed and up from chairs by pushing
042934 - with the hands to sit up, and lifting the food tray to clear the
042935 - bedside table and make room for other tasks.  All minor, routine tasks
042936 - bending the right wrist, and which nobody even considers during the
042937 - normal day are increasingly painful due to the IV catheter in the
042938 - right wrist.
042940 -  ..
042941 - Challenges placing an IV catheter on the inner right wrist were
042942 - reviewed with Alex who set IV catheters prior to surgery on 091216
042943 - 0600. ref SDS 34 XK9N
042944 -
042945 -        [...below Elizabeth delivered Metoprolol pill for oral
042946 -        medication. ref SDS 0 0N5V
042948 -  ..
042949 - Elizabeth examined the IV catheter on the right wrist.  She said the
042950 - penetration point and surrounding tissue appears infected, and so the
042951 - IV must be removed.
042953 -  ..
042954 - Elizabeth further advised that TCU ward protocol requires replacing IV
042955 - catherters set by Alex on 091216 0600. ref SDS 34 KE8T  This aligns
042956 - with Joy's work while recovery from heart surgery in Telemetry (which
042957 - is part of TCU) on 091101, saying that IV catheters have to be
042958 - replaced after 4 or 5 days to maintain viability and prevent
042959 - infection. ref SDS 23 EW5J
042961 -  ..
042962 - Since discharge is planned for today or tomorrow, per Doctor Stewart
042963 - yesterday on 091218 0541, ref SDS 36 5E4K, decided to avoid expense
042964 - and inconvenience of added pain replacing IV catheters; they should
042965 - simply be removed per protocol to prevent infection, and not be
042966 - replaced.
042968 -  ..
042969 - Elizbeth noted that removing IV catheters without replacement reqires
042970 - a doctor's order, because the protocol for all patients in the TCU
042971 - requires having IV catheters in place for timely care in case of
042972 - emergencies.
042973 -
042974 -
042976 -  ..
0430 -
0431 -
0432 - 0831
0433 -
043301 - After Elizabeth and Danny left, noticed the two doctors who visited
043302 - this morning, were completing work with another patient across the
043303 - hallway.
043305 -  ..
043306 - Got up and walked over to visit, following up discussion at 0745 this
043307 - morning, per above. ref SDS 0 PP5V
043309 -  ..
043310 - Asked initially for business cards, so there is a record of
043311 - understandings on the work plan.
043313 -  ..
043314 - They both said they did not have business cards, but their contact
043315 - information can be obtained from the nursing staff.
043317 -  ..
043318 - The doctors concurred that Metoprolol and all other medications,
043319 - previously taken through IV injections, e.g., simvistatin, can now be
043320 - given orally, per visit with Elizabeth and Danny at 0815, shown above.
043321 - ref SDS 0 PQPX
043322 -
043323 -        [...below Elizabeth delivered Metoprolol pill for oral
043324 -        medication. ref SDS 0 0N5V
043326 -  ..
043327 - The doctors further agreed that since the patient is scheduled to be
043328 - released today or tomorrow, there is no reason to place a new IV
043329 - catheter, otherwise required by ward protocol, per above. ref SDS 0
043330 - 0L46
043332 -  ..
043333 - Reviewed issue of pain and bloating in the stomach following
043334 - laproscopic surgery on 091216.  Asked how long this might take to
043335 - recover from Heller Myotomy surgery for resolving achalasia?  On
043336 - 091030, Doctor Stewart had explained that the stomach was bloated to
043337 - make room for the surgical procedure on the lower esophageal
043338 - sphincter. ref SDS 21 GM5I
043340 -  ..
043341 - One of the doctor's said that medications reduce pain, and hiking is
043342 - the best therapy to recover from the bloating problem.  This aligns
043343 - with efforts to recover from heart surgery, reported on 091029 0700.
043344 - ref SDS 20 01F9
043345 -
043346 -
043348 -  ..
0434 -
0435 -
0436 - 0942
0437 -
043701 - Nursing team, Elizabeth and Danny, visit.
043702 -
043703 - She has talked to the doctor.  The doctor was not aware that the two
043704 - attending doctors this morning entered an order that the patient does
043705 - not require an IV catheter per ward protocol. as discussed above.
043706 -
043707 -
043709 -  ..
