Team Lucia Puts Patient Back on Track

Lucia Contreras is the center of attention for her NorthBay team, which includes, from left to right, Medical Assistant Shon Jones, Primary Healthcare Coordinator Tiffany Montoya, R.N.; Certified Diabetes Educator Susan Rosten, N.P.; and Dr. Kulbir Bajwa.

For nearly 10 years, Lucia Contreras and her trusty pacemaker ticked along like clockwork, keeping the Vaca-ville woman energized and engaged, so neither she nor her heart missed a beat.

But pacemakers have a limited life, so in March 2013 she checked in to NorthBay Medical Center’s cardiac catheterization lab to get a new one.

A few months later, she started to experience chest pain. Although the pacemaker was functioning fine, her arteries were blocked, requiring triple-bypass heart surgery, and beginning a downward spiral of medical maladies that might have overcome a less determined individual.

“Don’t wait, visit your doctor, get your team in place to help you, listen to what the doctor says and know there is hope.”
—Lucia Contreras

But Lucia, who has already battled the odds with Type 2 diabetes for half her life, and a heart attack in 2004 (which resulted in the placement of the first pacemaker and three stents), has a NorthBay Healthcare team in place to help her navigate her dark days, which were plenty.

After a successful open-heart surgery, she went to a rehabilitation facility, but ended up back in the hospital because she couldn’t breathe. She was battling congestive heart failure, which caused swelling in her extremities as her organs started to shut down. “They were treating my liver, kidneys, everything,” she recalled.

She focused her energy on healing and started the New Year on a bright note: Released to come home. But, it wasn’t long before an infection and bleeding caused her sister Bertha Salort to drive her to the NorthBay VacaValley Hospital Emergency Department, where she received an ultrasound, antibiotics and some TLC.

Two more visits to the hospital followed in the months to come, including two stays at NorthBay Medical Center, where she received excellent care from a team of doctors who weren’t about to send her home until she was back in control.

This time, it was pneumonia, and she had to have a lung drained. “There was an amazing team of doctors—Drs. Anit Patel, Gurinder Dhillon and Pushkar Pandy, who really focused on my case. The nurses were so kind and attentive, and this time, when I went home, I took oxygen with me.”

She still has an oxygen tank set up in her bedroom, just in case. She’s focused on weaning herself off it, but it’s comforting to know it’s there.

Also comforting have been her support teams at the Center for Diabetes & Endocrinology and the Center for Primary Care, both affiliates of NorthBay Healthcare.

Lucia’s team from the Center for Diabetes and Endocrinology has supported her for years, but stepped it up after her medications became complex and she needed closer monitoring, according to Endocrinologist Deborah Murray, M.D., the center’s medical director.

Certified Diabetes Educators Susan Rosten, family nurse practitioner, and Collette DaCruz, R.N., work as a team to help Lucia monitor her insulin doses to prevent hypoglycemia and hyperglycemia, sometimes through phone calls and sometimes by office visits.

“Our care is individualized, depending on what the patient needs,” explains Susan. “Often patients need an intensive follow-up after hospitalization or sudden changes in their health.”

“I’ve had Type 2 diabetes for 40 years and it’s under control most of the time,” says Lucia. Still, she needs four shots of insulin a day and she must be very careful about what she eats.

“I’ve pricked my fingers so many times for blood readings that I have callouses,” smiles Lucia.

Her primary care team of Dr. Kulbir Bajwa and Tiffany Montoya, R.N., have been superb, says Lucia. “Any time I have a problem, they say, ‘Call us!’ And I do, I let them know right away.”

Lucia wanted to take back control of her life, says Tiffany. “I simply supported her by giving her a call and asking how her daily exercises, breathing, weight control and medications were going,” explains Tiffany. “From there, I taught her to call me, giving her the control of when the calls took place. Lucia has blossomed into what she knew she could be. Although she is still not at 100 percent, she’s willing to battle every day to regain her dignity and self-preservation.”

The team concept allows a physician and a nurse/care coordinator to reach out to the patient, to make sure they’re keeping appointments and to answer questions. Medical Assistant Shon Jones is also an integral part of the program, focused on time management and serving as the gatekeeper and front-line responder to all patient care issues.

“We are striving to provide team-based care to all of our chronic patients, especially those with multiple medical problems and confusing medications,” explains Dr. Bajwa.

“Lucia is a good example of someone who needed help, but wanted to be independent. She was afraid she might get her medications confused. With constant help and phone contact, there was plenty of support and she managed to regain her confidence.”

Lucia gives the credit to Dr. Bajwa and the team. “Dr. Bajwa is my lifesaver,” says Lucia. “She is extremely attentive, and a good communicator. And Tiffany works with me every day, checking my stats to see if there are any problems. I feel so much more confident with this team in my corner. Some days are hard, but there’s always lots of good support.”

Her message to people with diabetes or heart issues: don’t wait, visit your doctor and get your team in place to help you. Listen to what the doctor says, and know there is hope.

“I’m the luckiest woman in the world,” says Lucia. “I get up every day, and I think here’s another day I get to live. The sky is blue and I’m so very happy.”

What is CHF?

Congestive Heart Failure is not a heart attack, but a sign that the heart is not pumping blood the way it should to meet the body’s needs. It can lead to cardiac arrhythmia or an irregular heartbeat. It is the leading cause of hospitalization and death in those age 60 and over. Early symptoms include:

  • Easily tired.
  • Shortness of breath.
  • Heart is racing.
  • Weak or dizzy.

As heart failure gets worse, fluid builds up in the lungs and other parts of your body. The patient may experience:

  • Shortness of breath, even at rest.
  • Severe fatigue and weakness.
  • Dry cough or cough that produces blood.
  • Frequent urination during the night (right-sided failure).
  • Swelling of the ankles and feet.
  • Rapid weight gain due to fluid retention.
  • Abdominal pain and a feeling of fullness.
  • Swollen neck veins.
  • Loss of appetite, nausea and/or vomiting.
  • Irregular or rapid heartbeat.
  • Anxiety; in severe cases irritability, restlessness, and mental confusion.

Lucia Contreras keeps her oxygen machine close to her at night.

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