091815 - ..
091816 - Doctor Tucker asked how she was selected for this work?
091817 -
091818 - [On 170728 1649 received letter from Doctor Tucker
091819 - responding to letter transmitting the record today on
091820 - treatent with PRP, and reporting she read this record
091821 - reporting events today. ref SDS 26 0W5I
091823 - ..
091824 - Explained some months ago my cousin and step dad investiged injection
091825 - therapy. Robin had prolotherpay 20+ years ago in the 1980s with
091826 - Doctor Ongley, for her knee and back or somthing. This brought
091827 - recovery which other modalities failed to achieve, and lasted until
091828 - recent months. Doctor Ongley moved his pratctice to Mexico, so Robin
091829 - consulted Doctor Darrow and also Doctor Kochen for herself, and her
091830 - uncle. She is leaning toward prolotherapy. Doctor Kochen proposed
091831 - stem cell therapy to relieve episodic pain in Bob's back, who is 90.
091832 - He works out at the gym, and gets good care at the VA, but these have
091833 - not resolved severe back pain, so he is considering stem cell
091834 - treatments Doctor Kochen proposed.
091836 - ..
091837 - Doctor Tucker smiled and noted she knows Doctor Kochen well, and may
091838 - have collaborated with him on cases. Throughout the entire procedure,
091839 - the doctor's engaging personality advanced the work significantly.
091840 - She was enlightening, skilled, focused, timely and fun to work with,
091841 - essential for doctor patient partnership.
091842 -
091843 -
091845 - 
091847 - ..
091848 - Advised that Kathy and I met with Doctor Darrow on 170717, at his
091849 - office in Los Angeles, intending to get PRP to recover from plantar
091850 - plate tear. ref SDS 17 US6H The doctor and staff were very helpful
091851 - providing better understanding treating plantar plate injury with PRP.
091852 - Decided against treatment in Los Angeles, and to investigate injection
091853 - therapy services in the Bay Area with more convenient travel and
091854 - logistics.
091856 - ..
091857 - This past Friday, research on the Internet found health care providers
091858 - in the Bay Area offering injection therapy services, reported on
091859 - 170721 0848, ref SDS 18 F18F Connie suggested sending a letter to
091860 - Doctor Tucker explaining scope of work. ref SDS 18 TV8J Doctor
091861 - Tucker's response indicated appreciation for solving issues in the
091862 - case, and that there was good liklihood of forming effective doctor
091863 - patient partnership. ref SDS 18 PW9H
091864 -
091865 -
091867 - ..
091868 - Scope Expanded Include Metatarsalgia Right Foot
091869 -
091870 - Doctor Tucker explained she will make 2 injections on each side of
091871 - the plantar plate, shown by mark on bottom of right foot below long
091872 - toe. The doctor offered valium and another pill to moderate anxiety
091873 - from needle injections..
091874 -
091875 -
091877 - 
091878 -
091880 - ..
091881 - At some point, Doctor Tucker offered that she loves working with feet,
091882 - because they present very complex, interconnected systems that make
091883 - achieving effective care a significant challenge.
091884 -
091885 - [On 170727 1747 Doctor Tucker called to follow up injection
091886 - therapy for plantar plate tear, metatarsalgia, and left
091887 - knee osteoarthritis, ref SDS 22 QV5N; advised initial
091888 - results excellent; doctor approved low level hiking.
091889 - ref SDS 22 0W6V; and, she recommended metatarsal bar added
091890 - to new orthotic inserts. ref SDS 22 517O
091892 - ..
091893 - [On 170727 1747 at 2212 letter to Doctor Tucker confirms
091894 - understandings from call, ref SDS 22 RK5H, and commends her
091895 - kindness and generosity and skill performing expanded scope
091896 - adding treatment for metatarsalgia in both feet and for
091897 - left knee. ref SDS 22 MM51
091899 - ..
091900 - Doctor Tucker advised she could make injections on top of the right
091901 - foot to treat related metatarsalgia injuries described in the
091902 - radiologist's report for MRI on 170412. ref SDS 12 JG52 This was
091903 - offered at no additonal charge, and so agreed to this scope.
091905 - ..
091906 - The doctor marked the top of the foot for injections...
091907 -
091909 - 
091910 -
091911 -
091913 - ..