0438 -
0439 -
0440 - 1104
0441 -
044101 - Saw Doctor Ratcliffe and Neil in the hall through the doorway and
044102 - waved.  They are making rounds today in TCU examining other patients,
044103 - but came into the room for a 15 minute visit.
044105 -  ..
044106 - Doctor Ratcliffe asked about the current hospital stay?
044108 -  ..
044109 - Upon review, the doctor recalled discussions on 091029 about
044110 - performing surgery to correct the swallowing problem, ref SDS 20 RE6J,
044111 - which he emphasized at that time required correction in order to get
044112 - sufficient nutrition to recover from heart surgery on 091022.
044114 -  ..
044115 - Advised that Heller Myotomy surgery was performed on 091216 by Doctor
044116 - Stewart, planned by Paula to implement Doctor Ratcliffe's strategy on
044117 - 091030. ref SDS 21 5G9H  The CT team was notified in a letter that
044118 - schedule for Heller Myotomy surgery was advanced one day to 091216,
044119 - and that meeting to assess recovery from heart surgery could therefore
044120 - be performed in the hospital at a convenient time for the team,
044121 - reported on 091211 1523, ref SDS 30 448Q
044123 -  ..
044124 - Neil indicated that meeting today implements plans on 091119, for the
044125 - CT surgery team to review progress recovering from heart surgery.
044126 - ref SDS 27 FW6W  While we talked, Neil looked at the incision on the
044127 - right leg.  He noted the team has received lab reports on Heller
044128 - Myotomy surgery performed 2 days ago on 091216. ref SDS 34 KE8T   The
044129 - sonogram test on 091208, ref SDS 29 D26K, found full resolution of
044130 - blood clot (DVT) caused by cordis catheter. ref SDS 29 D24G  Neil
044131 - explained this record shows strong recovery from heart surgery on
044132 - 091022 0700. ref SDS 19 PQWU  As a result, discussed ending discharge
044133 - medications prescribed on 091104, to recover from heart surgery.
044134 - ref SDS 25 1Q6P  The team seemed aware that Doctor Stewart had already
044135 - ended treatment with warfarin (Coumadin), reported on 091208 1300.
044136 - ref SDS 29 D259
044138 -  ..
044139 - Today, we considered doing a clinical trial on case management with
044140 - tools and the doctor patient partnership that improves patient
044141 - ouctomes using a well organized record, explained in POIMS.
044142 - ref OF 3 1X6G
044144 -  ..
044145 - VA doctors and staff write excellent reports (Progress Notes) for
044146 - meetings, calls, and procedures.  The VA is far ahead of other health
044147 - care providers, and other organizations, including the private sector.
044148 - With patient assistance, Doctor Brezinski used the VA's computer
044149 - system to find patient history on Achalasia within a few minutes,
044150 - reported on 091022, ref SDS 19 JF54, and just in time to adjust
044151 - anesthesia in order to avoid complications during heart surgery.
044152 - ref SDS 19 GX4J
044154 -             ..
044155 -            [On 100305 1000 thanked Doctor Lee for good service, and
044156 -            requested a letter transmitting the doctor's report for
044157 -            incorporation into patient history. ref SDS 37 E18F
044159 -  ..
044160 - Doctor Margulies demonstrated excellent advantages of the VA computer
044161 - system for finding patient medical records that guide daily care for
044162 - patients, e.g., on...
044163 -
044164 -        070221 0819..................... ref SDS 13 5D88
044165 -        070226 1330..................... ref SDS 14 5D88
044167 -  ..
044168 - Of course at that time, Doctor Margulies was working with very few
044169 - records on the issue at hand, and so was not inundated with a high
044170 - volume of information.
044172 -  ..
044173 - Nobody on the planet, including the VA, can "connect the dots" for
044174 - context, causation, and alignment with prior events and authorities.
044175 - As records accumulate exponentially over days, weeks, and months of
044176 - medical care due to accelerating redundancy, nobody has time to
044177 - benefit from the power of knowledge recyclying intellectual capital,
044178 - explained in POIMS. ref OF 6 G15N  Chronology cannot be assembled for
044179 - particular subjects.  People have to read everything in order to
044180 - discover context on anything.  This was illustrated recently on
044181 - 091208, meeting with Doctor Stewart and Doctor Tabrizi, ref SDS 29
044182 - EQ6T, and previously meeting with Doctor Tseng on 091021. ref SDS 18
044183 - LJ7L
044185 -  ..
