Interlude and Induction Chemotherapy

 "How wonderful it is that nobody need wait a single moment before starting to improve the world." - Anne Frank   Amazing thoughts and insight from a child of such a young age!

As mentioned in the previous post, the oncologist had given a preliminary diagnosis of an aggressive form of leukemia called Acute Myeloid Leukemia.  To confirm the diagnosis, it was necessary to take a bone marrow sample and have it examined by a pathologist.  

The very first bone marrow sample was different from all following samples.  With the first one, they used a fluoroscope to get the correct placement, and used a power tool to drill into the bone.

 Below:  A fluoroscope.  This machine allows the medical technician to see x-ray video in real-time as they perform work inside the body.  The table was positioned horizontally for the bone marrow draw.

The technicians inserted an IV to inject a small amount of the powerful opioid fentanyl.  I told the supervising nurse that I didn't want fentanyl - but they gave me a half-dose anyway, shortly before drilling into the bone - only telling me afterwards.  They injected a local anesthetic called lidocaine, inserted the drill into a small incision on my backside above the butt, and quickly power drilled into my hip bone.  I jumped a bit at that point.  This wasn't exactly painful - but there was a bit of twinge as the drill cored in to the hip.

Next, they extracted the sample of bone marrow out of the tiny tube.  This also wasn't particularly painful, but it was a tad unpleasant -it's difficult to describe the feeling, but it's not very nice.  I've since had several bone marrow aspiration procedures, all of which were done bedside, without the use of a fluoroscope, using manual T-handle drills.  

Below: A bone marrow manual extraction drill.

The pathology result of the bone marrow test arrived a couple of days later, and confirmed the preliminary blood sample diagnosis of Acute Myeloid Leukemia (AML from now on).  The pathology report also showed that the amount of cancer cells circulating in my system was over 20%.  This high percentage of cancer cells explains why I was out of breath all the time - 20% of the blood was junk, and not carrying any oxygen.  It was just circulating, and doing nothing but multiplying.  A sample of the bone marrow was also sent to the Mayo Clinic for further analysis, to determine the genetic makeup of the leukemia.  There are various mutations of leukemia, some of which are susceptible to attack by certain chemotherapy drugs.  Unfortunately, my leukemia was a type that had no points to more effectively attack :(  

The next step was to for the hospital staff to get my blood cell levels back to functional levels as a temporary reprieve from the disease, and so they performed several transfusions of red blood cells and platelets.  Once counts were back to semi-normal levels, I was temporarily released from the hospital.  

I was able to be home for a couple of weeks, and was not in the hospital over Christmas.  We had not decorated the house, but I set up a small tree, taking it down shortly afterwards, because on New Year's Eve, I was readmitted to the hospital for "standard" leukemia chemotherapy.

There is no "staging" for AML.  If a patient is over 20% blasts and previously untreated, they receive what is called "standard induction chemotherapy".  The process involves four days of daily injections of Doxorubicin, to keep cancer cells from dividing, and seven straight days of IV flow of Cytarabine, to prevent the cells from growing. 

Before chemotherapy could even begin, it was necessary to install a "central line".  There are three different kinds of central line:  The port, the PICC line, and the Hickman line.  I've now had two of the three.

With the help of another fluoroscope session and a local anesthetic, the technicians installed a PICC line in my left arm.  It is necessary to install a central line because they are about to inject very toxic drugs, and it's important that these drugs are released at the heart suction.  By moving the release point to the heart, these toxic chemicals can mix and dilute in the heart chamber with large volumes of blood.  This avoids damaging a vein with concentrated toxic chemicals.  Both PICC and Hickman lines have two separate lines leading to the heart, with the lumens colored red and purple, while a chemo port is just a reservoir buried beneath the skin.

Below:  PICC line lumens.  The PICC line also allows staff to get daily blood samples without having to poke the patient each time.  It was really a blessing - although over time it would become a mixed blessing!  The bruising is from previous blood draws.

Below:  A view of the PICC line entry point at the inner bicep.  

The PICC line has a clear dressing to help prevent infections at the entry point, and also to monitor for redness that would indicate infection.  Showering requires a watertight sheet of plastic to be wrapped around this.  Showers would also have to wait until one of the IV bags of the week-long series of back-to-back IV to empty out. 