091914 - Pain Management Excellent Patient Support
091915 -
091916 - Doctor Tucker applied cream and Cold Spray to numb area before making
091917 - injection with lidocaine that prevents pain from PRP injections...
091918 -
091920 - 
091922 - ..
091923 - Wrapped both feet with ice packs...
091924 -
091926 - 
091927 -
091929 - ..
091930 - After a few minutes, the doctor tested for numbness of injection
091931 - area...
091932 -
091934 - 
091935 -
091937 - ..
091938 - Patient requested further lidocaine. While this was taking effect,
091939 - there was discussion about modality.
091940 -
091941 -
091942 -
091944 - ..
091945 - PRP Modality Chosen for Injection Therapy Rather than Dextrose
091946 - Platelet Rich Plasma (PRP) Modality More Effective than Dextrose
091947 -
091948 - Doctor Tucker seemed to say that platelet rich plasma (PRP) would be
091949 - more effective than dextrose for faster, longer lasting recovery from
091950 - plantar Plate injury, and preventing recurrance of metatarsalgia.
091951 - Doctor Shunk made similar analysis for having heart surgery, rather
091952 - than stents, after angiogram discovered several arterial blockages on
091953 - 091021 0716. ref SDS 2 WB3K Over the past 7 years, Doctor Shunk's
091954 - expectation has proven accurate. There have been no recurrent CVD
091955 - events. Possibly PRP will prove similarly more robust than dextrose.
091957 - ..
091958 - Asked the doctor if she has had PRP treatment?
091960 - ..
091961 - She said yes, and so part of her recommendation is based on personal
091962 - experience; but, more so on the many patients she has treated with
091963 - PRP in recent years.
091965 - ..
091966 - Since Doctor Darrow recommended PRP during the meeting on 170717, and
091967 - since Robin advised that Doctor Kochen also recommended PRP, ordered
091968 - injection therapy with PRP, hoping for stronger, recovery, and in time
091969 - to resume heavy training within 3 - 6 weeks, essential for hiking Half
091970 - Dome on 170913, planned in the letter to Doctor Tucker on 170721 0848.
091971 - ref SDS 18 V667
091972 -
091973 -
091975 - ..
091976 - Blood Draw for PRP Completed Despite Challenging Process
091977 -
091978 - Doctor Tucker drew blood for PRP platlete extraction...
091979 -
091981 - 
091982 -
091984 - ..
091985 - This required 4 sticks due to frequency of blood draws this past year
091986 - for EGD procedures, which cause adhesions that inhibit blood flow.
091987 -
091989 - 
091991 - ..
091992 - To ease tensions that accompany multiple blood draw sticks, Doctor
091993 - Tucker suggested the patient sing. This was such a terrible effort
091994 - that everyone laughed, accomplishing the objective.
091996 - ..
091997 - Kathy took a break from taking pictures, to hold my hand providing
091998 - emotional support, while the doctor drew blood. This is common
091999 - practice in medical work. Gracie, Mimi, Rodalie, Denis, Hazel, all
092000 - the nurses in the GI Clinic at VAMC Sacramento are sensitive when
092001 - blood draws are complicated.
092003 - ..
092004 - Most recently, Grace needed only 1 stick to set IV for conscious
092005 - sedation during EDG dilation on 170711 0800. ref SDS 16 544G But that
092006 - has been the exception in recent months, shown by case study on
092007 - multiple sticks reported in the record on 110429 1230. ref SDS 5 UO3G
092009 - ..
092010 - Kathy switched hats at one point, applying maternity expertise drawing
092011 - blood the past 30 years at Sutter General, to find a good vein on the
092012 - lower left arm. Doctor Tucker found the final vein on the outer side
092013 - of the left arm left elbow, that yielded sufficient blood for the
092014 - centrifuge equipment to extract platelets...
092015 -
092016 -
092018 - 
092019 -
092021 - ..
092022 - Thanked Doctor Tucker for persistence working with a difficult
092023 - customer. She mentioned several times that on difficult cases, she
092024 - draws on outside consultants. This would have required standing down
092025 - today, and returning perhaps in days or weeks when everyone could be
092026 - assembled again. Since the doctor knew time is of the essence
092027 - completing the work today, if only for patient collateral interests,
092028 - reported in the engagement letter on 170721 0848, ref SDS 18 4R4K, her
092029 - generosity and kindness was greatly appraciated making extended
092030 - effort, which thankfully was successful.
