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


S U M M A R Y


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

Recovery at VA from Heller Myotomy surgery correct achalasia.

1...Summary/Objective
2...Meeting CT Surgery Team Final Examination Discuss Clinical Trial


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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 - Meeting CT Surgery Team Final Examination Discuss Clinical Trial                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
044102 - 
044103 - Saw Doctor Ratcliffe and Neil in the hall through the doorway and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
044104 - waved.  They came into the room and explained making rounds today, in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044105 - TCU examining other patients.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
044107 -  ..
044108 - Doctor Ratcliffe asked about the current hospital stay?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
044110 -  ..
044111 - Upon review, the doctor recalled discussions on 091029 about                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
044112 - performing surgery to correct the swallowing problem, ref SDS 20 RE6J,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
044113 - which he emphasized at that time required correction in order to get                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044114 - sufficient nutrition to recover from heart surgery on 091022.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
044116 -  ..
044117 - Advised that Heller Myotomy surgery was performed on 091216 by Doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044118 - Stewart, planned by Paula to implement Doctor Ratcliffe's strategy on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044119 - 091030. ref SDS 21 5G9H  The CT team was notified in a letter that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
044120 - schedule for Heller Myotomy surgery was advanced one day to 091216,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044121 - and that meeting to assess recovery from heart surgery could therefore                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044122 - be performed in the hospital at a convenient time for the team,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
044123 - reported on 091211 1523, ref SDS 30 448Q                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
044125 -  ..
044126 - Neil indicated that meeting today, implements plans on 091119, for the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044127 - CT surgery team to review progress recovering from heart surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
044128 - ref SDS 27 FW6W  While we talked, Neil looked at the incision on the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
044129 - right leg.  He noted the team has received lab reports on Heller                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044130 - Myotomy surgery performed 2 days ago on 091216. ref SDS 34 KE8T   The                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044131 - sonogram test on 091208, ref SDS 29 D26K, found full resolution of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
044132 - blood clot (DVT) caused by cordis catheter. ref SDS 29 D24G  Neil                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
044133 - explained this record shows strong recovery from heart surgery on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
044134 - 091022 0700. ref SDS 19 PQWU  As a result, discussed ending discharge                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044135 - medications prescribed on 091104, to recover from heart surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044136 - ref SDS 25 1Q6P  The team seemed aware that Doctor Stewart had already                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
044137 - ended treatment with warfarin (Coumadin), reported on 091208 1300.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044138 - ref SDS 29 D259                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044140 -  ..
044141 - Neil adivsed that examination today ends care for heart surgery                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
044142 - performed on 091022.  The team finds the patient has recovered well,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044143 - so no further follow up treatment required.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044145 -  ..
044146 - Mark noted this was a very good outcome for CABG x4 surgery with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044147 - complications from achalasia and DVT, and cited effective doctor                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044148 - patient collaboration in this case.  Work with the team on 091030,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044149 - illustrates leveraging medical expertise and experience to aid                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
044150 - outcomes. ref SDS 21 03GF                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
044152 -             ..
044153 -            [On 100928 0706 medcal chart shows no record of meeting                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044154 -            today for follow examination. ref SDS 38 5S6H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
044156 -  ..
044157 - Today, we considered doing a clinical trial on case management with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044158 - tools and the doctor patient partnership that improves patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
044159 - ouctomes using a well organized record, explained in POIMS.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044160 - ref OF 3 1X6G                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044162 -  ..
044163 - VA doctors and staff write excellent reports (Progress Notes) for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
044164 - meetings, calls, and procedures.  The VA is far ahead of other health                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044165 - care providers, and other organizations, including the private sector.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044166 - With patient assistance, Doctor Brezinski used the VA's computer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044167 - system to find patient history on Achalasia within a few minutes,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
044168 - reported on 091022, ref SDS 19 JF54, and just in time to adjust                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044169 - anesthesia in order to avoid complications during heart surgery.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044170 - ref SDS 19 GX4J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044172 -             ..
044173 -            [On 100305 1000 thanked Doctor Lee for good service, and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
044174 -            requested a letter transmitting the doctor's report for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044175 -            incorporation into patient history. ref SDS 37 E18F                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044177 -  ..
044178 - Doctor Margulies demonstrated excellent advantages of the VA computer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044179 - system for finding patient medical records that guide daily care for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044180 - patients, e.g., on...                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044181 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
044182 -        070221 0819..................... ref SDS 13 5D88                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
044183 -        070226 1330..................... ref SDS 14 5D88                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
044185 -  ..