The PICC line looks painful and awful, but it was not.  It just made life a bit more difficult, because routine things are a bit more complicated while you are attached to an IV bag, plugged-in chemical pumps, and a rolling pole.  NOTE:  The fitting with the large gray plastic is a double walled connection for the chemotherapy drug.  The nurses handled those fittings with face shield and gloves on.

There were also a few other things that came before chemotherapy could start - an EKG, sonogram scans of the heart and liver, and a couple of other bloodwork tests.  Chemotherapy was not terrible.  There are side effects, of course - Hair loss and diarrhea were my main issues.  I never experienced any nausea or vomiting though.  

As mentioned earlier, the standard Induction treatment for AML is Doxorubicin for four days, which was injected manually over the course of about 10 minutes.  This is known as the "Red Devil", and they give you an anti-nausea IV about 30 minutes before the Doxorubicin is administered.  This chemotherapy is a legit horse shot!  I joked with a couple of the nurses that it looked like Jonestown Kool-Aid, but I'm not sure they were old enough to get the joke :)  The Doxorubicin also turns your urine a beet red color almost immediately!

Below: Injection of Doxorubicin into the IV line.

The other chemotherapy drug used in the Induction treatment is Cytarabine, which is a relentless seven day long IV.  Below is a picture of the IV pump, complete with the pink warning label to handle with care.  Meanwhile this stuff that was being injected into my heart.  LOL!

Below:  My view for 29 days.  

Below:  A view in the other direction while getting a transfusion of red blood cells.  Chemotherapy for AML destroys your bone marrow, so both your red and white blood cell counts fall out, as do the platelets.  They replace the red cells and platelets as necessary, but they cannot give white cells from another person, because they would attack you as a foreign invader.  More on this topic in a later post!

When you are hooked up to an IV pole for seven days straight, routine stuff like eating and using the bathroom is very different!  They encourage patients to get daily walks in, but since you are attached to an IV on a rolling pole, it's awkward walking the hallways.  I told a few of the staff that I never imagined at this point in my life that I would be a pole dancer :)

When you are on chemotherapy - at least the kind I was on - they insist that you drink a lot of water.  The chemo is killing billions of cancer cells, which the kidneys then have to filter out of your bloodstream.  In order for the dead cells not to clog up your kidneys - Tumor Lysis Syndrome - it's important to keep them flushed.  They also had me track water balance - how much water went in and how much urine came out.  I'm not sharing any pictures of that :)

Below:  The cleaning ladies from work came by for a visit!

While the chemotherapy only lasted a week, the hospital stay lasted much longer.  Chemotherapy for  AML destroys bone marrow, and therefore it also destroys white blood cell production - meaning it has weakened your immune system.

One of the key immune system measures the doctors were following was the "neutrophil count".  Neutrophils are the most common type of white blood cell, and they act as a rapid-response first responder to an infection.  Until the neutrophil count had recovered enough, I was considered immune-compromised enough that hospitalization was necessary.  The typical hospital stay following AML induction chemotherapy is 28 days.  I was hospitalized for 29 days before the neutrophils recovered, and toward the end of January 2026, I was allowed to return home.  Returning to work was not an option, per doctor's orders.

As an overall recount of the experience, during the first week of chemotherapy I felt just fine.  The second week was a bit of a crash and slump.  The third week was pulling out of the slump, and the fourth week was a return to normal energy levels. 

On a more personal note, one fascinating thing that I noticed about being hospitalized - I was overwhelmingly happy and cheerful.  It took me a while to realize why I felt so upbeat.  Had you asked me before my diagnosis and hospitalization if I was under any stress, I probably would have said "Yeah, a little, but not much."

Truth was, I had been under a great deal of stress.  

I supervised eight guys - some of whom had issues that affected their work, and needed guidance and a shoulder to cry on.  I had deadlines for all of them and myself.  I had trainings to attend, a hundred lab chemicals to ensure were ordered on time and ensure they were shipped.  I had to gather whatever information the facility's owners wanted from the power plant control network and import that into spreadsheets and do whatever calculations were needed, and never mind the daily stuff that they were trying to automate, with my inept assistance.  I also had planning for the next outage, which often began in the middle of the current outage due to long lead times on equipment.  

I mentioned this odd sense of peace to one of the nurses, and she said that it's very rare people feel relieved and happy in this situation, but that it happens occasionally  It was interesting that I felt lucky to be there.  I went from having a million problems to having one problem, and it wasn't even a problem that I could control.  For the first time since I was a child, there was very little to worry about...  Weird outlook for someone with a life-threatening disease, eh?