092031 -
092032 - [On 170727 1747 at 2212 letter to Doctor Tucker confirms
092033 - understandings from call, ref SDS 22 RK5H, and commends her
092034 - kindness and generosity and skill performing expanded scope
092035 - adding treatment for metatarsalgia in both feet and for
092036 - left knee. ref SDS 22 MM51
092037 -
092038 -
092040 - ..
092041 - Blood Draw Finds High Viscosity Commonly Treated with Baby Aspirin
092042 -
092043 - While she worked, Doctor Tucker commented that her practice includes
092044 - sports medicine. She feels viscosity of the blood drawn today, is
092045 - higher than expected for age 72, and so presents elevated risk of
092046 - myocardial infarction, which is commonly lowered by taking baby
092047 - asperin. This aligns with Doctor Egan's analysis at the VA on 110309
092048 - 0900. ref SDS 4 O43I This was reviewed previously on 101223 1030.
092049 - ref SDS 3 J64I Recently, on 170412 Doctor Simpson at VAMCSF discussed
092050 - opportunity for reducing coronary risks by taking Baby Aspirin and
092051 - increasing statins. ref SDS 13 OP5M Today, Doctor Tucker seemed to
092052 - say thicker blood found in the blood draw increases risk with age for
092053 - CVD events, because statistics show that older people suffer
092054 - atherosclerosis that narrows and hardens blood vessels. Aspirin thins
092055 - the blood, so it flows better, rather than clot up in narrow,
092056 - inelastic blood vessels.
092057 -
092058 - [On 170905 2350 blood draw at San Joaquin General reported
092059 - INR 1.1, indicating thinner blood. ref SDS 32 2B4N
092061 - ..
092062 - [On 170911 1040 Lab Tech commented blood looks excellent
092063 - drawn during lab at VAMCSF. ref SDS 33 A56O
092065 - ..
092066 - Blood plasma is commonly presented as 92% water. Patient has been
092067 - dehydrated the past year taking elevated dose proton pump inhibitor
092068 - (PPI) to resolve fundoplication issues treating achalasia. Elevated
092069 - PPI increased urination. On 170725, PPI protocol was reduced by 75%.
092070 - Over time normal hydration should follow, and thereon normalize blood
092071 - viscocity.
092073 - ..
092074 - We reviewed the record hiking 13K miles the past 5 years, shown in
092075 - the spreadsheet file...
092076 -
092077 - pix: 950 450
092078 - F:\05\00003\SM\CC\BNKG\120216cc\130101cc\hiking_miles_3.xlsx
092080 - ..
092081 - This experimental line of care seems to maintain elasticity of blood
092082 - vessels, shown by low blood pressure, and raises HDL and EPCs to
092083 - remove and prevent plaque build up through reverse cholesterol
092084 - transport (RCT), reported in the record on 131125 0005. ref SDS 6 HG7N
092085 - Stastically, few have raised HDL 30 at the time of CABG on 091022, to
092086 - HDL 73, 6 years later. On 151019, CCTA evaluated response to
092087 - treatment, and found no evidence of plaque buildup. ref SDS 8 SU62 On
092088 - 160715 1630 Doctor Yoo Neurology Progress Notes say in part given that
092089 - MRI on 160618 shows complete absence of vertebrobasilar disease, is
092090 - another way of saying there is no evidence of plaque in blood vessels
092091 - of the brain. ref SDS 10 TV4F
092093 - ..
092094 - Favorable unexpected result based on statistics comes from innovation
092095 - hiking 11 - 15 miles per day, enabled by great care at the VA, and
092096 - supplemented today, by Doctor Tucker's innovative PRP injection
092097 - treatment.
092099 - ..
092100 - The doctor urged taking baby aspirin.
092101 -
092103 - ..
092104 - Metatarsalgia PRP Treatment Both Feet
092105 - Centrifuge Kit Produces Enough PRP Treat Metatarsalgia Both Feet
092106 -
092107 - Doctor Tucker explained she will use a "centrifuge kit" to extract
092108 - platelets for PRP injections. The equipment requires a minimun amount
092109 - of blood and produces a fixed amount of PRP plasma. This will be more
092110 - than needed for the plantar plate injury. She offered to inject the
092111 - right and left foot at no additional charge to treat metatarsalgia, in
092112 - addition to treating the plantar plate injury.
