Saturday, February 28, 2015

Chemo

Just one week later after that last post, Julie and I went to Huntsman Cancer hospital for a check up with Martha Glenn.  She is the physician who sits on a national board that writes protocols for different types of lymphoma's.  Julie didn't want to bother with the appointment, but knew it was necessary.  She was primarily concerned with packing the bags for Hawaii just two days later.  We arrived to the appointment in a flurry due to the fiasco of getting the boys up a half hour late, taking a community shower with their baby brother, cooking their eggs and toast, and getting them off to school.  My dad came over to be with the rugrat.  There was a stat blood draw due at 8:45 am.  One of the panels they draw is her anti rejection medication level called "tacro" short for tacromilus which is generic for Prograf.  This level has to be taken at the trough, or when you normally take the medication so it is consistent, and measurable.  Last we had it taken it was 22, which was very high.  We suspected it was from the lung infection she was trying to fight and the cold little Charles gave to her shortly after we returned from the hospital a few weeks ago.  We were anxious to see it lower since she dropped her medication level at the advise of the UofU transplant clinic.  Being slightly late Julie asked if the order was there for the Prograf and asked how soon she could have the 8:45 blood draw.  The secretary looked at her with a big smile and said, "Ok, I will let them know!...Next?"  Julie came out and let me know about the exchange.  We both rolled our eyes, but also were a little on edge since the accuracy of this level is so critical to properly managing her anti rejection medication both for her graft, and in part to prevent further lymphoma growth.  Julie was uneasy.  As each minute passed that only increased.  I encouraged her to go back in and follow up.  She did and was again given the "don't call me, I'll call you" treatment.  A few more minutes passed by and Julie nudged me to put down the paper I was reading and go see what was going on.  By now it was just before 9:00.  I walked in and asked two phlebotomists standing there talking about Facebook or some crap if there was anything holding up Julie's blood work.   She said "we're just getting it ready."  I firmly told them, if we knew it was going to be this delayed we would have just gone to the lab down the hill at the U.  Flustered, shortly thereafter they called her back.  The phlebotomist asked Julie what time she arrived.  "8:40-8:45, I don't know."  She cut her off and said "8:48."  Julie started to explain the crazy morning and the lecture came back, "If you need to have a draw at a specific time you need to be here 15 min bef....THEN LET'S DRAW IT,"  Julie firmly replied.  That shut her up.  Correct as she may have been, it only adds misery to the fact that a 34 year old woman is in a cancer clinic when someone feels they need to "teach the patient" what they need to do.  It baffles me where individual pride inhibits patient care.  Patients for the most part are doing their best, even if their best is absolutely terrible, it is their best nonetheless.  This was a quibble over 3 minutes that really wasn't necessary.  Some might say we brought it on ourselves, maybe that is so, but we still needed the draw and didn't care if there was some confrontation involved to get it.

A little while later we were interrupted from doing our puzzle in the waiting room to be called back to see the doctor.  Dr. Glenn came in and checked Julie on the table.  She asked some questions about how she was feeling.  Julie casually mentioned she had been a little tired that weekend, but also let her know she felt fine doing Zumba the Saturday before.  Jules thought it was from the depo shot they had given her a few weeks before when they anticipated chemo.  In the back of her mind she didn't want to accept that it might be one of those changes the fellow Dr. Patel had mentioned at our last meeting.  If it was, we were there just in time, 48 hours or so after she started noticing it.  Dr. Glenn printed out Julie's blood work and handed it to her.  She talked a little about her prograf level; it was down to 6 thankfully.  They like to keep it in the range of 7-12 so just a little low.  Creatinine level measuring kidney function was high at 2.17; the higher it is, the lower the function.  Her Uric acid was very high at 14 (normal is less than 5) and then the doozy; LDH was a whopping 2780.  Normal is 200.  LDH is a marker for cell damage because when old cells breakdown, they release a protein.  The more rapid the proliferation of cancer, the more this protein can be found in the blood.  That number immediately jumped out to Julie when she was handed the paper, she said later "I knew it was high."  Dr. Glenn brought it up and told us what it should have been this far after the surgery.  It was 380 at our last visit but they attributed that to her surgery.  She said that, along with the high Uric acid made her very nervous.  I asked if we should do a scan to confirm her nervousness.  At this point I was just drawing straws to find more reasons to go home and pack for Hawaii.  She really gently tip toed around what she was going to say to her.  Julie asked how that LDH level compared to other aggressive lymphomas she had seen, and she replied, "It's one of the highest."  Julie just asked her, "So do you want me to come in today or tomorrow?"  Tears were welling up at this point.  Dr. Glenn was a little taken back by her candor.  She preferred that day but knew that getting the contrast drink mixed up and fitting her into the radiology schedule would take a modern miracle.  She decided that if we came in first thing Wednesday, they could do a scan and then admit her and start treatment.  "Guess we aren't going to Hawaii" Julie said with a somber chuckle.  Hawaii will always be there.  Towards the end of the appointment, Dr. Glenn said to Julie, "I can't believe how you are handling this."  She too had welled up a little.  I got the feeling during that appointment that she wasn't going to leave that room until we were ready to leave.  She spent a lot of her time with us and I will be forever grateful to her for that.  It was just what Julie needed as her patient to feel comfortable with her as her physician.

