5/21 - Cycle 4 Begins

Each chemotherapy cycle follows a similar formula, but like a game of Plinko the chips never quite follow the same path. (As bad as it is, I couldn't resist the Price Is Right simile after the tribute to Bob Barker the other night.) Monday morning starts at around 9am at the cancer center. We check in, settle our co-pay with the reception desk and within a few minutes Kristine is called in to give blood for analysis.

We proceed to one of the examination rooms to wait for Dr. Staddon and his nurse practitioner. When they arrive they begin by reviewing Kristine's blood work and clinical condition. Today they pay particular attention to Kristine's INR or International Normalization Ratio. This is the standardized measurement of time for blood to coagulate (clot). Since Kristine has recently changed her blood thinning medication it's important to calibrate her dosage to achieve an optimal coagulation level -- in her case 2.o. Last week, at a special office visit intended solely to gauge her INR, her reading was 1.0. This news sent the oncology team into a mini frenzy until Kristine disclosed her negligence in taking Coumadin for the two days prior. Her level this morning was 1.4 so her dosage was increased.

Discussion regarding longer term next steps typically follows. Dr. Staddon feels strongly about getting a cardiac specialist involved in Kristine's case early to, as he puts it, "start thinking about [Kristine]." He has encouraged us to have an initial consultation with one of Penn's top cardiac surgeons and a favored colleague of his, Dr. Bridges. Getting an appointment so far has been difficult as Dr. Bridges has been traveling in China for the last few weeks demonstrating state of the art techniques in "bloodless surgery"--techniques of which Penn is on the leading edge. We look forward to meeting Dr. Bridges and getting his perspective on Kristine's condition. Of course, given her rare case and the magnitude of risk with a potential procedure we'll also be exploring options for a second opinion -- it's important to both of us to find someone who has experience in operating on a similar situation.

With the examination and some dialog about possible next steps complete, we head across the hall to the treatment area, a large room with about 25 reclining chairs, most separated by a shallow frosted glass partition, all encircling a large central nurses station. Kristine is privileged in her seating arrangement. The port used to administer her medication is in her hip rather than in a more typical shoulder location. Since this is a sensitive and more private placement, she gets dibs on one of a handful of small private rooms.

Mondays usually starts with some delay. The nurses often have new patients who aren't yet familiar with the process and need more education. Linda is our oncology nurse today. We've requested her the last couple of cycles. She is one of the few nurses who seems to really understand Kristine's atypical port placement and has had success accessing it with minimal discomfort. Today, however, even Linda had trouble. One of the access points was implemented seamlessly but would not return blood through the tube. The other proved troublesome, as it has historically, this time producing a painful stinging in Kristine's side when accessed. Linda was able to get a blood return at the first access point after treating it with "clot buster." But as for the second, she thought it best not to irritate it any further and try again tomorrow. Kristine appreciated this decision.

With one port access in place Linda began administering the pre-meds. It was 12 noon at this point, an indication that this would be a late night. Kristine gets five pre-meds before receiving her chemotherapy drugs. These include Aloxi (a long lasting anti-nausea drug), Decadron (a multi-purpose steroid used in part to prevent swelling and allergic reactions), Ativan (another anti-nausea drug), Lasix (a diuretic or "water pill" that aids in the elimination of water retention) and Mesna (a drug that bonds with a harmful byproduct of one of the chemo drugs, IFEX, to render it inactive). Once the pre-meds have been administered the chemo drugs can be given. First Adriamycin (Doxorubicin) is given, which comes in the form of an injection tube, then IFEX (Ifosfamide, chemically related to the nitrogen mustard and most active in the resting phase of the cell). Ifex is given via an IV drip bag combined with a saline solution. Finally, a Sodium Bicarbonate and electrolyte mixture is given intravenously to prevent other side effects and replace fluids.

We didn't leave the center until around 4pm today and since Kristine needs to receive two additional doses of Mesna intravenously at home each four hours apart from one another, we didn't finish until around 12:30am. This makes our 8:30 start tomorrow a bit more difficult, but hopefully we will have a smoother day.