044186 - Poor access to chronology based on context required expending valuable
044187 - time presenting patient history on achalasia 14 times to 14 different
044188 - doctors, again reported on 091021 0716. ref SDS 18 LJ7L
044190 -  ..
044191 - Doctor Ratcliffe explained personal expertise and experience
044192 - developing computer systems for the VA using the Delphi programming
044193 - language.
044195 -  ..
044196 - Gary used Delphi at Boeing on the FCS project, reported in his record
044197 - on 030727 1006, ref SDS 7 UY88, and also, ref SDS 7 T563, and further
044198 - cited in the record on 030801 0554. ref SDS 8 J254
044200 -  ..
044201 - Doctor Ratcliffe's experience applying expertise performing medical
044202 - management to develop software tools reflects the process used for
044203 - creating the Schedule Diary System (SDS) program, reported on 010924
044204 - 0709. ref SDS 4 NK4J
044206 -  ..
044207 - Today, the doctor cited resistance to using technology for improving
044208 - patient outcomes with better case management.  Eight years ago, Tom
044209 - Munnecke was very discouraged feeling that the entire health care
044210 - system must collapse in order to make improvements, reported on 020911
044211 - 1434. ref SDS 6 KE5N  At that time on 020911, Tom related having
044212 - developed the VA's email system in the 1980s, but could not overcome
044213 - strong resistance to evolving more comprehensive support. ref SDS 6
044214 - T217
044216 -         ..
044217 -        [On 100305 1000 documentation on GI procedure illegible,
044218 -        ref SDS 37 HC7K, and doctor's report instantly accessible to VA
044219 -        staff, but patients have to get in the car and drive to the VA,
044220 -        get a printed copy and type it up for incorporation into the
044221 -        record of patient history to support doctor/patient
044222 -        partnership. ref SDS 37 HB49
044224 -  ..
044225 - Clearly, the VA has made progress since the 1980s, shown by ubiquitous
044226 - computers tracking patient diagnostics.  The next step is adding
044227 - intelligence that converts information into the power of knowledge,
044228 - explained in POIMS. ref OF 6 8555
044230 -  ..
044231 - Doctor Racliffe noted that rising emphasis the past 5 years on privacy
044232 - and confidentiallity discourages efforts to improve case management
044233 - with technology, because officials fear being called before Congress
044234 - to explain how patient records are made public, when people accidently
044235 - or purposefully disclose records on other patients and without
044236 - approval.  Worry about accountability from even slight lapses in
044237 - confidentiality, causes authorities to refuse approval for
044238 - improvements in health care from sharing patient medical records
044239 - within the team care model.
044241 -  ..
044242 - Competing forces are changing negative attitudes, toward positive
044243 - efforts to save lives, time, and money by automating medical records
044244 - for efficient case management through coordination and collaboration.
044245 - Synergy between team care and Kaiser's doctor/patient partnership
044246 - model provide a way forward, reviewed on 990625 0945. ref SDS 2 4185
044248 -  ..
044249 - Until now, case management driven by unreasoned and improper use of
044250 - HIPAA regulations has created extreme practices for confidentiallity
044251 - and privacy that resist electronic access to accurate patient records.
044252 - This causes poor case management of patient history that reduces
044253 - quality of health care, shown by national reporting on 990912 that
044254 - inaccurate, untimely communication is the biggest cause of medical
044255 - mistakes. ref SDS 3 0001  Case study on Millie's care at Kaiser gives
044256 - 160 examples of opportunities and urgency to improve care with timely,
044257 - accurate medical records, reported on 040416 1045. ref SDS 9 GN7J
044259 -  ..
044260 - Misguided use of HIPAA to resist efficient case management was evident
044261 - at UCSF, when the Director of Security confiscated a customer computer
044262 - from the cafeteria that was unattended for 10 minutes, reported on
044263 - 080529 0830. ref SDS 17 LD7L, and without any substantive grounds
044264 - because UCSF had been selling patient records to a marketing firm and
044265 - so when this came to light with articles in the press, ref SDS 17
044266 - 526J, UCSF over-reacted by preventing patients from enabling providers
044267 - with timely, accurate records.
