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, I had a preliminary diagnosis of an aggressive form of leukemia called Acute Myeloid Leukemia.  To confirm the diagnosis it was necessary to get a bone marrow sample and have it examined by a pathologist.  

They put me under a fluoroscope, and then set up an IV to inject a small amount of the powerful opioid fentanyl.  I told the supervising nurse that I didn't want fentanyl - and they gave me a half-dose anyway, shortly before drilling into the bone - only telling me afterwards.  Next 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, just a bit of twinge as the drill cored in to the hip.

 Below:  A fluoroscope.  This machine allows the medical technician to see x-ray type live video in real-time as they perform work inside the body.  Mine was set horizontal for the procedure.

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.  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.  Some of these sample procedures were more painful than others, but none of them were any worse than dental procedures or teeth cleanings that I've experienced over the decades - not fun, but not that awful either.

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 explains why I was out of breath all the time - that much blood was junk, and not carrying any oxygen.  It was just circulating, doing nothing but multiplying.

The hospital staff brought me up to functional levels of blood with several transfusions of red blood cells and platelets.  Once counts were back to semi-normal levels, I was released from the hospital temporarily.  A sample of the bone marrow was sent to the Mayo Clinic for further analysis, to determine the genetic makeup of the leukemia.  Apparently there are mutations that are susceptible to certain chemotherapy drugs, but as it turned out, my leukemia was a type that had no weaknesses to attack :(  

In any event, I was home for a couple of weeks, so I was not in the hospital over Christmas.  We had not decorated the house, and I set up a tiny tree, taking it down shortly afterwards, because on New Year's Eve, I was readmitted to the hospital for standard leukemia chemotherapy treatment.

There is no "staging" for AML.  If a patient is over 20% blasts, previously untreated, they get 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 cancer cells from growing. 

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

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 injecting very toxic drugs, and it's important that they are released at the heart suction.  By moving the release point to the heart, it avoids damaging a vein with concentrated toxic chemicals.  So a central line allows these chemicals to mix and dilute in the heart chamber with large volumes of blood.  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.  I was low on platelets, and had bruises up and down each arm from earlier daily blood samples.  The PICC line also allowed the staff to get daily blood samples without having to poke me each time, so it was really a blessing - although over time it would become a mixed blessing!

Below:  A view of the PICC line entry point at the inner bicep.  They apply a clear dressing to help prevent infections, and so they can monitor for redness that would indicate infection.  Showering requires a watertight sheet of plastic to be wrapped around this.  Showers would take place in between the week-long series of back-to-back IV bags. It looks painful and awful, but it was not.  It was just more difficult to do routine things while attached to an IV bag.  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.

Chemotherapy was not terrible.  There are side effects, of course - Hair loss and diarrhea were my main issues.  I never experienced nausea or vomiting though.

As mentioned earlier, the standard Induction treatment for AML is Doxorubicin for three days, which was injected manually.  This is known as the "Red Devil", and they give you an anti-nausea IV about 30 minutes before the Doxorubicin is administered.  A legit horse shot - I joked with the staff it looked like Jonestown Kool-Aid to me, 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!

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 wit the warning for the staff to handle with care the stuff that was being injected into my heart.  I thought this situation was pretty humorous!

Below:  My view for 29 days.  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 :)

Below:  My view in the other direction, getting some red blood cells.  Chemotherapy for AML destroys your bone marrow, so 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 you an IV of white cells from another person, because they would attack your entire body as a foreign invader.  More on this topic later!

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

While the chemotherapy only lasted a week, the hospital stay lasted much longer because AML chemotherapy destroys your bone marrow, and thus it destroys your white blood cell counts - meaning it has destroyed your immune system.

One of the key 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, and I was there for 29 days before the neutrophils recovered.  Pretty close!

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 was 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?