That night we told the boys what was going on and that we weren't going on our trip right now.  They didn't seem to be affected by the trip but were asking about their mom.  We told them she was going into the hospital for a while and Ben cut us off "to loose her hair?"  We all laughed.  I told them I would be shaving my head with her when she looses it.  They don't want any part of that.  Jack said, "You're going to look like Grandpa Art!"  We are glad they are young and resilient.  While we slept that night, Julie woke often feeling pressure in her bowels.  We arrived the next day for a 10:00 am PET scan and I worked while I waited for her.  At around noon she came out.  We went upstairs to admit her and sat in a room for about 2 hours.  We were later moved up to the ICU so they could keep a close eye on her when she received treatment that afternoon.  They told us they were moving her so we got her things and walked up there.  They weren't used to seeing a patient walking around in normal clothes in that area of the hospital.  The kidneys were not doing well since the creatinine had climbed to 2.34 and the Uric acid was still very high.  The LDH levels had climbed to 3350 in just one day.  This cancer was growing fast.  We saw Dr. Glenn's partner Dr. Stevens at around 5:00 on Wednesday.  She showed us the results of the PET scan and they were chilling.  Julie had small tumors all throughout her digestive tract.  There were a few other areas where the small tumors showed up too.  She told us we should start chemo within the next hour or so.  7:00 came and went.  All the while, people would come in and go over her extensive med list to try and correct it in the computers.  Knowing how it typically takes 2-4 hours to get admitted to a hospital, Julie brought her own meds so she could keep on schedule.  We anticipated having chemo in the afternoon since Dr. Glenn wanted to start as soon as possible after the scan.  She mentioned it should happen sometime during the day.  For that reason we stopped the prograf and Imuran, the anti rejection drugs since they can interfere with the chemo and the chemo fills the need to reduce the immune system.  From the beginning at about 1:00 pm, we were emphasizing the need to have her long acting insulin for that evening.  Last hospital stay, it took all 3 days for them to get that right and she had high blood sugars the entire stay.  After a long day of asking and receiving "okay I will call the doctor"  we finally received chemo at about 11:30 pm...almost.  They didn't have a consent form signed.  The oncologist during the day assumed it was signed in clinic, and the clinic assumed it would get signed the next day since we weren't admitted on the same day as the appt.  They called the fellow on call, and he told them he was home and wasn't coming back.  I was livid.  We spent the day waiting, 11 hours to be exact, to start this urgent therapy that was supposed to start shortly after our scan.  The urgency of our physician the day before didn't trickle down into the unit.  I told them I was ready to go to the fellow's house and rip him out of bed.  The other misnomer was we were off transplant meds, but not on chemo, so the immune system was getting less suppressed by the hour, putting her lungs at risk of rejection.  It may not have made a difference, but the apprehension this created was not ideal either.  I called our neighbor who is also a fellow at the hospital and he talked me down.  He mentioned that waiting another 6 hours wouldn't hurt and that it would give the kidneys time to continue to increase in function.  They had improved that evening with a dose of Rasburicase.  Julie nicknamed it "Raspberry days."  We woke a few times at night with apprehension about her rejection meds not being in her.  We have been so vigilant for 4 years that this felt totally irresponsible.  By early the next morning we received her long acting insulin.