044269 -  ..
044270 - Improper application of HIPAA regulations caused by extreme fear and
044271 - caution elevates confidentiality above more critical requirements for
044272 - productivity to save lives, time, and money delivering health care to
044273 - more patients, expecially the elderly, cited at UCSF on 080529 0830.
044274 - ref SDS 17 6O6F  Misuse of HIPAA drives staff to improper and legally
044275 - questionable conduct, illustrated at Kaiser on 071009 1644.
044276 - ref SDS 15 JW7M
044278 -  ..
044279 - Today, more people are becoming comfortable and expect benefits of
044280 - sharing timely, accurate information through public data base
044281 - environments like email, Facebook, and blogs.  This provides
044282 - opportunity to get permision from patients for efficient capture and
044283 - use of medical records for saving lives, time, and money.
044285 -  ..
044286 - Additionally, the national initiative in Congress to improve
044287 - productivity in health care through computerized medical records is
044288 - driven by objectives to reduce costs and expand care.  As people gain
044289 - confidence in benefits of better care and reduced costs, attitudes
044290 - will change that currently resist innovation.
044292 -  ..
044293 - The period ahead is therefore more conducive than the past 5 years to
044294 - using technology combined with staffing and work practices that
044295 - improve quality of care and reduce costs.  Favorable experience the
044296 - past 10 years on Millie's at Kaiser, UCSF, and recently for Rod at the
044297 - VA presents evidence that federal authorities might be receptive to a
044298 - proposal on studying SDS solutions for a "well ordered record" that
044299 - save lives, time, and money by lifting productivity of communications.
044300 - "Well ordered records" leverage time and context by integrating
044301 - chronology and connections, explained in POIMS. ref OF 6 8555
044303 -  ..
044304 - Ideally, we could do a joint project with UCSF, since the VA has
044305 - strong history of collaboration with UCSF, and SDS has common
044306 - application for case management.
044308 -  ..
044309 - Discussion with the medical team on 091029, concerning the feeding
044310 - tube issue, illustrates the premis proposal to be studied and
044311 - demonstrated. ref SDS 20 RE81
044313 -  ..
044314 - The doctor is concerned that UCSF is way behind developing automated
044315 - records to increase productivity of case management.  This is evident
044316 - from Millie's case, reported by Doctor Rugo on 080219 1100.
044317 - ref SDS 16 L18L
044319 -  ..
044320 - We considered that UCSF will move forward sometime; next week, next
044321 - month; next year, in 5 years.
044323 -  ..
044324 - Doctor Ratcliffe indicated he would like to see an initial submittal
044325 - outlining a grant proposal.
044327 -  ..
044328 - Neil said to send the proposal to Ramone, who will then make
044329 - appropriate distribution.  He advised that the team has received prior
044330 - communications, most recently on 091215 1017. ref SDS 32 5R5H
044331 -
044332 -
044333 -
044335 -  ..
0444 -
0445 -
0446 - 1201
0447 -
044701 - Elizabeth reports that an order has been placed for moving to another
044702 - ward that has reduced standards for IV catheters, because patients are
044703 - fully mobile and communicating (she seemed say "walking and talking"),
044704 - and so getting ready for discharge.
044706 -  ..
044707 - At this time, however, that particular ward is full, so for the time
044708 - being, will remain in TCU.
044709 -
044711 -  ..
0448 -
0449 -
0450 - 1642
0451 -
045101 - Elizabeth visits to do vitals.
045102 -
045103 - She reports notifying Doctor Brock (spelling??) that IV catherters are
045104 - scheduled to be changed according to VA protocol for the TCU ward.
045105 - The doctor said to follow protocol.
045107 -  ..
045108 - As a result, she said that Metoprolol would be given by IV on the
045109 - right wrist.
045111 -  ..
045112 - Elizabeth confirmed schedule to transfer the patient to another ward
045113 - that does not require IV catheters, but that transfer is delayed
045114 - because there are no rooms available at this time, per above.
045115 - ref SDS 0 0M8S
045117 -  ..
045118 - Since this is the end of care for Heller Myotomy surgery, and since
045119 - simvistatin cholesterol medication is now being given orally with
045120 - pills, and since the IV catheter on the right wrist no longer works
045121 - correctly, causing pain during injections, refused this procedure.
