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 10 0000, 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 10 KE5I, 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 10 QJ85, and
040919 - also ordered an interim blood draw on Friday to retest INR in order to
040920 - further adjust Coumadin on Friday, 100205. ref SDS 10 NT5T
040922 -  ..
040923 - On 100203 1148 Millie notified medical team that the Coagulation
040924 - Control Clinic has ordered a pause for 2 days in Coumadin treatments,
040925 - ref SDS 0 QJ85, and is also ordering an interim blood draw to test INR
040926 - on 100205, ref SDS 0 4Q4O, and that the Gloria wants the work
040927 - performed in Walnut Creek. ref SDS 0 J54T
040928 -
040930 -  ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Millie's letter says...
041302 -
041303 -    1.  Subject: INR 5.8 Medication Conflict Interim Lab Ordered for Friday
041304 -        Date: Wed, 03 Feb 2010 11:25:15 -0800
041313 -         ..
041314 -    2.  I just received a call from Gloria in the Kaiser Coagulation
041315 -        Control Clinic in Martinez [reported on 100203 1023.
041316 -        ref SDS 10 QJ85, responding to notice last night of elevated
041317 -        INR 5.8 for the lab yesterday. 100202 0830, ref SDS 6 848J
041319 -         ..
041320 -    3.  Gloria is pausing Coumadin for 2 days. ref SDS 10 NT4X  She has
041321 -        ordered another lab for INR only on Friday because interaction
041322 -        is erratic with Nortriptyline, ref SDS 10 9G3H, which you
041323 -        prescribed on 100128. ref SDS 5 FM4W
041324 -
041325 -           [On 100205 0938 Millie reports significant decline from INR
041326 -           5.8 to INR 3.2 for the lab ordered by Gloria, and asks for
041327 -           further guidance changing Coumadin medication to complete
041328 -           correction for INR to decline within 2.0 to 3.0. ref SDS 13
041329 -           IS7Q
041331 -         ..
041332 -    4.  Apparently, there is no published conflict between
041333 -        Nortriptyline and Coumadin, which is why she did not call last
041334 -        week to adjust the dose.  However, some patients suffer
041335 -        elevated INR, as I have, and so adjustments can only be made
041336 -        through trial and error.
041338 -         ..
041339 -    5.  Therefore, Gloria needs an interim lab in order to adjust the
041340 -        dose for resuming Coumadin on Friday, rather than resume the
041341 -        current regimen, and test results next Tuesday. ref SDS 10 9G3H
041342 -
041343 -            [On 100205 1143 Gloria called Millie and sent a letter
041344 -            confirming instructions to resume Coumadin medication to
041345 -            prevent pulmonary embolism, ref SDS 14 QJ85, and adjusting
041346 -            the dose so that INR blood counts decline to a safe level.
041347 -            ref SDS 14 F28V
041349 -         ..
041350 -    6.  Gloria wants the lab drawn at the Chemo Infusion Lab in Walnut
041351 -        Creek, to get same day results.  She indicates the Kaiser Lab
041352 -        in Martinez cannot get same day results on Friday's.
041353 -        ref SDS 10 NT5T
041355 -         ..
041356 -    7.  Gloria has ordered a lab for me at Kaiser in Walnut Creek for
041357 -        Friday, 100205.  I already had a meeting scheduled with
041358 -        Chemothreapy Infusion Clinic on Friday to get a second Neupogen
041359 -        treatment.  This morning, Barbara canceled Neupogen on Friday,
041360 -        because blood counts are elevated.  Ideally, I can come in and
041361 -        get the blood draw for INR at the 0730 time slot that was
041362 -        previously scheduled for Neupogen [reported on 100203 0730.
041363 -        ref SDS 9 YF5O  The blood draw is needed in the morning, so
041364 -        Gloria can get results in time to issue adjustment to Coumadin
041365 -        treatment by COB on Friday.
041367 -         ..
041368 -    8.  On 100104 Doctor Zhang ordered an emergency blood draw to
041369 -        assess requirements to care for shingles [reported on 100104
041370 -        1115, ref SDS 3 0P4S].  Laurie in the Chemo Infusion  Clinic
041371 -        said this only takes 5 minutes, and to come back at 1230 for
041372 -        the blood draw [reported on 100104 1216, ref SDS 4 4P4U].  When
041373 -        I returned from the Pharmacy 20 minutes later at 1230, someone
041374 -        else decided there wasn't enough time, so we had to scramble.
041375 -        ref SDS 4 4Q30  A 5 minute job, took over an hour in the lab in
041376 -        the basement, and required a conventional IV that is high risk
041377 -        for my patient profile [reported on 100104 1216. ref SDS 4
041378 -        4Q40].
041380 -         ..
041381 -    9.  Please verify I am scheduled for an interim lab on Friday in
041382 -        the Chemo Infusion Clinic.  Again, 0730 is best for me, and
041383 -        typically, the Clinic has very few patients at that time.  This
041384 -        morning I was the only patient until 0745, so that should be
041385 -        plenty of time to do an INR blood draw.
041386 -
041387 -            [On 100203 1410 Arlette called and advised she received
041388 -            Millie's letter notifying the medical team that Gloria
041389 -            ordered an interim blood draw to test INR on Friday,
041390 -            100205, and in order to make timely adjustment to Millie's
041391 -            Coumadin prescription on Friday to reduce the risk of
041392 -            pulmonary embolism, ref SDS 11 QJ85; Arlette reported that
041393 -            Chemotherapy Infusion Clinic in Walnut Creek refuses to
041394 -            perform the doctor's order to use Millie's Power Port for
041395 -            blood draws, because of new general policy to reduce the
041396 -            risk of complications which some patients have from using
041397 -            Heperin to maintain port catheters. ref SDS 11 124J
041399 -             ..
041400 -            [On 100204 1325 Millie's letter to the medical team asks
041401 -            the primary care physician to enter in Millie's medical
041402 -            chart and notify the Chemotherapy Infusion Clinic that
041403 -            Millie's patient profile requires drawing blood from
041404 -            Millie's Power Port rather than use IV needle penetration
041405 -            balancing very low risks of Heprin contamination in the
041406 -            Power Port which has never occurred in Millie's case over 8
041407 -            years, against lymphedema recently diagnosed in the right
041408 -            arm which, has prevented IV needle penetrations in the left
041409 -            arm for 8 years. ref SDS 12 SB6S
041411 -             ..
041412 -            [On 100205 0938 Doctor Johnson did not have time to align
041413 -            Kaiser practices for Millie's blood draws, with Millie's
041414 -            patient profile, so Millie was forced to get the blood draw
041415 -            with an IV in her right arm despite rising IBC and
041416 -            lymphedema, ref SDS 13 IS6R; fortunately, the lab was
041417 -            successful on the first needle penetration, and the lab
041418 -            reported the test shows INR 3.2, significant improvement
041419 -            after pausing Coumadin for 2 days. ref SDS 13 IS7Q
041421 -             ..
041422 -            [On 100205 1143 Gloria called Millie and sent a letter
041423 -            confirming instructions to resume Coumadin medication to
041424 -            prevent pulmonary embolism, ref SDS 14 QJ85, and adjusting
041425 -            the dose so that INR blood counts decline to a safe level.
041426 -            ref SDS 14 F28V
041427 -
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041435 -
041436 -
041437 -
041438 -
041439 -
0415 -