Saturday 21 July 2012

Was the second IVE chemotherapy any better than the first?

The second IVE chemotherapy session involved the same treatment as the first session, but this time was administered via my recently inserted hickman line; The daily blood samples were taken from the hickman line too.  I find having pretty much all of the tests and treatment done using the hickman line to be much better really - It's not that I'm bothered by needles; It's just that given the choice of being used as a pin cushion or not, then choosing "not" doesn't exactly require much thought.

You might expect that after having countless blood samples taken and cannulas inserted etc, I'd be even less bothered about needles now than I was originally, as it would all just be routine, but it actually bothers me a little bit (not much) more these days - It's not that it feels any different now, or even that it hurts for that matter; I guess it's just the expectation that it will take several attempts before being successful, and I'll probably end-up with a bunch more bruises on my hands and/or arms, which sometimes take weeks to fade away and can become a bit of a reminder of being ill.

Needles aside, the treatment itself went fine, and other than having a couple of red blood cell transfusions just involved being hooked-up to the IV machine for about eighty-one hours!  If you do the math, the treatment is therefore pretty much constant for about three and a half days; the only time it really stops is when waiting for a nurse to disconnect the empty bag and connect either some saline solution (to flush through the remainder of the chemotherapy drug, if about to switch to a different one) or another full bag.  Usually once a day, when disconnecting and connecting the fluids, the nurse will also take a blood sample, and give you the opportunity to get a shower, hence if you factor-in the various stops and starts the full treatment tends to take more like four days in total.

Despite having a hickman line, I did still end-up having to have a cannula inserted, as it was needed for the red blood cell transfusions: the hickman line couldn't be used (at the same time) for both the chemotherapy and the red blood cell transfusions, and the chemotherapy couldn't be stopped whilst the transfusions took place, so given the chemotherapy is pretty much constant for a few days there wasn't another option.  A couple of nurses each had one slightly reluctant try to insert a cannula, as being anemic my veins were even harder to find than usual, before finally requesting a doctor to come and do it.  The doctor actually put the cannula in the top of my forearm, which is somewhere I've never even seen nurses or doctors look before (let alone try there), but it went in fine and did the job nicely; About three hours later, the red blood cell transfusions were complete and the cannula was removed.

In terms of the side effects for the second IVE chemotherapy session, it definitely wasn't as bad as the first one: The nausea was similar and my sense of taste was affected a lot more, but I didn't really lose my appetite (or further weight), nor feel anywhere near as tired or out-of-breath.  Interestingly, I did still find I'm itching a fair bit, albeit slightly less, so perhaps the doctor and myself were wrong about what caused the itching, i.e. perhaps it was actually a side effect of the chemotherapy itself.  I'm also told I didn't look "nearly dead" this time too - The black around my eyes the first time was pretty bad!

After four nights in the hospital ward, I was discharged with the same medications as last time (only without the Allopurinol), and with the knowledge that in the next couple of weeks, before the third (hopefully final) IVE chemotherapy session, I'd need to come back: a couple of times for blood tests and getting the hickman line flushed, just in case I needed any further transfusions and to keep the line working properly; for a lung function test, which involves breathing using a tube connected to a computer, so that it can analyse your lung capacity etc; for another echocardiogram (and perhaps electrocardiogram) to ensure fluid is not building-up around my heart again; and for a PET scan to see whether the cancer is responding to/shrinking as a result of the IVE chemotherapy.

Monday 16 July 2012

Does a bone marrow biopsy really hurt that much?

In case you are wondering, the bone marrow biopsy just takes place on a hospital bed, i.e. you don't need to go into theatre or anything, and all you have to do as the patient is lay on your side (flashing a bit of bum!) whilst a doctor first numbs the area at the back of your hip with a local anaesthetic and then inserts a large needle into your hip bone to extract a sample of: bone marrow (the flexible tissue in the centre of your bones) and the bone itself.  Once the procedure is completed, the samples are sent off for analysis, which takes a few days, and you are left with a small plaster over the biopsy site, which you can remove in a couple of days.  When the local anaesthetic wears-off, you will probably feel a dull ache at the biopsy site for a day or two, after which you may still feel some discomfort (it can take up to a couple of weeks before you no longer feel anything), but it is all pretty minor really; Initially, you may wish to take some paracetamol if you feel the need - I never bothered myself.

