CONTACTS
SUBJECTS
Stroke Symptoms After EGD Dilation Pocedure VAMC Sacramento Left Si
0403 -
0403 - ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 38 0000. ref SDS 37 0000.
040502 -
040503 -
040504 -
040505 - [On 160907 1420 letter notifies medical team that
040506 - Triamcinolone may have caused stroke symptoms on 160617,
040507 - because dose over 3 month period accumulated to
040508 - significantly more than commonly given in this case.
040509 - ref SDS 39 BI60
040510 -
040511 -
040512 -
040513 -
040514 -
040516 - ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - Earlier this morning, tried sending a letter to Doctor Vora at
040902 - Stanford Neuroscience on completing work for 2nd opinion, and
040903 - proposing conference call with Doctor Massa at VAMCSF, to collaborate
040904 - on what caused stroke symptoms, reported in another record on 160823
040905 - 0906, ref SDS 38 R66J, following EGD dilation procedure at the VA on
040906 - 160617 1637. ref SDS 5 5F6F
040908 - ..
040909 - Sent letter to Doctor Massa saying...
040910 -
040911 - 1. Subject: Coordinate Call with Doctor Vora/Doctor Kim at Stanford Neuroscience
040912 - Date: 2016-08-23 09:29
040916 - ..
040917 - 2. Dear Doctor Massa,
040919 - ..
040920 - 3. Here is a letter sent to Doctor Vora this morning, proposing
040921 - call to collaborate on determining what caused stroke symptoms
040922 - in this case. ref SDS 38 R66J
040924 - ..
040925 - 4. I will be on campus later today seeing Doctor Stewart on
040926 - possible alternatives to EGD dilation, and hoping we can
040927 - somehow call Doctor Vora together on her letter dated 160802
040928 - ...[received in the record on 160820 0940. ref SDS 36 R66J...],
040929 - as set out in the letter to you yesterday. [...shown on 160822
040930 - 1321. ref SDS 37 SH4G...].
040932 - ..
040933 - 5. Can you call and let me know if this might be possible. I
040934 - realize you have a full schedule, and may not even be on site,
040935 - so if we cannot do this today, let me know when you might be
040936 - able to squeeze in 15 minutes to discuss progress with me and
040937 - Doctor Vora.
040938 -
040947 -
040948 -
040950 - ..
0410 -
0411 -
0412 - 0924
0413 -
041301 - Steve called.
041302 -
041303 - He has read the letter sent earlier today, per above. ref SDS 38 JO4J
041305 - ..
041306 - Steve said he talked to Doctor Kim last week or yesterday. Steve
041307 - seemed to indicate that he and Doctor Kim, speaking on behalf of
041308 - Doctor Vora, feel the medical team cannot determine what caused stroke
041309 - symptoms following EGD dilation on 160617. They feel Welch is a
041310 - unique case of particular stroke symptoms occurring after EGD
041311 - dilation, here on 160617. Steve indicated that VA Neurology, UCSF
041312 - Neurology, and Stanford Neuroscience cannot find literature reporting
041313 - similar circumstances, and therefore most likely there is no
041314 - literature, indicating this is a unique case.
041316 - ..
041317 - Asked if Steve has reviewed Progress Notes for the procedure on
041318 - 160617, and compared with prior procedures to identify differences,
041319 - recommended by Doctor Vora during the meeting at Stanford on 160802?
041320 - ref SDS 19 JE6N
041322 - ..
041323 - Steve said he has not had time.
041325 - ..
041326 - Cited the letter to Stanford Neuroscience on 160730, ordering 2nd
041327 - opinion on the cause of stroke symptoms on 160617. 160730 0926,
041328 - ref SDS 17 DW60 During the meeting at Stanford Neuroscience on
041329 - 160802, Doctor Vora said her team would determine what caused stroke
041330 - symptoms. ref SDS 19 GY4J
041332 - ..
041333 - Steve asked if Doctor Lee injected triamcinalone steriod into the LESV
041334 - again during the procedure on 160816, as was done for prior
041335 - procedures, including EGD dilation on 160617, which resulted in stroke
041336 - symptoms?
041337 -
041338 - [On 160907 1420 letter notifies medical team that
041339 - Triamcinolone likely not administered for EGD on 160817,
041340 - because dose over prior 3 month period accumulated to
041341 - significantly more than commonly given in this case.
041342 - ref SDS 39 BI60
041344 - ..
041345 - Reported having checked this morning for Doctor Lee's Progress Notes
041346 - on 160816. Found that Progress Notes reporting description of
041347 - procedure, findings, impressions, and recommendations for EGD
041348 - procedure on 160816, have not been posted at this time. Accordingly,
041349 - do not know if triamcinalone was injected. Doctor Lee advised
041350 - following the procedure that he could not dialate LESV, because of
041351 - severe ulceration, reported on 160816 0800. ref SDS 30 RZ3G Dilation
041352 - would risk more serious injury, also confirmed in a letter to the
041353 - medical team later that day on 160816 1532. ref SDS 31 NK98 Do not
041354 - recall him discussing injecting the steriod. It may not have been
041355 - injected; or, he might have injected it in order to prevent further
041356 - contraction.