092114 - ..
092115 - Agreed to this offer. There has been 0 - minimal pain doing hikes in
092116 - left foot since January. However, due to injuries hiking is only
092117 - about 20% of normal. Since recovery from plantar plate tear, will
092118 - enable normal hiking, this will increase stress on feet causeing
092119 - increased risk of metatarsalgia. The new orthotics Doctor Tang
092120 - designed and ordered, and now received yesterday 170725 1636,
092121 - ref SDS 21 KD8H, will reduce stress and so resist further injury.
092122 - Adding injection therapy with PRP for metatarsalgia aligns with this
092123 - objective. The work plan for today, was to experiment treating the
092124 - platar plate tear in the right foot, and if that was successful, then
092125 - would return and treat the left foot. Doctor Tucker's offer to inject
092126 - left foot today, was great news, and a big help.
092127 -
092128 - [On 170929 1010 Mark Wachter, CEO On-the-Run proposed Hoka
092129 - Bondi wide width 2E shoes to relieve pressure on
092130 - metatarsals and on plantar plate injury, and he offered
092131 - orthotic inserts with small groove to relieve pressure on
092132 - plantar plate, and also a small protrusion, which may
092133 - correlate with Doctor Tang's design at VAMCSF received on
092134 - 170725, and further implement Doctor Tucker's
092135 - recommendations for a "metatarsal bar" on 170727.
092136 - ref SDS 34 124L
092137 -
092139 - ..
092140 - PRP Injections Pain Free Both Feet Excellent Patient Care
092141 -
092142 - Doctor Tucker injected PRP into left foot metatarsals.
092143 -
092146 - 
092147 -
092148 -
092151 - 
092152 -
092154 - ..
092155 - Asked when she would inject the right foot plantar plate and
092156 - metatarsals?
092158 - ..
092159 - The doctor smiled and said that is already completed. Realized this
092160 - went unnoticed, because while we talked, I was looking up at the
092161 - ceiling. The 4 point array of injections to bottom of right foot are
092162 - barely noticable...
092163 -
092166 - 
092168 - ..
092169 - [On 170816 1400 for 2nd phase of regeneration injection
092170 - treatment with PRP Doctor Tucker used pain management
092171 - protocol similar to 1st phase, when no pain was experience,
092172 - but on this 2nd phase there was considerable pain, because
092173 - injections were deeper and more PRP was injected to achieve
092174 - benefits of regenerating (healing) plantar plate tear,
092175 - which were not achieved with 1st phase of treatment.
092176 - ref SDS 29 S543
092178 - ..
092179 - [On 170819 1352 letter from Doctor Tucker says injury
092180 - symptoms return 3 - 5 days after treatment, ref SDS 30
092181 - 0W5I, and regeneration healing from PRP injection treatment
092182 - becomes manifest about 4 - 6 weeks after treatment.
092183 - ref SDS 30 C29V
092185 - ..
092186 - Injections of PRP in the top of both feet between metatarsals caused
092187 - only minor inflammation...
092188 -
092191 - 
092192 -
092193 -
092195 - ..
092196 - PRP Left Knee Compare Supartz Right Knee Assess Quality and Longevity
092197 - Left Knee PRP Injections Compare Supartz Treatment Scheduled 170731
092198 -
092199 - After completing injections for left foot metatarsals, Doctor Tucker
092200 - advised there was still a small amount of PRP plasma available. She
092201 - asked if there is another area where this might be used?
092203 - ..
092204 - Explained that on Monday, 170731, Joan in Orthopedics at VAMCSF is
092205 - scheduled to inject Supartz in both knees.
092207 - ..
092208 - The doctor recalled that the right knee was previously treated with 3
092209 - injections completed on 170206. ref SDS 11 LL5N, shown in the letter to
092210 - Doctor Tucker on 170721 0848. ref SDS 18 V730 Today, she suggested
092211 - injecting PRP in the left knee, and continuing planned line of care
092212 - with Supartz on Monday in the right knee. Performance can then be
092213 - compared. If the left knee fails, then Supartz can be tried, along
092214 - with the right knee as currently planned. She seems to expect PRP
092215 - injection today, may last for a year or more. In that case
092216 - consideration might be given to injecting both knees with PRP.