Putting aside the background information, the real question is: Does the procedure itself really hurt that much?  Well, in the last few years, I've actually had three bone marrow biopsies, one when I was initially diagnosed and another after each relapse, and every time the experience has been different, so the honest answer (at least as far as I'm concerned) is: It depends.  I'm not sure why each time was different, but they were all performed by different doctors, and the amount of time taken did vary - It may be a coincidence, but it seemed like the quicker the procedure was done the more it hurt, so perhaps waiting that bit longer for the local anaesthetic to fully kick-in is what made the difference.

My first bone marrow biopsy was nothing really, as all I noticed were three things: the first was the stinging as the local anaesthetic went in; the second was a weird kind of shooting sensation go down my leg as the doctor extracted the sample of bone marrow; and the third was some pressure as the doctor extracted the sample of bone itself.  To be honest, I was pretty relieved, as prior to having the procedure, the doctor (and a nurse) explained that the pain can be pretty bad, especially in younger patients due to their bones being harder, so I should feel free to swear or scream!  I was actually even offered "gas and air" (Entonox) to help take the edge off, but as it happened I needed to pick my parents up from the airport a few hours later, and I had driven myself to the hospital, so it wasn't really an option - You are not supposed to drive for about twenty-four hours after having it.

It was actually during my first bone marrow biopsy that I was introduced to the head haematology consultant, which is a bit of a bizarre story (one that never fails to amuse me), as I was pretty much just facing a wall at the time, so I couldn't see him, and I also can't help but think that the focus point for his view was probably my bum!  It was a while before I learnt what he looked like, and I'm not sure how long it was before he stopped recognising me by my bum, but it certainly made for one of the more unusual introductions I'm ever likely to have.

My second bone marrow biopsy was not too different from the first, as I mostly just felt the same things; The only exception was that early on in the procedure I also felt a sharp shooting pain go all of the way down my leg, which definitely hurt, but was over pretty quickly.  It was after this bone marrow biopsy though that I saw what the samples looked like; There was nothing really all that noteworthy about the bone marrow sample, but I was quite surprised at the sample of the bone itself, as it was much bigger than I was expecting: It was cylindrical in shape, a couple of millimetres in diameter and a few centimetres in length!

My third bone marrow biopsy was without a doubt the worst of the three, as I felt the sharp shooting pains a few times early on in the procedure, i.e. leading up to the sample of bone marrow being taken, and even the extracting of the bone marrow sample seemed to result in more of a pain than an odd sensation, but fortunately the latter part of the procedure was fine really - That didn't seem to match the expectation though, so I can only assume that typically patients find extracting the bone sample to be the worst bit.

A student nurse was present during my third bone marrow biopsy, as she wanted to see what happens during the procedure, but about halfway through a nurse asked her whether she was feeling alright, as it was clear the colour was draining from her face; The student nurse left shortly afterwards, as she said she was feeling sick - She was fine once she'd had a glass of water, but would have probably fainted if she had stayed!  I'm told seeing the size of the needle and it being pushed in does tend to have that effect on people.  After my first bone marrow biopsy, I remember a nurse telling me that they had to stop family and friends from being present during the procedure, as they had more problems with them fainting than with the patient having the bone marrow biopsy!

Thursday 12 July 2012

Can I see your bum?

I'd been home for nearly a week after my first IVE chemotherapy when I needed to go for my first check-up for this round of treatment.  It went fine really, as I didn't have that much to say beyond mentioning I'd had some of the expected/typical side effects: tired, out-of-breath, nauseous and loss of appetite/weight.  The only additional things that were a bit unusual for me were that I had been itching quite a bit, and I had a bunch of marks/discolourations on my skin, which for the most part were on the edges of where the various sticky dressings and sensors had been.  I asked whether the itching was a slight allergic reaction to those sticky dressings and sensors, which had perhaps been made worse by scratching, and the doctor said it was a possibility, but the itching could have actually been a side effect of the Allopurinol I'd been prescribed.