045123 -  ..
045124 - Elizabeth removed the IV catheter in the left arm.  She reports the
045125 - element appears clear and without any evident cause for mal-function
045126 - to account for poor performance.
045128 -  ..
045129 - Received daily dose of Metoprolol.  This is half a pill for oral
045130 - medication, per discussion this morning, ref SDS 0 0L58, and required
045131 - by the medical chart on 091104 0718. ref SDS 25 UN6L
045132 -
045134 -  ..
0452 -
0453 -
0454 - 1718
0455 -
045501 - Dinner arrived.
045502 -
045503 - Main dish is stew with carrots, potatoes, meat and some other stuff.
045505 -  ..
045506 - Ate some of each, in total about 4 or 5 bites, and everything seemed
045507 - to go down okay.
045509 -  ..
045510 - There is some kind of soup.  Had 5 or 6 spoonfulls of soup.
045512 -  ..
045513 - Canned spinach was served; had only a bite of this.
045515 -  ..
045516 - Got another can of Ensure.  Had this last.  There was a sensation of
045517 - liquid flowing into the stomach, which is a wonderful new feeling
045518 - because it indicates that everything swallowed before the Ensure had
045519 - also gone into the stomach, rather than get clogged in the throat.
045520 -
045521 -
045523 -  ..
0456 -
0457 -
0458 - 1728
0459 -
045901 - Went for a hike to help digest dinner.
045902 -
045903 - Near the end of the first lap, a nurse at a control station asked to
045904 - change some of the leads for the heart monitor.  She complained that
045905 - while hiking, her computer beeps and this is very distracting for her
045906 - work.  The nurse changed several leads.  Initially she did not remove
045907 - the ones replaced.  Asked her to go ahead and remove them as well.
045908 - She asked if this should be done quickly, or slowly.  Decided on
045909 - quickly.  One caused considerable discomfort because of chest hair.
045910 - The other 2 or 3 were less troubling.
045912 -  ..
045913 - Experimented to see if this solved the problem, and found the beeping
045914 - continued.
045916 -  ..
045917 - Elizabeth who was sitting in an adjacent chair suggested putting the
045918 - remote control unit in the pocket of pajamas, rather than hold it in
045919 - a hand.  Tried this.  Beeping continued, but the nurse and Elizabeth
045920 - felt this was a reduced volume, which is more tolerable.
045922 -  ..
045923 - Suggested that while hiking laps in the ward, that the remote control
045924 - unit be disconnected and left in the room.  This would eliminate
045925 - beeping entirely.  Since the unit cannot send data during the hike,
045926 - there would no loss of data.
045928 -  ..
045929 - Elizabeth advised that since ward protocol requires the patient to
045930 - have the remote control active at all times, it should not be
045931 - disconnected.  She advised that since she compromised on removing the
045932 - IV catheter on the left arm, and not using the IV catheter on the
045933 - right wrist to inject Metoprolol, the patient should compromise and
045934 - not insist on holding the romote control while hiking.
045936 -  ..
045937 - Agreed to this compromise.  The nurse, and Elizabeth go off shift in
045938 - an hour or so, and can work out procedures with the night folks.
045939 -
045941 -  ..
0460 -
0461 -
0462 - 1823
0463 -
046301 - Doctor Bzrezinski came into the room looking for the patient, Joe, who
046302 - had surgery yesterday, reported on 091218 0541. ref SDS 36 SN9I and
046303 - was later moved to another ward. ref SDS 36 JQ4F
046305 -  ..
046306 - The doctor remembered work on 091022 providing anesthesia medical
046307 - services for heart bypass surgery (CABG).  Thanked him for excellent
046308 - work, reported on 091022 0700. ref SDS 19 LN6F  Cited Doctor
046309 - Brzezinski's research on patient history that helped shape procedures
046310 - to handle achalasia. ref SDS 19 3W6L
046312 -  ..
046313 - Asked if his paper on setting IVs has been published, also, discussed
046314 - on 091022. ref SDS 19 LN88
046316 -  ..
046317 - The doctor apologized for not following up on submitting his paper.
046318 - He seemed to say it has not yet been published, but was cited in a
046319 - recent CNN report on medical advances.
