Wednesday, February 18, 2004

The Best Laid Plans of Mice and Men....

Dave’s Great Adventure, Book 2
Chapter 2, Verse 2
February 18, 2004
“... gang aft aglay...”

Monday February 16th was a Rituxan day. I’m going to get four total infusions of just Rituxan while we’re “priming” my marrow for the collection. This drug is, again, a pure antibody against one specific protein that CLL cells have. It attaches to that specific protein and then my immune system, if it’s working right, will attack and destroy the cell, thinking it’s a foreign cell. I mentioned a long time ago that Rituxan is actually a murine antibody. That means it’s derived from mouse cells. Yeah, mouse cells. Yet I keep going down in the basement and setting traps for those little guys who come in out of the prairie behind our house in the winter looking for some warmth, while their cousins are producing antibodies to try to prolong my life. Like I’ve said, many times; life's not fair.

We had to get to the Rocky Mountain Cancer Center by 8AM for my appointment. Now, those of you who know my wife know that we NEVER get anywhere late. We usually get places quite early. Like, to the loading gates at the airports about two hours before loading times! Monday was about the same at the RMCC. We got there at about 7:30 and had to wait for the staff to show up to check me in.

Then we went to the infusion area. Today my nurse was a nice young gal named Krista, a very young nurse. I think she’s a rookie. And I think someone told her I was a doc, so she was acting a little nervous and intimidated, even though I didn’t growl, scowl or even mention my profession. Krista had to start my IV today.

I’m surprised that the nurses at the RMCC don’t seem to like to start IVs, and don’t seem especially expert in the skill. I think a lot of their patients already have central lines of some kind and all they have to do is plug the IV into the hub of the central line and it’s all hooked up. It takes more preparation if you have to put in an IV line, however.

Now, I really have great veins. That is, if you’re into veins, as nurses should be. When warm, they bulge out all over the place. Rarely do nurses miss my veins when starting IVs or drawing blood. Back in ‘02 when I was getting my first series in infusions at Kaiser, I found that every time I went in to get my drugs, the nurses would apply a warm moist heating pack before starting the IV, to make the veins stand out even more, making it easier for them, and me too, frankly. They do that routinely, for everyone.

So, last Thursday when I went in to the RMCC, it was 6 degrees (-14 C) outside. I was cold, and when one is cold, your veins collapse and blood is shunted to the interior of your hand and arm conserving warmth. I expected the heating pad treatment, especially since it was cold, but instead, my nurse, a real nice gal named Kelly, took a look at my hands and arms and said, “You’ve got lousy veins!” Uh, excuse me, but when it’s 6 degrees outside everybody has “lousy veins.” Kelly didn’t even try to put in an IV. She called for Patty, whom she said was their expert in starting IVs.

Patty came over, looked at my arms and hands and agreed with Kelly that my veins were bad, but she applied a tourniquet and found something she thought would do. But she didn’t like it...too many “nubbies” she said. But she managed to get a small IV line started in a vein that normally is about the size of a ten penny nail. It shouldn’t really have been hard at all.

So, on Monday, Krista is getting ready to start my IV. I had learned by my previous experience and was wearing warmer clothing and Kathy drove in so I wouldn’t be having to hold onto the cold steering wheel. My hands were warm and my veins were lookin’ good. But, Krista was, as mentioned, a bit nervous. She kept looking for a suitable vein. I suggested using a vein on the back of my left hand that looked about the size of a pencil, which, really, anyone should be able to get into, even without a heating pad. Krista started preparation. She was pulling out a small IV needle, a piece of tape, an alcohol swab. I was looking around...I didn’t see an IV pole, any bags of fluid, or the multiple pieces of tape that are usually used to hold the IV in place when you finally get it there. But, I figured, she really couldn’t do too much harm.

She started placing the IV. She got it close to the vein, which is really huge by IV standards. She even got the tip of the needle in, but that’s about all. A little blood came back out, but not much. She couldn’t advance the needle, so I guess she was going to see if she could expand the vein or something by pushing in some fluid from a syringe she had. “Pop” went the vein! Krista called Patty for help. Patty went back to my other arm and quickly got a line in, but again mentioned my “bad veins,” “bad valves” and such. She attached the syringe of fluid since there still was no IV set up.

So we went into one of the infusion rooms, I read a bit while we waited for Krista to come in, and after a bit she came in with the IV setup, the drugs and the pump. We talked a little about the drugs and I’m happy to tell you that I was able to talk her out of giving me the Ativan, the sedative tranquilizing drug. It was ordered to be used “as needed” anyway. And I didn’t think I needed it. Krista got a lot of help from Kelly in setting up, the pump, setting the infusion parameters, etc. That’s okay for Rituxan, ‘cause everybody’s got to learn their stuff somehow, but when I get the Cytoxan (cyclophospamide) later this week, I want someone with a little gray in their hair. If that goes in wrong, too fast, etc., well, that’s where you could encounter some pretty serious side effects.