The next day, Thursday, we were consented around 7:30 am.  It took another 3 hours to start the chemo, still a ridiculous amount of time since the meds were in the room the night before and ready to go.  I also spent the day waiting for her spinal tap version of Chemo since she wanted me by her side.  On the way back at 3:00 pm  I found out that it was done in the ER and I couldn't be there. The back story to all this, was our doctor was livid as well.  She is soft spoken, but apparently carries a lot of weight and when she is not happy, she will get what she wants for her patients.  There were multiple reports written up about the discontinuity.  So sad it had to be Julie that had to deal with it, but so grateful she just took it in stride.  The care since then has been excellent.  Her transplant doc called Julie and they spoke about the insulin.  She said "Tell them you manage your diabetes very tightly."  It feels like they are managing her care from more of a multifaceted approach now as they had planned to from the beginning.  Thanks to everyone at the UofU and Huntsman Cancer for taking good care of my sweet wife.  You have helped her beat the odds so many times.  The care given to her should never be forgotten since it is the means by which we believe we have been blessed.  We are looking forward to this summer when we can put this behind us as another bump in the road.

She felt more and more bloating that night, and after chemo has started the LDH levels continue to skyrocket.  This is an indicator that the tumors in her bowels are being broken apart.  Luckily her kidney function has stayed normal so they have been able to take this extra work.  Each day she has said she feels more and more bloated.  Today she said she feels pregnant.  She didn't sleep very well last night, but all in all is in good spirits.  She was able to meet us out front yesterday and see her kiddos.  That lifted her a lot.  She is such a champ.  Never complaining.  She told me she wanted me to stay home last night and today to be with the boys and give them some consistency.  She is always thinking of the other person.

Looking back at our decision a few weeks ago to forgo chemo was something we immediately did with the physician on Tuesday.  She confirmed it was the right move since Julie had a lung infection at the time.  That was one of the first things she asked Julie about (knowing she wanted us to do chemo) and was happy to hear it was all but gone.  We felt right about it and it proved to be the right move, for the time.  We were able to spend 3 weeks in more normal life; hoping for the cancer to be gone, but recognizing it may come back we just lived as if the former were the case.  We were able to go on several dates, and take a quick trip to Zion National Park and the sand dunes with the boys.  I will forever be grateful for these memories in such a tumoltuous time.  We are also grateful that this happened before our trip.  To see how aggressive this cancer has been just over the course of a few days has been chilling.  I am so glad we weren't out of town as its aggressive growth occurred.  My hope in posting is the reader will see what Julie is facing with such high spirits and say to themselves,  "I can face...."  The truth is, you can face anything if you place hope first and doubt second.  For Julie I would be remised if I didn't credit her faith is Jesus Christ, since she attributes her strength to putting Him first in all of this.  She sees things so clearly, even the mundane.  When you are faced with death your whole life, during these times of facing it, you tend to not get caught up in the minutia of who said what and who's doing that.  During these times it is so easy to realize what matters most in life is your relationship with God and how you treat and have treated others.  How others live and what others do becomes less and less important to you.  The important stuff becomes, how am I treating others, is it the way I should be treating them, as a loving Savior would want me to treat them.  The things that normally get us worked up and upset become as futile as they actually are.  I am humbled at this opportunity to learn from such a wise soul in Julie.

If you have never fasted, or seldom do, or frequently do, this Sunday is a great opportunity to witness it's real power.  Fast with us for Julie.  People always ask, what can I do to help.  This is what you can do.  It has a real and tangible power that hopefully you have witnessed carry us through these posts.  It doesn't matter if you don't know anything about fasting.  Just start with a prayer or meditation about Julie and her well being.  Spend tomorrow morning and afternoon without food or water (unless you need medication of course) and see what it does to you.  You will feel a love for those around you that you have never felt.  If nothing more it is a gesture of sacrifice as a petition to God that we are willing to do without.  No need to tell others you are fasting as this just cheapens the experience.  Thanks again for your thoughts and prayers.  They make a difference!

3 comments:

  1. Hey Julie, just read this post and felt sad that you are not feeling well. Hang in there with your "can do" attitude and your beautiful personality. Your husband wrote the post/article well about the difficulties of dealing with non-caring attitudes of health care workers. Wishing you a speedy recovery. I remember you as one of my favorite patients on 2 East. I am still working at the U on Maternity. Take Care and Have Hope. Karen MacArt RN

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  2. I am Don Nicoll's (Carill Ina's grand daughter) daughter. My family fasted for Julie on Sunday and hope she has the strength she needs through this treatment.

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  3. Julie you are an amazing woman and Dave is a lucky and wonderful man. We missed you both and of course your cute kids. We know of your great strength and testimony and know it will carry you thru. We love you and are praying, fasting, and sending all good vibes your way. We know our Heavenly Father loves you and is always aware of you. Happy belated birthday, Lets have a huge party in the summer for your half birthday!!! I'll make the cake!! we'll be back home in June and can party with you then ;)

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