044186 - Of course at that time, Doctor Margulies was working with very few                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044187 - records on the issue at hand, and so was not inundated with a high                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044188 - volume of information.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044190 -  ..
044191 - Nobody on the planet, including the VA, can "connect the dots" for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044192 - context, causation, and alignment with prior events and authorities.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044193 - As records accumulate exponentially over days, weeks, and months of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044194 - medical care due to accelerating redundancy, nobody has time to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
044195 - benefit from the power of knowledge recyclying intellectual capital,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044196 - explained in POIMS. ref OF 6 G15N  Chronology cannot be assembled for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044197 - particular subjects.  People have to read everything in order to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044198 - discover context on anything.  This was illustrated recently on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
044199 - 091208, meeting with Doctor Stewart and Doctor Tabrizi, ref SDS 29                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
044200 - EQ6T, and previously meeting with Doctor Tseng on 091021. ref SDS 18                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
044201 - LJ7L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044203 -  ..
044204 - Poor access to chronology based on context required expending valuable                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044205 - time presenting patient history on achalasia 14 times to 14 different                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044206 - doctors, again reported on 091021 0716. ref SDS 18 LJ7L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
044208 -  ..
044209 - Doctor Ratcliffe explained personal expertise and experience                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
044210 - developing computer systems for the VA using the Delphi programming                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044211 - language.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
044213 -  ..
044214 - Gary used Delphi at Boeing on the FCS project, reported in his record                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044215 - on 030727 1006, ref SDS 7 UY88, and also, ref SDS 7 T563, and further                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
044216 - cited in the record on 030801 0554. ref SDS 8 J254                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
044218 -  ..
044219 - Doctor Ratcliffe's experience applying expertise performing medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044220 - management to develop software tools reflects the process used for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044221 - creating the Schedule Diary System (SDS) program, reported on 010924                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044222 - 0709. ref SDS 4 NK4J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
044224 -  ..
044225 - Today, the doctor cited resistance to using technology for improving                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044226 - patient outcomes with better case management.  Eight years ago, Tom                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044227 - Munnecke was very discouraged feeling that the entire health care                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
044228 - system must collapse in order to make improvements, reported on 020911                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044229 - 1434. ref SDS 6 KE5N  At that time on 020911, Tom related having                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044230 - developed the VA's email system in the 1980s, but could not overcome                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044231 - strong resistance to evolving more comprehensive support. ref SDS 6                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
044232 - T217                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044234 -         ..
044235 -        [On 100305 1000 documentation on GI procedure illegible,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044236 -        ref SDS 37 HC7K, and doctor's report instantly accessible to VA                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
044237 -        staff, but patients have to get in the car and drive to the VA,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044238 -        get a printed copy and type it up for incorporation into the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044239 -        record of patient history to support doctor/patient                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
044240 -        partnership. ref SDS 37 HB49                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
044242 -  ..
044243 - Clearly, the VA has made progress since the 1980s, shown by ubiquitous                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044244 - computers tracking patient diagnostics.  The next step is adding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044245 - intelligence that converts information into the power of knowledge,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044246 - explained in POIMS. ref OF 6 8555                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
044248 -  ..
044249 - Doctor Racliffe noted that rising emphasis the past 5 years on privacy                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044250 - and confidentiallity discourages efforts to improve case management                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044251 - with technology, because officials fear being called before Congress                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044252 - to explain how patient records are made public, when people accidently                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044253 - or purposefully disclose records on other patients and without                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
044254 - approval.  Worry about accountability from even slight lapses in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044255 - confidentiality, causes authorities to refuse approval for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
044256 - improvements in health care from sharing patient medical records                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044257 - within the team care model.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044259 -  ..
044260 - Competing forces are changing negative attitudes, toward positive                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
044261 - efforts to save lives, time, and money by automating medical records                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044262 - for efficient case management through coordination and collaboration.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044263 - Synergy between team care and Kaiser's doctor/patient partnership                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
044264 - model provide a way forward, reviewed on 990625 0945. ref SDS 2 4185                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        
044266 -  ..
