THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: February 4, 2010 01:25 PM Thursday; Rod Welch

Millie asks Kaiser to perform blood draws through Power Port much less
risk for Millie's patient profile than using IV in right arm.

1...Summary/Objective
2...INR 5.8 Medication Conflict Nortriptyline Acyclovir Prednisone


..............
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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 13 0000. ref SDS 12 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 13 KE5I, ref SDS 12 KE5I.
040904 -
040905 - On 100202 0830 Millie had a blood draw at Kaiser in Martinez.
040906 - ref SDS 7 AS5H
040908 -  ..
040909 - On 100202 1927 Laurie called yesterday evening and reported INR 5.8,
040910 - ref SDS 8 KE5I, for Millie's blood draw at 0830. ref SDS 7 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 8 KW6Q
040916 -  ..
040917 - On 100203 1023 Gloria, Case Manager Kaiser Coagulation Control Clinic,
040918 - called to order changes in Millie's Coumadin, ref SDS 11 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 11 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 12 QJ85, and is also ordering an interim blood draw to test
040926 - INR on 100205, ref SDS 12 4Q4O, and that the Gloria wants the work
040927 - performed in Walnut Creek. ref SDS 12 J54T
040929 -  ..
040930 - On 100203 1410 Millie received a call from Arlette who advised that
040931 - the Kaiser Chemotherapy Infusion Clinic has a new policy implemented
040932 - this year to avoid using Power Port technology to perform blood draws
040933 - for INR testing, because Heprin used to maintain port catheters is
040934 - believed to have caused medical problems for some patients who had
040935 - blood drawn from port catheters for INR testing.  To avoid the risk of
040936 - medical problems caused to other patients, Kaiser wants Millie to get
040937 - blood drawn for the INR test on Friday from the Lab in the basement
040938 - which can only use IV needle penetrations which present risks for
040939 - Millie's patient profile. ref SDS 13 QJ85
040941 -  ..
040942 - On 100204 1325 Millie notifies primary care physician to submit
040943 - results of CA 15-3 test for blood draw on 100202, ref SDS 0 QJ85, and
040944 - to approve Millie for getting interim blood draw through Power Port to
040945 - reduce the risk of complications for Millie's patient profile compared
040946 - with high risk using IV needle penedtratios in the left and right
040947 - arms.
040948 -
040949 -
040950 -
040952 -  ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Millie's letter to the primary care physician says..
041302 -
041303 -    1.  Subject: Cancer Marker CA 15-3 Lab on Feb 2nd
041304 -        Date: Thu, 04 Feb 2010 13:43:29 -0800
041312 -         ..
041313 -    2.  Can you please submit results for CA 15-3 on the blood test
041314 -        this past Tuesday, 100202.  My MRN... 03573704
041316 -         ..
041317 -    3.  Arlette called yesterday, and presented a new policy in the
041318 -        Chemotherapy Infusion Clinic that now gives preference to using
041319 -        conventional IV for blood draws.  Not sure if this is all blood
041320 -        draws or only for INR [reported on 100203 1410. ref SDS 13
041321 -        115H].  In any case, evidently Kaiser has recent experience
041322 -        showing blood draws from port catheters cause medical problems
041323 -        for some patients, due to Heprin to maintain the port after
041324 -        blood draws. ref SDS 13 124J
041326 -         ..
041327 -    4.  To comply with the new policy aimed at avoiding emergent risks,
041328 -        the Chemotherapy Infusion Clinic indicates preference that the
041329 -        blood draw ordered by Gloria for Friday, to check INR for
041330 -        adjusting my prescription for Coumadin, be performed in the
041331 -        basement Lab, which uses IV needle penetrations.
041333 -         ..
041334 -    5.  As you know, IV needle penetrations present severe risks for my
041335 -        patient profile.  You addressed this problem by ordering a
041336 -        Power Port, which has been effective, though a struggle at
041337 -        times getting protocols lined up in the ER and CT Departments.
041338 -        Thanks to your support, most recently, I gathered that
041339 -        protocols to use Power Ports are now in place for both the ER
041340 -        and CT folks.
041342 -         ..
041343 -    6.  Since I have had blood drawn without incident from port
041344 -        catheters and Power Ports for 5 years, mostly on a weekly
041345 -        basis, this record demonstrates that my risk is de minimis,
041346 -        which the new policy for the Chemotherapy Infusion Clinic seeks
041347 -        to address, as related by Arlette yesterday [reported on 100203
041348 -        1410. ref SDS 13 124J].
041350 -         ..
041351 -    7.  I am concerned that cancer has spread to the right arm, with
041352 -        lymphedema diagnosed in your medical chart, I believe in
041353 -        October [actually December].  More recently, this subsided in