041357 -
041358 - [...below on 160823 0920 at 1024 checked again for VA
041359 - Progress Notes on EGD performed last week 160816, and found
041360 - nothing is posted yet. ref SDS 0 VR3J
041362 - ..
041363 - Asked Steve if he has seen the Progress Notes, or discussed the
041364 - procedure on 160816, with Doctor Lee, following up his telecon with
041365 - Doctor Lee reported in Progress Notes on 160811 1546? ref SDS 27 OT3H
041367 - ..
041368 - Advised that the only reason the procedure was performed on 160816,
041369 - was because Doctor Lee assured there would not be a repeat of stroke
041370 - symptoms or worse, reported on 160812 1626. ref SDS 29 RS4F The
041371 - consent for the procedure was signed on further such assurance on
041372 - 160816 0800. ref SDS 30 BH9G
041374 - ..
041375 - The only evident basis for giving assurance that neurology symptoms
041376 - would not repeat is having confident knowledge of what caused stroke
041377 - symptoms after the procedure on 160617, and having absolute control to
041378 - avoid what caused them.
041380 - ..
041381 - Steve seemed to disagree, saying something like doctors perform
041382 - procedures without having confidence they can avoid adverse coronary
041383 - and neurological outcomes.
041385 - ..
041386 - Asked Steve for published authority for doctors performing procedures
041387 - without a rational basis to believe adverse outcome can be avoided.
041389 - ..
041390 - Asked if Steve has requested from Doctor Lee the Peer Review report
041391 - done at VAMC Sacramento; is there an interim report? What work
041392 - product has been produced at this time?
041394 - ..
041395 - Steve said he has not seen Doctor Lee's Progress Notes, and has not
041396 - followed up with Doctor Lee, since his discussion on 160811 1546.
041397 - ref SDS 27 OT3H Neither has he seen the Peer Review report Doctor Lee
041398 - ordered, cited in Progress Notes on 160715. ref SDS 12 8Q48
041400 - ..
041401 - Steve said triamcinalone steriod injection issue remains a viable line
041402 - of inquiry on what caused stroke symptoms following the procedure on
041403 - 160617.
041404 -
041405 - [On 160907 1420 letter notifies medical team that
041406 - Triamcinolone may have caused stroke symptoms on 160617,
041407 - because dose over 3 month period accumulated to
041408 - significantly more than commonly given in this case.
041409 - ref SDS 39 BI60
041411 - ..
041412 - Asked how Steve will follow up on this? Would an over-injection for
041413 - the procedure, shown in Progress Notes for 160617 0800, ref SDS 4
041414 - 4V53, have caused stroke symptoms in this case? Has Steve inquired?
041416 - ..
041417 - Steve feels further work is not justified to determine what caused
041418 - stroke symptoms. He explained that since a follow up procedure was
041419 - done on 160816, and symptoms did not repeat, the benefit of investing
041420 - more time to discover what caused stroke symptoms on 160617, is
041421 - unnecessary expense.
041423 - ..
041424 - Asked Steve to write a closing Progress Note (report) listing issues
041425 - that have been considered for causing stroke symptoms in this case,
041426 - the evidence that has been examined, and then assess likelihood for
041427 - each potential cause. He can close the review saying spending more
041428 - time to discover why an odd scenario occurred, and that the liklihood
041429 - of this repeating with worse consequences for the patient and other
041430 - patients does not justify spending more time, as he relates today.
041432 - ..
041433 - Steve said he does not have enough time to write a report on what has
041434 - been done, and then conclude that the case cannot be resolved. He
041435 - feels that further review of medical records would be tedious and time
041436 - consuming, so he wants to end work on this matter with his last letter
041437 - on 160811 1546. ref SDS 27 OT3H
041439 - ..
041440 - We discussed prior meeting with Doctor Abrams on 160619, when he
041441 - indicated determining what caused stroke symptoms is critical to avoid
041442 - recurrence that could cause worse outcome in this case, and further
041443 - and to avoid other patients suffering similar neurological symptoms.
041444 - ref SDS 10 SV54
041446 - ..
041447 - Steve said that the record is there for anyone to review further, if
041448 - symptoms recur. He does not have time do anything more.
041449 -
041450 - [...below on 160823 0920 at 1024 checked again for VA
041451 - Progress Notes on EGD performed last week 160816, and found
041452 - nothing is posted yet. ref SDS 0 VR3J
041454 - ..
041455 - Stanford Medical Center Neuroscience was hired to supplement efforts
041456 - constrained by limited time at the VA, as set out in the letter to
041457 - Stanford on 160730 0926. ref SDS 17 DX31
041458 -
041459 -
041460 -
041462 - ..
0415 -
0416 -
0417 - 1024
0418 -
041801 - After the call from Steve, checked again for VA Progress Notes and
041802 - found none are posted as yet for EGD dilation procedure on 160816.
041804 - ..
041805 - As a result, cannot determine if triamcinalone was injected into LESV
041806 - for procedure on 160816, as Steve asked during his call per above.
041807 - ref SDS 0 NG47
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