044267 - Until now, case management driven by unreasoned and improper use of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044268 - HIPAA regulations has created extreme practices for confidentiallity                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044269 - and privacy that resist electronic access to accurate patient records.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044270 - This causes poor case management of patient history that reduces                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044271 - quality of health care, shown by national reporting on 990912 that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044272 - inaccurate, untimely communication is the biggest cause of medical                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044273 - mistakes. ref SDS 3 0001  Case study on Millie's care at Kaiser gives                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044274 - 160 examples of opportunities and urgency to improve care with timely,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044275 - accurate medical records, reported on 040416 1045. ref SDS 9 GN7J                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
044277 -  ..
044278 - Misguided use of HIPAA to resist efficient case management was evident                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044279 - at UCSF, when the Director of Security confiscated a customer computer                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044280 - from the cafeteria that was unattended for 10 minutes, reported on                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044281 - 080529 0830. ref SDS 17 LD7L, and without any substantive grounds                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
044282 - because UCSF had been selling patient records to a marketing firm and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044283 - so when this came to light with articles in the press, ref SDS 17                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           
044284 - 526J, UCSF over-reacted by preventing patients from enabling providers                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044285 - with timely, accurate records.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    
044287 -  ..
044288 - Improper application of HIPAA regulations caused by extreme fear and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044289 - caution elevates confidentiality above more critical requirements for                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044290 - productivity to save lives, time, and money delivering health care to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044291 - more patients, expecially the elderly, cited at UCSF on 080529 0830.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044292 - ref SDS 17 6O6F  Misuse of HIPAA drives staff to improper and legally                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044293 - questionable conduct, illustrated at Kaiser on 071009 1644.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044294 - ref SDS 15 JW7M                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044296 -  ..
044297 - Today, more people are becoming comfortable and expect benefits of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044298 - sharing timely, accurate information through public data base                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
044299 - environments like email, Facebook, and blogs.  This provides                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
044300 - opportunity to get permision from patients for efficient capture and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044301 - use of medical records for saving lives, time, and money.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         
044303 -  ..
044304 - Additionally, the national initiative in Congress to improve                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
044305 - productivity in health care through computerized medical records is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044306 - driven by objectives to reduce costs and expand care.  As people gain                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044307 - confidence in benefits of better care and reduced costs, attitudes                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044308 - will change that currently resist innovation.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
044310 -  ..
044311 - The period ahead is therefore more conducive than the past 5 years to                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044312 - using technology combined with staffing and work practices that                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
044313 - improve quality of care and reduce costs.  Favorable experience the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044314 - past 10 years on Millie's cancer care at Kaiser, UCSF, and recently                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044315 - for Rod at the VA presents evidence that federal authorities might be                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044316 - receptive to a proposal on studying SDS solutions for a "well ordered                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044317 - record" that save lives, time, and money by lifting productivity of                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044318 - communications. "Well ordered records" leverage time and context by                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044319 - integrating chronology and connections, explained in POIMS.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044320 - ref OF 6 8555                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044322 -  ..
044323 - Ideally, we could do a joint project with UCSF, since the VA has                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044324 - strong history of collaboration with UCSF, and SDS has common                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
044325 - application for case management.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044327 -  ..
044328 - Discussion with the medical team on 091029, concerning the feeding                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044329 - tube issue, illustrates the premis to be studied and demonstrated.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                
044330 - ref SDS 20 RE81                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044332 -  ..
044333 - Doctor Ratcliffe is concerned that UCSF is way behind developing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
044334 - automated records to increase productivity of case management.  This                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044335 - is evident from Millie's case, reported by Doctor Rugo on 080219 1100.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044336 - ref SDS 16 L18L                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044338 -  ..
044339 - We considered that UCSF will move forward sometime; next week, next                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               
044340 - month; next year, in 5 years.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     
044342 -  ..
044343 - Doctor Ratcliffe indicated he would like to see an initial submittal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
044344 - outlining a grant proposal.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       
044346 -  ..
044347 - Neil said to send the proposal to Ramone, who will then make                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
044348 - appropriate distribution.  He advised that the team has received prior                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
044349 - communications through Ramone, most recently on 091215 1017.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      
044350 - ref SDS 32 5R5H                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             
044351 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
044352 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
044353 -                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
044355 -  ..
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 -