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 14 0000. ref SDS 13 0000.
040502 -
040503 -
040504 -
040506 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - INR 5.8 Medication Conflict Nortriptyline Acyclovir Prednisone
040902 -
040903 - Follow up ref SDS 14 KE5I, ref SDS 13 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 14 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.
040949 -  ..
040950 - On 100205 0938 Millie notifies medical team that Kaiser failed to
040951 - provide blood draw services that align with her patient profile to
040952 - avoid needle penetrations in her right arm, ref SDS 0 QJ85, and the
040953 - lab resutls today showed INR 3.2 which is significant improvement
040954 - after pausing Coumadin for 2 days. ref SDS 0 IS6U  Millie asks the
040955 - Coagulation Control Clinis to adjust Coumadin medication so that INR
040956 - will decline to a safe level for treating pulminary embolism.
040957 - ref SDS 0 IS7Q
040958 -
040959 -
040961 -  ..
0410 -
0411 -
0412 - Progress
0413 -
041301 - Millie's letter to the primary care physician says..
041302 -
041303 -    1.  Subject: INR 3.2 Returning to Normal After 2 Day Pause with Coumadin
041304 -        Date: Fri, 05 Feb 2010 10:02:38 -0800
041313 -         ..
041314 -    2.  Since you did not have time to coordinate the blood draw issue
041315 -        presented in the letter to Kaiser yesterday [reported on 100204
041316 -        1325. ref SDS 14 SB8X], this morning I went to the Lab in the
041317 -        basement at Kaiser in Walnut Creek, and got the blood draw to
041318 -        test INR ordered by Gloria on 100203 [1023, ref SDS 11 NT5T].
041320 -         ..
041321 -    3.  This went very well, requiring only a single needle
041322 -        penetration.  I expect the same would occur on the left arm,
041323 -        since it has never had needle penetrations.
041325 -         ..
041326 -    4.  The issue of balancing risks still remains.  As cancer and
041327 -        lymphedema rise in the right arm, signaled by recent rise of 70
041328 -        points in CA 15-3 275, [should] Kaiser's protocol to avoid
041329 -        drawing blood and injecting transfusions in the left arm now,
041330 -        as well, be avoided in the right arm, reported on 100204 1325?
041331 -        ref SDS 14 SB6S
041332 -
041333 -            [On 100301 0005 Millie notified medical team that doctor's
041334 -            order for Millie to have blood draws from Power Port are
041335 -            not fast and easy to find in Kaiser's Knowledge Management
041336 -            computer system, and so Chemotherapy Clinic refuses to
041337 -            perform standard of care for Millie's patient profile,
041338 -            ref SDS 16 PRWP; Millie asks for letter authorizing blood
041339 -            draws from Power Port that avoids trauma to infected right
041340 -            arm from needle punctures that cause cancer to spread.
041341 -            ref SDS 16 OP5T
041343 -             ..
041344 -            [On 100302 0830 during meeting at Kaiser to approve
041345 -            starting treatment to recover from 10th relapse of cancer,
041346 -            the doctor did not have time to submit a copy of
041347 -            authorization for Millie to get blood draws using her Power
041348 -            Port at the Oncology Chemotherapy Infusion Clinic in Walnut
041349 -            Creek, as performed routinely at Kaiser's Clinic in
041350 -            Martinez. ref SDS 17 7M6H
041352 -             ..
041353 -            [On 100329 2322 Millie notified medical team of rising
041354 -            lymphedema in right arm signaling beginning of IBC
041355 -            infection, both of which prevent needle penetrations
041356 -            according to Kaiser protocols, and which therefore require
041357 -            blood draws using Millie's Power Port for laboratory tests.
041358 -            ref SDS 18 WA8P
041360 -             ..
041361 -            [On 100330 0830 Doctor Johnson again observed rising
041362 -            lymphedema in Millie's right arm, signaling beginning of
041363 -            IBC, and which Kaiser protocol prevents needle penetrations
041364 -            for blood draws, taking blood pressure on the right arm, as
041365 -            well as the left arm. ref SDS 19 C54N
041367 -             ..
041368 -            [On 100427 0830, during examination at Kaiser Doctor
041369 -            Johnson entered in Millie's medical chart work plan
041370 -            instruction to use Power Port for blood draws due to
041371 -            bilateral lymphedema. ref SDS 20 X74Q
041373 -         ..
041374 -    5.  For Gloria, INR 3.2 in the test this morning shows that
041375 -        skipping Coumadin the past 2 days has us on the right track
041376 -        again [ordered 100203 1023. ref SDS 11 NT4X].  Should I pause
041377 -        again today, take half dose, or resume prior regimen.
041378 -
041379 -            [On 100205 1143 Gloria called Millie and sent a letter
041380 -            confirming instructions to resume Coumadin medication to
041381 -            prevent pulmonary embolism, ref SDS 15 QJ85, and adjusting
041382 -            the dose so that INR blood counts decline to a safe level.
041383 -            ref SDS 15 F28V
041385 -         ..
041386 -    6.  Please let me know.
041387 -
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0415 -