Apheresis has finally begun!
Over the last week and a half, my mom has been trekking over to SCCA every single morning, bright-eyed and bushy-tailed at 7 or 8 AM for lab draws. It's been amazing to hear the multitude of people willing and available to drive her between her home and the center.
Since increasing her GCSF dose, the transplant team has been checking her plasma for the CD34 marker which signifies enough stem cells. (The CD34 marker is biologically analogous to the CD4 marker that signifies helper-T cells, the cells compromised in HIV, which is a more well-known example of surface antigens or "markers.") She had to have her GCSF dose increased to the maximum, however, and only finally had enough for apheresis (collection) yesterday midday. She will have her second round of collection this morning.
Meanwhile she's been getting transfusions mainly of platelets, which unfortunately dropped again more than we would have liked.
In other news, my mom and I had previously discussed, during her last inpatient chemotherapy, what would happen during the two months in between her final chemotherapy (week of April 14th) and her big blast/transplantation (late June). We were both concerned that, during such relatively long period of time on the cellular level, that "bad things" could happen. The week following that conversation, she met with the transplant team, and they were shocked that it'd been scheduled two months out. The transplant has now been rescheduled a mere four weeks after the final round of chemotherapy, and she will likely be post-transplantation by the end of May. (She still won't be able to come to my graduation, though. Argh!)
In summary, the rush is finally totally and completely upon us. Hopefully it all works out in our favor.
Resources:
Detailed Information on CD4 Cells
10 April, 2008
05 April, 2008
Codes
I've always understood that codes are important; I've come within 20 seconds of calling a code pink (missing pediatric patient), I've had training for aggressive patients/visitors to avoid calling security codes, and I've been down the hall from code blues.
Nothing quite highlights the necessity of quickly answering call lights or monitor alarms as a code blue though. From my earliest days working in healthcare, it's been engrained that you had to answer calls within 30 seconds if possible, and anyone available should be answering them, not just CNAs or RNs or the unit secretaries, anyone.
Imagine you have a small sick baby as your patient. She's been doing well all day, and you're 5 hours into your eight hour shift. It's time for routine vitals and checking on her gastronomy tube and assessment. You walk in, administer medications, take the set of vital signs; all goes well, and you turn to leave, parents quietly sitting bedside. Two steps from the door, alarms sound, so quickly you spin around and see her face. She's not breathing and she's turned blue, without warning. "Respiratory arrest!" You call a code blue, and the team is there within two minutes.
What if you had not been in the room? It easily could have been another 3 or 4 minutes before someone else was available (or, worse, not too lazy) to answer the alarms and declare the code. It illustrates so clearly the meaning of time in a medical emergency and the responsibility of healthcare professionals to respond promptly, consistently and continuously.
The chaos following is almost thrilling to watch. Staff physicans race down the hall, almost losing their carefully balanced stethescopes around their necks or sheets of papers. Not far behind follow the respiratory therapists and the unit charge nurse. A large button is pushed and bright lights illuminate every face within the patient's room, as 10 or more people crowd around the crib. A red light blinks repeatedly signifying that, yes, here is where the code blue is happening, come, come, yes it is here.
Eventually, the crib comes down the hall, escorted by several gowned staff members, one bagging a limp body, his left hand holding the mask in place and his right hand contracting in symphony with imagined breaths.
Imagine you have a small sick baby as your patient. She's been doing well all day, and you're 5 hours into your eight hour shift. It's time for routine vitals and checking on her gastronomy tube and assessment. You walk in, administer medications, take the set of vital signs; all goes well, and you turn to leave, parents quietly sitting bedside. Two steps from the door, alarms sound, so quickly you spin around and see her face. She's not breathing and she's turned blue, without warning. "Respiratory arrest!" You call a code blue, and the team is there within two minutes.
What if you had not been in the room? It easily could have been another 3 or 4 minutes before someone else was available (or, worse, not too lazy) to answer the alarms and declare the code. It illustrates so clearly the meaning of time in a medical emergency and the responsibility of healthcare professionals to respond promptly, consistently and continuously.
The chaos following is almost thrilling to watch. Staff physicans race down the hall, almost losing their carefully balanced stethescopes around their necks or sheets of papers. Not far behind follow the respiratory therapists and the unit charge nurse. A large button is pushed and bright lights illuminate every face within the patient's room, as 10 or more people crowd around the crib. A red light blinks repeatedly signifying that, yes, here is where the code blue is happening, come, come, yes it is here.
Eventually, the crib comes down the hall, escorted by several gowned staff members, one bagging a limp body, his left hand holding the mask in place and his right hand contracting in symphony with imagined breaths.
Now that tiny intubated patient is in the ICU pictured above, alive. All because we were right there.
Questions
I've been asked several questions constantly, so I thought I'd deliever an update here:
How is she doing?
