Watch Out, Radioactive Man!!

(10/12/09)
My work week:


Monday (10/05/09)

CT angiogram didn't show anything conclusive in terms of finding the source of the bleed. Nuts. But I was definitely bleeding because my hemoglobin counts kept slowly dropping. I was also having episodes where I would stand for a while and start to feel nauseated and drained, but once I sat down I'd be fine. I imagine this was partly because of dehydration (I wasn't allowed to eat or drink before the angiogram) and partly because of having low blood counts. Since then I've been on constant hydration, which definitely helps. After the angiogram, they still wouldn't let me eat or drink, since they wanted to see the results and potentially do another procedure. It got later and later, and I was pretty sure they weren't going to do anything that night, but still I was ordered NPO (non per ostium = nothing by mouth).


Tuesday (10/06/09)

I didn't have to do much, though I did get a blood transfusion to boost up my counts. In addition, they scheduled me for a radio-embolization procedure, which is similar to the previous liver embolization procedure I had, but it uses radioactive particles to try to embolize and kill the tumor. Previously they used gel-foam, a clotting agent to cut off the blood supply to the right hepatic artery, which feeds most of the right lobe of the liver. The gel-foam dissolves after 3-4 weeks, however, so it's possible that after it dissolved it just started bleeding again. Hence, my return to the hospital.

The radio-embolization procedure is done in two parts on two days. First, they go in with a catheter through the femoral artery in the groin and clot off any arteries that go from the right hepatic artery in the liver to other organs, like the stomach or intestine, so that no particles are delivered there (they can cause nasty ulcers and other badness). Then they inject a radioactive tracer and send you to nuclear imaging to make sure they contained the right areas. The next day, they go in and actually deliver the radioactive particles.

Once we figured out that the first part wasn't going to happen today, I was finally allowed to eat. Hallelujah.


Wednesday (10/07/09)

We basically waited all morning for the first part of the procedure to start. Somehow I had forgotten to ask the most basic question of the IR docs: how long would every thing take? So I asked the oncology attending: he said the procedure itself would be about an hour, but prep time and imaging might take longer. The nurse said probably 3 hours for the first interventional part and about 2 hours for the imaging, maybe 6 hours total. They took me out around 11:30am and straight into the IR suite. I'm not sure how much prep there was but I was definitely in there until at least 5pm. I was awake the whole time, though under some sleepiness medication. I could see the screen a little bit as they injected contrast into my liver and lit up all the arteries there. They took a few images first and then started blocking off arteries that feed from the liver to other organs. I'm not sure how many stray arteries they blocked off, but I guess it was quite a few. At the end, they injected the radioactive tracer and sent me to nuclear medicine for some scans. The scans took about an hour, and I didn't get back to my hospital room until 6:30 or 7pm. Turns out the nurse was much closer than the attending, but maybe he was playing the "Price is Right" move of betting $1 so as not to go over.

So there was a bit of confusion when I got back. I called my oncologist to let her know I was back in the room and to see if she was still able to come by as she said she would. She called me back and said she had spoken with my previous oncologist (Dr. J, the one who went on sabbatical) and she (Dr. J) suggested doing a right lobe liver resection to just get rid of the mass all together, so that it wouldn't keep bleeding and cause problems while I was getting chemotherapy later. Well then did we still need to do the liver embolization? Or at least, did we need to do it with radioactive particles (the IR docs said that it wouldn't be safe for the surgeon to operate for a least two weeks after the embolization)? Unfortunately we wouldn't get a chance to talk to the surgeon (Let's call him Surg N), since he'd be in surgery (imagine that) all the next day. So, what to do, what to do. . . We talked to the oncology resident who had been following me (Resident V), and he said this was the first he had heard about doing the surgery, so he would go and try and coordinate with everyone to figure out what was going on.


Thursday (10/08/09)

So in the morning Resident V came by and said the embolization procedure was scheduled for 1:30pm. He said he talked to Dr. G (my onc doc), who had spoken with the IR docs, and everyone seemed to agree it made the most sense to continue with the embolization. The other sticking factor was that the radioactive particles that they were going to use would expire the following day, meaning they had to be used that day. Also, apparently it takes a week to get the particles, so if we were to wait a day, talk to Surg N, only to have him say he couldn't do anything about the bleeding, we'd have to wait another week to get the procedure done.

Sometime in the morning a medical student showed up to chat with me. At first I was a little annoyed, because one of the teaching coordinators had come by the previous day and asked if she could have one of the med students come in to practice taking patient histories. I normally would say yes, but this time I was just not in the mood, so I said if they couldn't find someone else then I would do it. Anyway, my initial response of annoyance dissolved immediately when I realized she was a) a 4th year (why would they be sending 4th years to take patient histories?) and b) was there to get my history for Surg N. She said he had specifically asked her to come see me for this purpose. My mom and I told her a few of our concerns, that the embolization might delay the time to do surgery, which in turn would delay the time within which I could get chemo, etc. She reassured us that Surg N had a way of seeming to know what was going on everywhere in the hospital. Specifically, since he obviously knew about my case, he probably knew what steps were being taken, and since he hadn't taken any steps to change the course of action, he probably agreed with the current course. Well, that was at least somewhat reassuring. Later she came back after speaking with Surg N in the OR (operating room) to let us know that yes, he definitely agreed to proceed with the embolization. Furthermore, he had said that he wouldn't do surgery to stop the bleeding anyway, so this seemed like the right course.

Meanwhile, the IR docs were working on an emergency procedure that ran late, so I was waiting around as usual and didn't actually leave the room until about 3pm or so (I had been NPO again since midnight). Apparently right after I left, Surg N showed up to talk with me. Doh. Anyway, they carted me down to the same suite and did the same prep: I shifted from my bed to the operating table, they covered me with a sterile sheet, and gave me some happy cocktail to make me slightly sleepy. The IR doc came in and they did things in much the same way, taking some images to start with. Then they delivered the radioactive particles. The doctor showed me the device they used. The particles are kept in this rectangular plexiglass container with two small tubes coming out. One tube gets attached to the catheter that was in my femoral artery, and the other is attached to a syringe with saline in it. Inside the container the tubes lead down into a small vial that contains the particles, so somehow as saline is forced from one side it pushes the particles out the other side and into my liver.

Up until this point, the procedure had been pretty painless. After the radioactive particles were injected, though, they still had to stop the bleeding, and that's when they delivered the embolization particles. Now, that was painful. All of a sudden the blood supply to the whole right lobe of my liver was cut off - turns out the body doesn't like that so much. So in the last couple minutes of the procedure I was literally writhing in pain. They gave me some pain meds and then sent me to the recovery room to get my pain under control. The kicker there is that the doctor didn't put in enough orders for meds, so the recovery room nurse just had to keep calling and paging the doctor to write for more medication to get the pain under control. Finally, she got enough to get me back to my room (which was private, now that I was radioactive). They ended up having to switch up some of the orders in my room, too, because the original orders were definitely not enough. That first night was pretty rough as far as pain goes, but finally I got a push of IV dilaudid, and things felt all right in the world.


----- OK peeps, I've been trying to write this on and off over the past few days, and I need a break. I feel I need to post this, so I'll have to finish the hospital stay update at a later time. Right now I'm at home (got here Sunday) and am doing okay except for continuing to have fevers and annoying sweats. I have an appointment with Dr. G on Wednesday to figure out next steps. Cancer sucks.