So, they started the drugs, the Benadryl knocked me out in a hurry, and I went to sleep, as expected. But without the added Ativan, I was awake in about two hours and feeling pretty well. We were out by a little after noon. As we left, Kelly, noting that I’ll have a central line by the next visit, said that the next time everyone will want to take care of me ‘cause I’ll be so easy. Hmmm. I didn’t think I was hard to deal with at all, but I guess the absence of that line makes a big difference up there.

Lunchtime! Kathy took me to a little place near the barbeque place we went a few days ago that is said to have the best burgers in Denver, The City Grille. Now, I don’t usually trust places that spell “grill” with an “e” on the end. Usually that means that there’s going to be a lot of fru-fru, or that the menu will have been “Californicated,” as the locals like to say. But, this place had good food, real burgers without the guacamole-picante-cilantro blue cheese spread and gorgonzola wine sauce on top, or whatever. We’ll probably go back after some other treatment in the near future.

And, for the rest of the day, I felt well, not drowsy as I had after the first time, when I had been given the Ativan. I’ll remember that.

I felt well again the next day, Tuesday, not so flushed and tired as I had after the first Rituxan infusion. Kathy and I did a few chores and then went to a movie, “Mystic River.” A very well done movie, moving and suspenseful. We’ll not be able to do much in the next couple of weeks, so we wanted to get things done while I was still able to get out. Meanwhile I was dreading the next morning when we would have to get up early, about 5AM or so, to get down to the Cardiovascular Lab at Presbyterian-St. Luke’s Hospital for the placement of the double lumen (a tube within a tube) catheter in my chest.

But, as Robert Burns said, as “translated” from the original Scottish, “The best laid plans of mice and men often go awry.” The little scratchy throat I’d had a few days ago developed into a deep cough. I began coughing Tuesday afternoon, and Wednesday morning, when I went to PSL to have the central line, the catheter placed, I was still coughing deeply. I wondered if they’d put it in, if I was sick. But after talking to the folks there, they went ahead with the procedure. “Don’t cough while I’m placing the catheter in your jugular,” said Doc Jamboz. I assured him I wouldn’t. And he got the thing inserted, tunneling through the chest wall up to the jugular, and got the tip of it placed in the upper chamber of my heart within a few minutes. It was just about painless, too, except when he put a couple of stitches in my chest without anesthesia. But, the drugs they had put in my IV made even that tolerable.

But I was still coughing. I really wondered if I shouldn’t start some antibiotics if I were to get two more doses of chemotherapy in the next two days. Doc Matous’ office is just a couple of blocks from PSL, so Kathy and I walked over there to see if I could ask Jeff about the need for antibiotics or something. This is where things began to go awry. Jeff wasn’t in, so his nurse had me see one of his partners, who listened to my chest, ordered an X-ray and postponed the next two days of the chemotherapy!!!

Now it really makes sense to insure that I’m healthy before I get drugs which are going to seriously damage my immune system. But I didn’t expect him to stop the therapy; I thought he’d just add more drugs to protect me. But, now the whole process of the collection, where each appointment depends upon the one before it, is on hold. I have appointments for each of the next four weekdays to be reevaluated, have the dressings on the catheter changed and to see when we can restart the chemotherapy regimen. I hope it will be soon!

So now I’m at home and my chest hurts a little, I don’t want to move my right arm because it makes the insertion site painful, and I’m upset ‘cause the collection process isn’t going forward as we had planned. I’m hopeful that this cold will blow over rapidly and we can get on with this stuff. I’m forcing fluids, taking echinachea and sucking on zinc lozenges, for whatever they’re worth. I’ll keep you updated.

Meanwhile, my sister Diane, out in Crockett, Texas, wrote that she was the person who ordered the Irish cap for me to keep my noggin warm when the hair falls out. Thanks Diane. I owe you one.

And I had a question about my patient and friend, Marlene, who now has CLL too, and recently lost her son and brother-in-law. I made it sound as if they had died together, in a car wreck, or something. In fact, they died in separate incidents a week or two apart. Her 41 year old son died suddenly of a heart attack, and her brother-in-law died of a seizure. I hadn’t mentioned that she lost her husband last summer! I called her last week. “God is testing me,” she said. This wonderful woman, who had a Mass said for me in her church, told me that she has been so worried about ME! I’m simply amazed that she can think of anyone else when she’s had so many personal tragedies in just the last few months. It shows you what a wonderful person she really is.

I think I’ve written enough for now. I’ll attach another picture from Antarctica for you, a picture of a friend we made on South Georgia Island!

Until later,


God, give us the grace
to accept with serenity
the things that cannot be changed,
courage to change the things
that should be changed,
and the wisdom to distinguish
the one from the other. Amen.
---Reinhold Niebuhr
(this is the original, uncopyrighted version
of this famous verse, which was written by Rev.
Niebuhr in about 1943)