Day Zero

 "Accept the things to which fate binds you, and love the people with whom fate brings you together, but do so with all your heart." - Marcus Aurelius

"Day Zero".  It sounds very dramatic.  It's the day they've scheduled a patient for their bone marrow transplant.  Oddly enough, a bone marrow transplant is both very sensational while at the same time being pretty mundane.  Let me explain.

 At the end of the previous post, I had just completed treatment in a Phase IIb trial, where researchers use human test subjects to determine the optimum dose of a new medicine to get the greatest effect with the least side-effects.  They had injected me with monoclonal antibodies that would selectively attach to leukemia cells, attached to which were alpha-particle emitting Astatine-221 atoms.  This trial happened on Day -7.  I am still participating in this trial - all medical results until my death will be forwarded to the study.

I felt just fine after the trial, and three days later went on a four-mile walk around the city of Seattle, up and down the hilly streets.  I could have gone much further, but the day was growing long.  It was a good time to walk around Seattle - the city was hosting several FIFA cup soccer (football) matches, and they had rounded up most of the homeless, placing them in communities of temporary "tiny houses".  I took a few pictures - I always do that.

Below:  A relic of better times.  The Space Needle, an atomic age structure, built for the 1960 world's fair.

A raised pool in Lake Union Park - possibly a fountain - being used by some elderly gentlemen with radio-controlled sailboats.

Below: The bicycle section of REI, an outdoors outfitter based in Seattle.  Sadly, I learned that this was not the original downtown store.

At day -5, I was put under anesthesia for the installation of a Hickman line.  This is a different critter than the three PICC lines that had been installed in my arm(s) previously.  The Hickman line is a long-term "central line".  The PICC line is inserted into an arm vein, while the Hickman line enters the upper chest, travels along under the skin and over the collarbone, then enters the Jugular vein.  The risk of systemic infection with the tunneled line is greatly reduced, because so much tissue lies in between the entry point and the circulatory system.

Below: Yep, that's me with a sheet of Aqua Guard over the entry point, about to take a shower.  If you look carefully, you can see where the lines travel over the collarbone.  The iFit watch data was downloaded weekly for an unrelated aging study.

On day -4, they started me on a standard "Conditioning" pre-treatment prior to transplant.  This conditioning is a combination of chemotherapy and whole-body radiation that is intended to kill off any remaining leukemia prior to transplant on Day Zero.  My conditioning regime was "Reduced-Intensity Conditioning", in part due to my age, but also due to the fact that I'd already been through the previous Astatine-221 study.  

Alas, I forgot to ask what chemicals they were using for the chemo.  I received three days of chemotherapy at the clinic.  Each day we would take the shuttle over, get an IV of something, and then we would return to the apartment.  On day -4, they also had me start taking drugs to suppress the immune system - Cyclosporine, and MMF (Micophonylate Motefil).

The MMF is a pain in the butt, because you can't have dairy for two hours on either side of a dose, and I was taking it 3x per day - so there were six hours each day that were outside of the dairy window.  A tough proposition for a guy who likes whey protein, cheese, and breakfast cereal.  The Cyclosporine pill smelled like a dead skunk, and leached minerals out of the body, like magnesium and potassium, requiring oral and intravenous supplementation for weeks on end.

After three days of outpatient chemotherapy, it was Day Zero.  The big day, when I would get a new opportunity at life.  It started with two Grays of whole body X-radiation at 21 Kilo electron Volts (KeV).  This is 200 Rads for us old-school nuclear guys - a hell of a lot more than you want to be exposed to, but not enough to make you sick (vomit).  I missed the opportunity to take a picture of the equipment, to my chagrin. 

They laid me on my side, and placed an inch-thick leaded glass plate between myself and the linear accelerator.  The plate scattered the beam so that it would irradiate me more equally.  They put a shielding device around my neck to attenuate the radiation, as there was not much tissue there, and a lot of energy would otherwise be deposited in my neck.  They attached diodes at various points for measuring the dose in real-time, to ensure every part of my body was dosed equally.

Below:  The setup looked like this, except I was lying on one side, facing the wall.

Then they put on the music - I requested "I wanna be sedated" by the Ramones.  That got a laugh out of the X-ray techs.  They dosed me for about 10 minutes, flipped me over, and did the other side.  I met the wife afterwards and we took the shuttle back to the apartment again, waiting for word on the arrival of my new bone marrow.

The bone marrow donor was a 28 year old male from England - not terribly surprising that they found a perfect 12/12 match in England, since my mother's family all arrived from there two generations ago.  A 12/12 match is more refined than the 10/10 match for other transplants, and has higher survival rates and much less likelihood of complications.

The marrow had been harvested from the donor earlier in the day, flown across the Atlantic Ocean an the US, and had to clear customs before it could be brought to the Fred Hutchinson Cancer Institute by ground.  It wasn't clear how late it would arrive, so we were told the transplant might take place at the clinic, or it might mean an overnight stay at the hospital across town if the package arrived late.

The cells arrived late, but not so late that the clinic had shut down.  The process took just over an hour, and it was just like a blood transfusion.  Into the Hickman line at a slow rate, check for signs of problems, like a fever, then increase the pump speed.  Really it wasn't anything special, except that it was.

Below:  Unboxing the gift of life - donated bone marrow cells

Below:  Beginning the transplant.  They don't need to drill into your bones to transplant bone marrow cells.  They know where to go.

The transplant process was really mundane after having had so many blood transfusions - up to a point.  It ran about 90 minutes, however at the 80 minute mark, I started experiencing chills, and developed almost uncontrollable shivers.  They halted the infusion and consulted the attending physician.  He came in, checked me out, and told them to continue - since each transplant cell is precious.  The process continued until the bag of cells was empty.  The chills eased somewhat, but I still felt incredibly cold.  I asked the nurse what would cause the reaction, and she explained.

The donor and I didn't have the same blood type.  His blood was B+ and mine was O+.  His blood type was not compatible, and while the bone marrow is filtered, some of that blood came along for the ride. Thus the immune reaction.  

Once the shivers subsided, they released me.  We made our way to the underground garage - the shuttle service having long since concluded for the day - and I had the wife crank up the heated seats and turn off the fan in her car before I would even enter it.  It was that bad.  Once we were back to the apartment, I turned the heating pad on high and covered up.  

For the next few days, every time I passed the air conditioning unit, chills set in.  I was told it could either be chronic reaction to the cells or a side-effect of the whole body radiation treatment.  Either way, it eventually subsided.  

It was an eventful day, to be sure!