041354 -        December [actually January 2010], after starting Navelbine in
041355 -        November.  Since treatment has now been paused for 3 weeks,
041356 -        cancer in the right arm is likely now on the rise again, for
041357 -        reasons you presented on 090921. ref SDS 3 4Q6I
041358 -
041359 -            [On 100330 0830 Doctor Johnson again observed rising
041360 -            lymphedema in Millie's right arm, signaling beginning of
041361 -            IBC, and which Kaiser protocol prevents needle penetrations
041362 -            for blood draws, taking blood pressure on the right arm, as
041363 -            well as the left arm. ref SDS 18 C54N
041365 -         ..
041366 -    8.  Lymphedema in the left arm has always prevented IV penetrations
041367 -        to draw blood or inject chemotherapy treatments now going on 9
041368 -        years.  This required all IVs to be made on the right arm.  In
041369 -        2004 nurses began having difficulty finding a vein to access
041370 -        with IV; by 2008, it became nearly impossible, so you ordered
041371 -        the Power Port.  Thus, not only are IV needle penetrations
041372 -        painful and difficult to accomplish, lymphedema and cancer
041373 -        prevent IVs in the right arm for the same reasons they have
041374 -        been avoided in the left arm.
041376 -         ..
041377 -    9.  These extreme risks of injury from needle penetrations in the
041378 -        right arm seem to outweigh mere emerging risks, and which have
041379 -        never materialized in my case using the Power Port to draw
041380 -        blood, including INR.  This may reflect that nurses spend extra
041381 -        time cleansing (flushing) my port with saline after each use.
041383 -         ..
041384 -   10.  You have long balanced risks in my case.  You and Doctor Rugo
041385 -        routinely exercised discretion for medical necessity ordering
041386 -        chemotherapy treatment, even though blood counts were often
041387 -        well below Kaiser protocols.
041389 -         ..
041390 -   11.  Accordingly, please consider noting in my medical chart that
041391 -        balancing risks in my patient profile requires blood draws
041392 -        through my Power Port, ref SDS 0 SB6S, and notify the
041393 -        Chemotherapy Infusion Clinic of your approval, with guidance to
041394 -        continue post procedure saline flush for 5 minutes, rather than
041395 -        the usual 2 minutes. ref SDS 0 SB8R
041397 -         ..
041398 -   12.  Please call to let me know your determination.
041399 -
041400 -            [On 100205 0938 Doctor Johnson did not have time to align
041401 -            Kaiser practices for Millie's blood draws, with Millie's
041402 -            patient profile, so Millie was forced to get the blood draw
041403 -            with an IV in her right arm despite rising IBC and
041404 -            lymphedema; fortunately, the lab was successful on the
041405 -            first needle penetration, and the lab reported the test
041406 -            shows INR 3.2, significant improvement after pausing
041407 -            Coumadin for 2 days. ref SDS 14 IS6R
041409 -             ..
041410 -            [On 100205 1143 Gloria called Millie and sent a letter
041411 -            confirming instructions to resume Coumadin medication to
041412 -            prevent pulmonary embolism, ref SDS 15 QJ85, and adjusting
041413 -            the dose so that INR blood counts decline to a safe level.
041414 -            ref SDS 15 F28V
041416 -             ..
041417 -            [On 100317 0730 Anne used Millie's lower right leg to obain
041418 -            pulse and blood pressure diagnostics, because Millie's
041419 -            right arm is swelled with lymphedema. ref SDS 16 QR4X
041421 -             ..
041422 -            [On 100329 2322 Millie notified medical team of rising
041423 -            lymphedema in right arm signaling beginning of IBC
041424 -            infection, both of which prevent needle penetrations
041425 -            according to Kaiser protocols, and which therefore require
041426 -            blood draws using Millie's Power Port for laboratory tests.
041427 -            ref SDS 17 WA8P
041429 -             ..
041430 -            [On 100330 0830 Doctor Johnson again observed rising
041431 -            lymphedema in Millie's right arm, signaling beginning of
041432 -            IBC, and which Kaiser protocol prevents needle penetrations
041433 -            for blood draws, taking blood pressure on the right arm, as
041434 -            well as the left arm. ref SDS 18 C54N
041436 -             ..
041437 -            [On 100427 0830, during examination at Kaiser Doctor
041438 -            Johnson entered in Millie's medical chart work plan
041439 -            instruction to use Power Port for blood draws due to
041440 -            bilateral lymphedema. ref SDS 19 X74Q
041441 -
041447 -
041448 -
041449 -
041450 -
041451 -
041452 -
041453 -
041454 -
041455 -
041456 -
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