Thursday, August 14, 2014

Getting Ready for Chemo

By Jay Ellis, MD

Editor's Note: This is the second in a series of articles written by San Antonio anesthesiologist Jay Ellis, MD, a member of the Bexar County Medical Society Communications/Publications Committee. The series, published monthly in San Antonio Medicine, examines the physical, emotional, financial and spiritual burden of life-threatening illness. Check out part I, Dealing With Cancer.

After I made the trip to the emergency room (ER), I called my oncologist, Dr. Greg Guzley. He saw me right away. The bone marrow exam was inconclusive, and he told me that we needed tissue to confirm the diagnosis and establish the right chemotherapy. He gave me some tasks to accomplish. Get a vascular access port placed. Get an echocardiogram as a baseline, and schedule a percutaneous biopsy of my retroperitoneal mass.

Having specific tasks to accomplish gave me focus. My friends and collea
gues were wonderful. Dr. Mack Sykes inserted the port, and Dr. Bob Saad arranged my echocardiogram. The only delay was getting the biopsy. The procedure schedule at Methodist was booked solid for over a week. My wife, Merrill, was not happy about this, and several doctor friends I spoke to listened to my story and tried to pull some strings, but sometimes the schedule is the schedule. I resolved to be patient and bide my time. After all, what difference could a few days make? Greg gave me some tramadol to manage the pain, and it helped. I was able to go to work. For years, I have told my pain patients they need something to focus on besides their pain, best done by engaging in meaningful activity. It helps distract people from their distress. For the first time I had a chance to test my hypothesis. In my personal series of one patient, I concluded that it does work. When I went to the operating room or when I was in the clinic, the need to focus on someone else’s problem distracted me from my own. In clinic, I would sit each day and discuss with patients the necessity of moving past the sadness and anger from their illness and focus on the good things in their life. I found that I felt better after these discussions. I wasn’t preaching to the choir. I was preaching to the preacher.

PAIN INCREASES

As the days passed leading up to my biopsy, my pain began increasing at an exponential rate. The irony of the pain doctor dealing with his own cancer pain wasn’t lost on me. The pain wasn’t so bad during the day, but the nights were misery. After an hour lying down, my dull, aching left upper quadrant pain would become a severe, constant, cramping sensation. I wondered if this is what labor pain felt like, and if it is, women have a bad deal. At first, the tramadol would buy me a few hours of sleep. One night I took it so often that I woke up with tremor and agitation. The pain management physician gave himself serotonin syndrome from tramadol overdose. I called Greg Guzley, and he gave me some oxycodone at my request. It seemed to ease the pain and allowed some sleep.

My biopsy was done at Methodist radiology, and the staff could not have been nicer. I did get the traditional two sticks of the IV, obligatory for every physician requiring health care, but after my counseling for the procedure I received my sedation and remember nothing else. The turnaround on the pathology specimen was rapid, and we had our diagnosis, non-Hodgkin B cell lymphoma. I was ready to start treatment right away, but since I have private insurance, the next step is, of course, preauthorization. Greg assured me that the turnaround time was three working days. Unfortunately, that included a weekend. Being on the other end of insurance authorization is no more fun than being on the providing end. My nighttime pain continued its exponential increase. The combination of tramadol and oxycodone was no longer effective. I would sleep for an hour, awake in pain and walk the floor for 30 minutes until the pain subsided. I would repeat this process several times each night. I got little sleep, and I suspect my poor spouse got even less. I thought about taking some Ambien, but I realized, despite my pain-addled state, that if the Ambien, tramadol, and oxycodone all peaked at the same time I might fall asleep and never awaken. I pride myself in being an expert on cancer pain and realized that I had the same problem as the patients I see in the office. It is hard to control severe, episodic pain with oral opioids at doses that don’t impair cognition, or in the worst case, ventilation. I called Greg the next day, and he started me on some steroids, which helped significantly. I was not pain-free, but I was able to sleep for more than one to two hours.

During this time I also had to make the phone calls to family. I called my mother, my children, and my brother and sister. My mother found that great balance of being appropriately concerned and reassuring, a gift that is somehow bestowed on all mothers. My brother and sister argued over who was a better match if I needed a bone marrow transplant. My daughter told me she was flying in to see me. I told her this was a bad idea. She was pregnant, with two sons — a 3-year-old and an 11-month-old — and she was packing up her house for a move to Germany. I told her she just couldn’t afford to come. Just as she did when she was a teenager, she ignored me and booked the tickets. My son told me he was coming to San Antonio, but I suggested we all meet in Houston to celebrate his birthday. I hoped that a trip out of town might distract me from my condition. My stepson, Brent, called and “Breaking Bad” fan that he is, told me he hoped that I would not start cooking meth. Humor is always a great relief. Through all this, Merrill constantly monitored my health. I don’t think I’d ever felt so loved in my entire life.

EATING BECOMES CHALLENGING

Merrill noted first, and the scale confirmed, that I was losing weight at a rapid rate. In two weeks I dropped 10 pounds. The cancer was consuming me. I could not maintain weight. Eating was a challenge since I had no appetite. I would be full after just a few bites of food. I made every effort to eat to keep Merrill happy, but there was certainly no enjoyment in it. Horrible night sweats began, accompanied by fever. I marveled at my own positive review of systems. Still no word on the start of my treatment.

We made the trip to Houston to see my son, his wife, my daughter, and grandsons. My brother and his family came as well. The weather was glorious. We spent the day in a park playing with the boys. My pain was manageable, and I even had a little bit of an appetite. It would be the best day I would have for long time. That night the pain reached its zenith. The cramps became daggers and lying down felt as if I were being impaled. I took an extra dose of steroids, which worked well enough to keep from going to the ER. Merrill insisted that I call Greg and get some help. We made the trip home to San Antonio, and I called Greg the next day. I told him I couldn’t take it anymore. We either had to start treatment or he would have to hospitalize me. My ability to cope was gone. I was 15 pounds lighter. He made some phone calls, increased my steroids, and got me through the 48 hours until I started my first chemo.

Up next: In the Chemo Room

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