046321 -  ..
046322 - Research found that Doctor Brzezinski has been awarded a grant for
046323 - $250K funded jointly by DOD and VA to perform a 2-year study on care
046324 - for veterans suffering Post Traumatic Stress Disorder (PTSD); however,
046325 - nothing in this publicity release indicates advances or solutions to
046326 - problems setting difficult IV catheters, cited by the doctor on 091022
046327 - 0700. ref SDS 19 LN88
046329 -         ..
046330 -        UCSF Headlines
046332 -         ..
046333 -        Assistant Clinical Professor Marek Brzezinski Receives Grant
046334 -        to Study PTSD
046335 -
046336 -              http://anesthesia.ucsf.edu/extranet/home/defaultnoflash.php?page=message199
046338 -         ..
046339 -        The two-year, $250,000 joint Department of Veteran's Affairs
046340 -        and Department of Defense grant will fund Dr. Brzezinski's
046341 -        research on the "Effect of Prophylactic, Perioperative
046342 -        Propranolol on Reduction in Peri- and Postoperative
046343 -        Complications in Patients with Post Traumatic Stress
046344 -        Disorder". Dr. Brzezinski's work raises important questions
046345 -        about the care of patients with PTSD. According to Dr.
046346 -        Brzezinski, "This is the first research to examine the
046347 -        mortality of patients with PTSD after surgery".
046349 -         ..
046350 -        With the number of veterans with the condition only due to
046351 -        increase, Dr. Brzezinski's research takes a much needed step
046352 -        towards understanding its effects on patient outcomes.
046353 -        As he states, "It's important for physicians to treat PTSD not
046354 -        only as a mental condition, but also as an independent risk
046355 -        factor for other health problems". Dr. Brzezinski's
046356 -        collaborators and mentors in this work include VA
046357 -        Anesthesiologists Drs. Art Wallace and Brian Cason as well as
046358 -        Dr. Charles Marmar in the Department of Psychiatry.
046360 -  ..
046361 - Another article...
046362 -
046363 -        CNN Health
046364 -
046365 -        PTSD linked to higher post-surgery death rate
046366 -
046367 -              http://www.cnn.com/2009/HEALTH/10/20/ptsd.veterans.mortality/index.html
046369 -         ..
046370 -        By Elizabeth Landau, CNN
046371 -        October 24, 2009 4:32 p.m. EDT
046373 -         ..
046374 -        New Orleans, Louisiana (CNN)  -- Post-traumatic stress
046375 -        disorder may be a condition of the mind, but research has
046376 -        implicated it in the ills of the body. Now, a new study
046377 -        suggests it may be associated with death after surgery.
046379 -         ..
046380 -        The study shows that veterans with PTSD were more likely to
046381 -        die within a year after surgery than those without the
046382 -        disease, regardless of how many years had passed since their
046383 -        service. The study was presented at the annual meeting of the
046384 -        American Society of Anesthesiologists this week.
046386 -         ..
046387 -        This is the first research to examine the mortality of
046388 -        patients with PTSD after surgery, said study author Dr. Marek
046389 -        Brzezinski, anesthesiologist and assistant professor at the
046390 -        University of California, San Francisco.
046391 -
046392 -        "If you consider that perhaps more and more patients are
046393 -        coming, and they're going to be with us for years to come,
046394 -        this is obviously a huge field that needs to be addressed," he
046395 -        said.
046396 -
046397 -        ....
046399 -         ..
046400 -        One year after surgery, 8.5 percent of the patients with PTSD
046401 -        had died, compared with 6.8 percent of patients who did not
046402 -        have the psychiatric disorder, representing a 25 percent
046403 -        increased risk for those with PTSD. The researchers did not
046404 -        find substantial differences in mortality among the kinds of
046405 -        surgeries that patients had.
046406 -
046407 -
046408 -
046409 -
046411 -  ..
0465 -
0466 -
0467 - 1937
0468 -
046801 - The elderly neighbor who has been complaining of constant pain,
046802 - reported yesterday on 091218 0541. ref SDS 36 ZQ67 was moved to a
046803 - private room for increased care.
046804 -
046806 -  ..