She's doing quite well, thank you. She has bad days, incredibly bad days, and pretty good days. This is a complicated question, of course. Emotionally, she has continued to be positive and driven about her prognosis. Physically, she is suffering a lot of side effects, ranging from deep bone pain from the GCSF, nausea and diarrhea from the chemotherapy, and fatigue from low blood counts. Internally, however, her spleen is shrinking and her lymph nodes are disappearing from sight on CT scans. It's a mixed package, as I discussed before, but it's paying off.
Is she working?
She was initially told that most people on chemotherapy are able to work on a limited basis, if not more. However, her program is extremely aggressive and rapid, also requiring inpatient stays of approximately one week every three weeks, so it's pretty ridiculous to expect her to work just knowing how fast-paced her therapy is. Additionally, she's quite in need of recovery the two weeks following inpatient therapy. During those two weeks, she also undergoes outpatient therapy, CTs, bloodwork, and other lab and diagnostic tests. So currently, she is not working and does not plan to return to her occupation until fall at the earliest. Following her transplant, there will be a long duration of recovery of at least a few months, and then after evaluating her energy levels and response to treatment, she may return part-time during the fall.
What are the blood counts like?
Her WBC (white blood cell) count is essentially at zero. This is a good thing because this means the cancer cell population, which are also from white blood cells, is decreasing. Of course, we still need to stimulate the immature blood stem cells for her apheresis. Currently, her platelet count is high (at ~50K), which we'd like to maintain. Previously, her platelet count had been crashing post-chemotherapy to 10K and lower, at which point, the protocol is to give platelet transfusions. Hopefully, she won't need a transfusion until after the next few drugs.
What drugs is she receiving?
Her core treatment consists of: rituximab, cyclophosphamide, vincristine, doxorubicin, and dexamethasone, followed by a round of cytarabine and methotrexate. She also has numerous drugs on the side such as mesna, acyclovir, ciprofloxacin, prednisone, and ativan, and hydrating infusions and blood product transfusions.
So what exactly is the program?
She is on her third cycle, ending week two this weekend. Next week she starts apheresis. The following Monday, 04/14, she will begin her last scheduled cycle of chemotherapy. Each cycle is 3 weeks long, beginning with approximately one week inpatient and the following two weeks at home.
What follows this last cycle?
More cat scans and pre-transplant workups and then radiolabeled immunoglobulin therapy, which will be inpatient at the university. She will be completely without an immune system at this point, and very vulnerable to microbes, so she will be kept in an isolation room during the therapy, perhaps even up to the date of transplantation and beyond.
Is the hospital food good?
Psh! Of course not! But we pretend it is. =O)
How is she doing?
She's doing quite well, thank you. She has bad days, incredibly bad days, and pretty good days. This is a complicated question, of course. Emotionally, she has continued to be positive and driven about her prognosis. Physically, she is suffering a lot of side effects, ranging from deep bone pain from the GCSF, nausea and diarrhea from the chemotherapy, and fatigue from low blood counts. Internally, however, her spleen is shrinking and her lymph nodes are disappearing from sight on CT scans. It's a mixed package, as I discussed before, but it's paying off.
Is she working?
She was initially told that most people on chemotherapy are able to work on a limited basis, if not more. However, her program is extremely aggressive and rapid, also requiring inpatient stays of approximately one week every three weeks, so it's pretty ridiculous to expect her to work just knowing how fast-paced her therapy is. Additionally, she's quite in need of recovery the two weeks following inpatient therapy. During those two weeks, she also undergoes outpatient therapy, CTs, bloodwork, and other lab and diagnostic tests. So currently, she is not working and does not plan to return to her occupation until fall at the earliest. Following her transplant, there will be a long duration of recovery of at least a few months, and then after evaluating her energy levels and response to treatment, she may return part-time during the fall.
What are the blood counts like?
Her WBC (white blood cell) count is essentially at zero. This is a good thing because this means the cancer cell population, which are also from white blood cells, is decreasing. Of course, we still need to stimulate the immature blood stem cells for her apheresis. Currently, her platelet count is high (at ~50K), which we'd like to maintain. Previously, her platelet count had been crashing post-chemotherapy to 10K and lower, at which point, the protocol is to give platelet transfusions. Hopefully, she won't need a transfusion until after the next few drugs.
What drugs is she receiving?
Her core treatment consists of: rituximab, cyclophosphamide, vincristine, doxorubicin, and dexamethasone, followed by a round of cytarabine and methotrexate. She also has numerous drugs on the side such as mesna, acyclovir, ciprofloxacin, prednisone, and ativan, and hydrating infusions and blood product transfusions.
So what exactly is the program?
She is on her third cycle, ending week two this weekend. Next week she starts apheresis. The following Monday, 04/14, she will begin her last scheduled cycle of chemotherapy. Each cycle is 3 weeks long, beginning with approximately one week inpatient and the following two weeks at home.
What follows this last cycle?
More cat scans and pre-transplant workups and then radiolabeled immunoglobulin therapy, which will be inpatient at the university. She will be completely without an immune system at this point, and very vulnerable to microbes, so she will be kept in an isolation room during the therapy, perhaps even up to the date of transplantation and beyond.
Is the hospital food good?
Psh! Of course not! But we pretend it is. =O)
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