092218 - ..
092219 - Agreed to this work plan.
092221 - ..
092222 - PRP injection in left knee was similar to the feet, with initially
092223 - spraying the area for numbness, and then inject lidocaine for pain
092224 - control getting the larger injection...
092225 -
092230 - ..
092231 - The doctor then injected the remaining amount of platelet rich plasma
092232 - (PRP) into the knee joint. There was no pain during this process, as
092233 - occurred Injecting for plantar plate tear, and into metatarsals of
092234 - both feet, per above. ref SDS 0 HS7H
092235 -
092236 - [On 170929 1010 biomechanics review by Mark Wachter, CEO
092237 - On-the-Run, reported normal gait, possibly indicating
092238 - recovery from prior findings on 151215, of early lift off
092239 - on left foot due to long-standing osteoarthritis in left
092240 - knee - indicating recovery with PRP treatment from severe
092241 - injury decades earlier. ref SDS 34 VW50
092243 - ..
092244 - Small bandaid is the only dressing for the knee.
092245 -
092246 -
092248 - ..
092249 - Follow Up Treatments Not Required
092250 - Dressing PRP Injections Final Instructions and Payment
092251 -
092252 - Doctor wrapped both feet with loose gause and ace bandages. She
092253 - explained this helps hold injected plazma in place. She further said
092254 - to walk flat footed for a day or so, to avoid pressure on metatarsals
092255 - while regeneration of tissue occurs.
092256 -
092260 - ..
092261 - Not sure what "walking flat footed" means?
092263 - ..
092264 - On completing the work, Doctor Tucker indicated loose bandaging can be
092265 - removed in a few days.
092267 - ..
092268 - The doctor recommended acetaminophen (Tylenol) for pain management, as
092269 - needed. Do not take anti-inflammatory drugs (NSAIDS), such as
092270 - ibuprofen, naproxen (Aleve), because these drugs prevent collagen
092271 - growth. This aligns with Doctor Darrow's documentation reviewed in
092272 - the record on 170710 1708. ref SDS 15 EP4L
092273 -
092274 - [On 170728 1649 letter from Doctor Tucker saying to avoid
092275 - Diclofenac gel topical treatment to feet, since it
092276 - restricts blood flow, and that will harm PRP treatment.
092277 - ref SDS 27 EE4F
092279 - ..
092280 - Patient should avoid hiking for 2 - 4 weeks. She would prefer 6
092281 - weeks.
092282 -
092283 - [On 170727 1747 Doctor Tucker called and said walking 1
092284 - mile 2 days after feet injections, and then slow for about
092285 - 3 miles helps distribute PRP in the feet. ref SDS 22 0W6V
092286 -
092288 - ..
092289 - Hugged Doctor Tucker, and said thank you for terrific care.
092291 - ..
092292 - Jane prepared the bill...
092293 -
092294 - $975
092296 - ..
092297 - Paid with credit card.
092299 - ..
092300 - Post expense ledger...
092301 -
092305 - ..
092306 - Doctor Tucker said no further treatment seems required at this time.
092307 - This single injection process today, should regenerate (heal) torn
092308 - plantar plate, and other injuries listed in radiologist's report on
092309 - MRI performed 170412 to fully relieve metatarsalgia pain in both feet.
092310 - Equally, the left knee should recover from degenerative arthritis for
092311 - months, if not years depending on level of activity.
092312 -
092313 - [On 170816 1400 for 2nd phase of regeneration injection
092314 - treatment with PRP Doctor Tucker used pain management
092315 - protocol similar to 1st phase, when no pain was experience,
092316 - but on this 2nd phase there was considerable pain, because
092317 - injections were deeper and more PRP was injected to achieve
092318 - benefits of regenerating (healing) plantar plate tear,
092319 - which were not achieved with 1st phase of treatment.
092320 - ref SDS 29 S543
092322 - ..
092323 - She said progress notes for work performed today, will be submitted
092324 - tomorrow.
092326 - ..
092327 - Advised will submit understandings for the doctor to review. Doctor
092328 - Tucker said to include a summary.
092330 - ..
092331 - Thanked her again for best possible care.
092332 -
092333 -
092334 -
092335 -
092336 -
092337 -
092338 -
092339 -
092340 -
092341 -
092342 -
092343 -
092344 -
0924 -