0469 -
0470 -
0471 - 2014
0472 -
047201 - Went hiking.  Asked the nurse at the control station who has been
047202 - assigned for the night shift to take over for Elizabeth.  The nurse
047203 - said she has this watch tonight.
047205 -  ..
047206 - Reviewed objective to remove the IV catheter on the inner right wrist,
047207 - as Elizabeth removed the one on the left arm earlier today, per above.
047208 - ref SDS 0 0N51
047210 -  ..
047211 - The night nurse is Saida.
047213 -  ..
047214 - Saida planned to check with the charge nurse and contact the doctor
047215 - on call tonight for guidance.
047217 -  ..
047218 - Hiking felt really good this evening; there was no pain of any kind,
047219 - despite not having pain medication since 0300 yesterday morning.  As a
047220 - result, increased speed comparable to hiking the hills at Lafayette
047221 - Reservoir.
047223 -  ..
047224 - About the 7th lap, saw Saida consulting with the charge nurse in the
047225 - hallway near the control station.  She said pulse was showing 180 on
047226 - the heart monitor system.
047227 -
047229 -  ..
0473 -
0474 -
0475 - 2048
0476 -
047601 - On the 9th lap, Saida said the doctor wants the patient to stop
047602 - hiking, and will visit to review IV issue.  The doctor also ordered
047603 - an EKG.
047605 -  ..
047606 - Went into the room.  About 5 minutes later, another nurse brought the
047607 - EKG equipment for the test.  Saida came and assisted with the EKG
047608 - test.  This took about 10 minutes.
047609 -
047611 -  ..
0477 -
0478 -
0479 - 2103
0480 -
048001 - Saida takes vitals.
048002 -
048003 - Pulse shows 76.  If pulse while hiking 10 to 15 minutes ago was 180,
048004 - then this is remarkable recovery, indicating a strong heart.
048006 -  ..
048007 - EKG test shows perfect sinus, meaning heart rythm.
048008 -
048010 -  ..
0481 -
0482 -
0483 - 2110
0484 -
048401 - Doctor arrives.  This is Steve, who was part of the medical team this
048402 - morning, per above. ref SDS 0 PP5V
048404 -  ..
048405 - He is concerned about pulse increasing to 180 while hiking, per above.
048406 - ref SDS 0 NS5T
048408 -  ..
048409 - Considered prospect that pulse may not be registering accurately
048410 - while hiking laps throughout the ward.
048412 -  ..
048413 - The doctor is concerned that a patient having heart bypass surgery
048414 - should not do activity that elevates heart rate to 180 just 2 months
048415 - after the procedure on 091022.
048417 -  ..
048418 - Reviewed patient history showing the CT surgery team encouraged hiking
048419 - as the best therapy to recover from heart surgery.  For 2 weeks after
048420 - surgery and until 091104, the CT surgery team was aware from observing
048421 - the patient hiking at the same route 3 - 5 miles per day, that has
048422 - caused concern today.
048424 -  ..
048425 - The doctor then recalled that his colleage said this morning that
048426 - hiking is also the best way to recover from Heller Myotomy surgery,
048427 - per above. ref SDS 0 7Q6P
048429 -  ..
048430 - Under the circumstances to be a good partner, agreed not to hike any
048431 - more on this shift.  This will be a significant break from patient
048432 - history the past 4 days, but provides comfort to the medical team.
048434 -  ..
048435 - The doctor further ordered removal of the IV catheter in the inner
048436 - right wrist, because it shows signs of infection, and failure,
048437 - reported earlier today, per above. ref SDS 0 0L6R and TCU protocol
048438 - requires removal after 5 days, also, per above, ref SDS 0 0L46, and
048439 - this is the 5th day.
048441 -  ..
048442 - The doctor further ordered that the patient continue staying in the
048443 - TCU department for monitoring heart rate, reported elevated per above.
048444 - ref SDS 0 NS5T  This seems to change the schedule for moving to
048445 - another less critical ward when a room becomes available, per
048446 - Elizabeth, above. ref SDS 0 0N42
048447 -
048449 -  ..
0485 -
0486 -
0487 - 2119
0488 -
048801 - Saida removed the IV catheter in the inner wrist of the right arm.
048802 -
048803 -
048804 -
048805 -
048806 -
048807 -
048808 -
048809 -
048810 -
0489 -