Thursday, August 28, 2014

In the Chemo Room

By Jay Ellis, MD

Editor's Note: This is the third 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, and part II, Getting Ready for Chemo.

I doubt anyone was as relieved to start chemotherapy as I was. It was my best hope for recovery and relief from the scourge of the abdominal pain that tormented me nightly. My wife, Merrill, prepared for my first chemotherapy session with a proficiency and precision reminiscent of the logisticians of Desert Storm. She packed enough food for a regiment, assembled what looked like a year’s worth of reading material, and packed a bag full of sweaters and blankets in case I felt cold, or decided on Arctic travel. Carrying all these bags into chemotherapy reminded me of the Clampetts arriving in Beverly Hills.

Greg Gulley saw me that morning to review my lab work and treatment plan. It was comforting to see him. I did complain that I had only 54,000 platelets and everyone seemed to want to draw my blood and take a look at them. He responded by giving me an article from the New England Journal of Medicine confirming that patients are often phlebotomized into anemia. OK.

EGALITARIAN GATHERING PLACE

The chemotherapy room is a great egalitarian gathering place, like the DMV or divorce court. Cancer is an affliction that crosses all social barriers without prejudice. We were the first ones there, and Merrill staked out a plum position, then began making friends as others arrived. While we were in chemotherapy we would meet other professionals, laborers, little old ladies, little old men, and too many young people. Everyone is there for the same purpose and everyone asks your diagnosis, not unlike being in prison and asking, "What are you in for?"  It is a mutual support society. There are even moments of humor, such as one man who spent his entire treatment session standing and yelling, “I'm not sick. I don't know why I'm here. I don't need this," all the while hooked up to his infusion.

The chemotherapy nurses are caring, professional, and they inspire confidence. They reviewed each medication with me. I did have memories of CHOP (Cytoxin, vincristine, doxorubicin, prednisone) therapy from my medical student and resident years. I can still recall the hemorrhagic cystitis, heart failure and peripheral neuropathy experienced by my patients. I had vivid memories of the intractable nausea and vomiting they all developed with each session of therapy and for days later. The specialty of oncology should be commended for improving this bleak picture. First, I received several premedicant drugs to minimize my symptoms and risk for side effects. I experienced mild nausea, but not the intractable vomiting so starkly remembered. In addition, I would get the CHOP-R version with the addition of the monoclonal antibody drug rituximab. Unlike the old days where chemotherapy was an applied exercise in selective toxicology, I now had the “magic bullet.” Rituximab would be specific for the lymphocytes of my lymphoma, sparing me from many of the side effects of the old CHOP regimen.

After I finished my premedication, the rituximab infusion began. My bride is a great doer, but not good at sitting and watching. I can tell when she is getting fidgety and asked her to go and get me a Starbucks coffee. Soon after she left things got strange. I started getting the rigors/shaking chills I once had with pneumonia. They started small, but began to crescendo in intensity and duration. I raised my hand like a school child and the nurses quickly recognized my problem and descended on me. I became the center of attention in the chemo room, not a distinction I wanted. The nurses rapidly went through the algorithm to treat symptoms they saw often. One nurse stopped my infusion. One covered me with blankets and another brought the diphenhydramine and steroids to treat my symptoms.  My symptoms became worse. I was shaking uncontrollably and wondered if this is what seizures felt like. The muscles in my neck began to contract, and my head bent to the left with a strange, torticollis-like position. I had never felt so helpless in my entire life. I had no control over my body, and I thought I would vibrate myself right out of my chair. Fortunately, after some meperidine, my symptoms subsided. I was exhausted. I doubt the whole episode lasted more than 10 minutes, but I felt like I had been exercising for hours. The combination of the medication and the physical exertion of the shaking chills left me exhausted. I fell asleep and woke later with Merrill sitting next to me with a cold cup of coffee. The nurses slowed my infusion rate. It took the entire day to finish my regimen, and we left late that afternoon.

SMOLDERING EMBERS

I woke the next morning feeling is if someone had lit a fire throughout my body. It wasn't the flaming inferno of the forest fire. It was a low, smoldering sensation like the last embers of the campfire as it consumes the final ounce of fuel. I felt the smoldering most intensely in my back at my biopsy site. I wondered if it was my tumor shrinking away from the effects of chemotherapy, but quickly extinguished that thought as the silly wishes of a desperate man. I was tired, in pain and just felt awful. Merrill began what soon became our thrice-daily ritual. She would prepare something for me to eat, and I would refuse to eat it, lacking any appetite and certain that ingesting food would result in catastrophe. She would respond by first persuading, then cajoling and finally insisting that I eat. I only made the attempt because I knew it was important to her. I'm convinced that had she not been there I would not have eaten anything that day, or for several days after. Friends called and sent text messages of encouragement. I tried to respond to everyone, but fell asleep. Merrill swiped my phone and answered the messages for me so that I would rest during the day.

The next day the diarrhea started. The smoldering now became a hot torch centered in my rectum. Every time I tried to lie down the diarrhea would return. The burning sensation in my rectum was accompanied by spasmodic contractions of the viscera of my abdomen. It was misery. I began to pray to God fervently for relief. I was afraid to be more than a few steps away from the bathroom. The designer who placed three commodes at different locations in our downstairs now seemed like an architectural genius. By the next day these symptoms passed as well, and I went from being severely distressed to just miserable. Then I noticed something remarkable. My abdominal pain was gone. I hadn't touched any pain medication for 24 hours. The stabbing torment in my abdomen vanished. The distress I felt over the previous days seemed like more than a fair trade. There was hope that the chemotherapy was working.

After five days, I tried to go back to work. I overestimated my recuperative powers. The walk from the parking garage to my office took every morsel of physical energy I possessed. I sat at my desk, completely exhausted. After two cups of coffee and a 30-minute rest, I began to rally. As always, work was a tonic, and I survived the day. My office staff could not have been more supportive. They made little changes to make my work easier and my life more comfortable. Their concern increased my resolve to get through the day. I did finish my schedule, but when I arrived home I was exhausted. I was too tired to argue with Merrill about whether or not I would eat. After I ate, I just went to bed. I would repeat this routine for several days, but as the days went by my strength seemed to grow and my stamina increased. I certainly wasn't well, but I had hope that I was moving in the right direction.

ROUND TWO

I approached my next chemotherapy with some trepidation. The nurses were a great comfort, telling me that by slowing the infusion rate they could get me through my chemo without the drama of the first encounter. They were right. This session went smoothly, without the near-epileptic activity associated with the first visit.

Three weeks later, I went for my first CT scan since my diagnosis. I did have to choke down two bottles of oral contrast which, despite the flavoring, will never replace Coke or Pepsi. The CT scan would determine my progress on chemotherapy. The staff at South Texas Radiology was polite and encouraging. After my scan, Dr. Todd Tibbetts took the time to review the images with me. The results were obvious even to the average anesthesiologist. The abdominal mass, the lesions in my spleen and the lymph nodes shrank to a fraction of their former size. The chemotherapy was working, and the success was better than anything I could have imagined. For the first time I understood what it felt like to want to weep for joy.

Up next: Complications.

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