CONTACTS 

SUBJECTS
INR 6.4 Blood Test 061214 Very High Danger Risk Hemorraging Contiual

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 7 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - INR 5.8 Medication Conflict Nortriptyline Acyclovir Prednisone
040902 -
040903 - Follow up ref SDS 7 KE5I.
040904 -
040905 - On 100202 0830 Millie had a blood draw at Kaiser in Martinez.
040906 - ref SDS 6 AS5H
040908 -  ..
040909 - On 100202 1927 Laurie called yesterday evening and reported INR 5.8,
040910 - ref SDS 7 KE5I, for Millie's blood draw at 0830. ref SDS 6 848J  Since
040911 - this is 100% above Kaiser's range of safety for controlling Millie's
040912 - pulmonary embolism, Laurie said that Gloria, the case manager for
040913 - Millie's Coumadin treatments, will call today with instructions for
040914 - adjusting Coumadin. ref SDS 7 KW6Q
040916 -  ..
040917 - On 100203 1023 Gloria, Case Manager Kaiser Coagulation Control Clinic,
040918 - called to order changes in Millie's Coumadin, ref SDS 0 QJ85, and also
040919 - ordered an interim blood draw on Friday to retest INR in order to
040920 - further adjust Coumadin on Friday, 100205. ref SDS 0 NT5T
040921 -
040923 -  ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Gloria called this morning.  She is Millie's case manager for warfarin
041302 - (Coumadin) treatments to prevent pulmonary embolism, and works in
041303 - Kaiser's Coagulation Control Clinic in Martinez.
041305 -  ..
041306 - Gloria received Millie's letter to the medical team sent last night on
041307 - 100202 2317. ref SDS 8 PPVX and reporting Laurie's call on 100202
041308 - 1927. ref SDS 7 KE5I, advising INR 5.8 in the lab yesterday on 100202
041309 - 0830, ref SDS 6 848J, requires adjustments to Millie's Coumadin, also
041310 - reported on 100202 2317. ref SDS 8 OH3Q, and that Gloria would call
041311 - this morning, reported earlier on 100202 1927. ref SDS 7 KW6Q
041313 -  ..
041314 - Gloria further advised that Kaiser Coagulation Control Clinic received
041315 - Millie's letter on 100128, reporting that Doctor Johnson prescribed
041316 - Nortriptyline to help Millie sleep, ref SDS 5 FM4W, and asking for
041317 - guidance on adjusting Coumadin to maintain INR within the range for
041318 - required for safely treating Millie's pulmonary embolism. ref SDS 5
041319 - FM5P
041321 -  ..
041322 - Gloria seemed to say that Kaiser did not notify Millie to change
041323 - Coumadin treatments last week on 100128, nor alert Millie that changes
041324 - may be needed, because Kaiser has limited experience on how
041325 - Nortriptyline affects on INR vary, and so adjusting Coumadin
041326 - (warfarin) when taking Nortriptyline can only be determined through
041327 - trial and error.
041329 -  ..
041330 - Since Millie's INR 5.8 demonstrated excessive increase in the lab
041331 - yesterday above a safe level, Gloria wants Millie to pause Coumadin
041332 - for 2 days.
041333 -
041334 -        [On 100203 1148 Millie notified medical team that Gloria
041335 -        ordered a 2-day pause in Coumadin to reduce INR to a safe
041336 -        level. ref SDS 10 J53X
041338 -         ..
041339 -        [On 100205 0938 Millie reports significant decline from INR
041340 -        5.8 to INR 3.2 for the lab ordered by Gloria, and asks for
041341 -        further guidance changing Coumadin medication to complete
041342 -        correction for INR to decline within 2.0 to 3.0. ref SDS 11
041343 -        IS7Q
041345 -  ..
041346 - She has ordered another lab for INR only on Friday to test interaction
041347 - with Nortriptyline, and in order to adjust the dose for resuming
041348 - Coumadin on Friday, 100205, rather than resume the current regimen,
041349 - and test results next Tuesday, when Millie is scheduled to get another
041350 - blood draw to evaluate safety for getting the 2nd treatment in the 3rd
041351 - cycle of Navelbine to recover from the 9th relapse of cancer.
041353 -  ..
041354 - Gloria wants the lab drawn this Friday on 100205, at the Chemo
041355 - Infusion Lab in Walnut Creek, to get same day results.  She indicates
041356 - the Kaiser Lab in Martinez cannot get same day results on Friday's.
041357 -
041358 -        [On 100203 1148 Millie notifies medical team that Gloria
041359 -        ordered an interim blood draw to test INR on Friday, and wanst
041360 -        the work performed at Kaiser in Walnut Creek, because that lab
041361 -        can issue same-day results, needed to adjust Coumadin on
041362 -        Friday, 100205, and the lab in Kaiser, Martinez, where Millie
041363 -        usually gets blood draws on Tuesdays, does not provide same-day
041364 -        results. ref SDS 10 J53X
041366 -  ..
041367 - Since Millie already had a meeting scheduled with Chemothreapy
041368 - Infusion Clinic on Friday to get a second Neupogen treatment.  This
041369 - morning, Barbara canceled Neupogen on Friday, because blood counts are
041370 - elevated, reported on 100203 0730. ref SDS 9 YF5I  Therefore, Kaiser
041371 - should be able to perform the blood draw for INR at the 0730 time slot
041372 - that was previously scheduled for Neupogen.  Gloria wants the blood
041373 - draw in the morning on Friday in order to get results in time to issue
041374 - adjustment to Millie's Coumadin treatment before close of business on
041375 - Friday, 100205 1700.
041377 -  ..
041378 - We reviewed patient history showing difficulties getting blood draws
041379 - at the Chemo Infusion Clinic for Kaiser in Walnut Creek.
041381 -  ..
041382 - On 100104 Doctor Zhang ordered an emergency blood draw to assess
041383 - requirements to care for shingles.  Laurie in the Chemo Infusion
041384 - Clinic said this only takes 5 minutes, and to come back at 1230 for
041385 - the blood draw. ref SDS 4 4P4U  When Millie returned from the Pharmacy
041386 - 20 minutes later at 1230, Laurie advised that Cisi decided there
041387 - wasn't enough time for any of the 10 or so nurses to draw blood for
041388 - the emergency lab ordered by Doctor Zhang, and proposed instead that
041389 - Millie go to Martinez for the blood draw, or go to the lab in the
041390 - basement and have blood drawn using a conventional IV, which is high
041391 - risk for Millie's patient profile. ref SDS 4 4Q30
041393 -  ..
041394 - Millie went to the lab in the basement, because delaying the blood
041395 - draw by going to Martinez was high risk for missing the meeting Doctor
041396 - Zhang scheduled with Doctor Dossetor in the Opthalmology Clinic later
041397 - that day at 1500.
041399 -  ..
041400 - Setting an IV is very difficult to accomplish, and so tramuatic for
041401 - Millie and the nurses, who perform the work, reported on 080425.
041402 - ref SDS 2 FP6F  In the recent case, on 100104, a 5 minute job, took 90
041403 - minutes. ref SDS 4 4Q40
041405 -  ..
041406 - Gloria advised that when she places an order for a blood draw, the
041407 - Chemotherapy Infusion Clinic must perform the order.
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0415 -