As expected, the blood test performed upon arrival at the check-up showed that the chemotherapy had affected the levels of hemoglobin, white cells, platelets and neutrophils in my blood, as they were all low now (some more so than others).  I had already been prescribed injections for boosting my white cell count and neutrophils, but the doctor mentioned that given my platelets level it was worth arranging another check-up for a few days later just to make sure they don't drop too low, as it may be that I would need to have a platelets transfusion.  I also discussed with the doctor when I would be having the hickman line inserted, as all I knew was that it would be before my next session of the IVE chemotherapy; The doctor did try to find out the exact date and time, but was unable to do so there and then as the relevant person was otherwise engaged - I did find out that my next IVE chemotherapy may start a bit more than three weeks after the previous one though, as it may take me a few extra days to recover; the treatments that I'd had for my previous run-ins with Hodgkin's Lymphoma could mean I require that bit more recovery time (it makes sense that the treatments would take their toll).

I went home thinking that I'd be back in a few days to have another blood test, which would perhaps mean having a platelets transfusion, and that I'd then most likely find out when I would have the hickman line inserted too.  However, later that evening I started to feel a bit cold and tired, so I went and laid on the bed for a bit under a blanket, where I ended-up staying until it was time to call it a night, but when I then checked my temperature I found it was quite high: It was about 38.7°C, and if it goes over 38°C I'm supposed to contact the hospital.  It was quite late on now, so it took a bit of time to get in touch with someone at the hospital, but when I did I was asked to come in, as I'd likely picked-up some kind of infection, and would probably need to be on antibiotics for a few days so that I could recover.

After packing a few things and driving to the hospital it was about 1:30am when I was admitted to the ward, where a nurse tried to put a cannula in one arm, and a doctor tried to take a blood sample from the other (as I've mentioned before, my veins are not so good any more); The doctor had prescribed an antibiotic, which the nurse would inject via the cannula, and the blood sample was for sending off for analysis (presumably to identify the type of infection, just in case I needed a different antibiotic).  The doctor did ask whether I'd noticed any other symptoms, but the only one that came to mind was my teeth aching a bit when biting/chewing.  I also mentioned to another nurse that there was a small area at the top of my right leg (just below my bum) that was a bit tender and slightly pink/red, hence she wanted to have a look; After looking, she asked a colleague to look too, and decided to leave it for now and just keep an eye on it.

As it turns-out, hospitals are quite keen on regularly checking the pressure points of inpatients these days, just to make sure that they are not getting bed sores, so with your consent this means checking your heels, elbows and bum.  Fortunately, I get the feeling that a bit of common sense comes into though, as if they know that you're regularly walking around the hospital ward etc, then it's clear that you're unlikely to get bed sores, as you've not been laid in the same position for prolonged periods.  Unfortunately for me though I had this tender area at the top of my right leg, and that was close enough to a pressure area that it meant for the next week I was regularly flashing my bum to numerous nurses!  Some nurses came to have a look just out of curiosity, as the tender and pink/red area later turned into what looked like a pretty large and angry spot, which I have to say was quite uncomfy at times, but others were just doing their duty, so to speak.  I even had felt tip lines drawn around it later on to make sure it was getting better, so it ended-up looking a bit like a target.  I don't think it was ever decided what it actually was, as several things were suggested, but if it was a bite the last thing that I needed was a target drawing on me - Mosquitos are a pain in the ass (ba dum tish!) at the best of times; never mind when your immune system is compromised.

It may come as no surprise that the whole flashing of my bum thing became a bit of an ongoing joke with some of the nurses that I saw more regularly, which at least brightened-up the day for me (if not for them).  One nurse did say something along the lines of: "Can I see your bum? I know it's a pain, but it's procedure these days, so I need to cover my ass!".  In fact, it was that nurse that late one evening (when no-one else was around) was walking down the main ward corridor as I was walking the other way, so I just turned around and bent over - You'll be pleased to know that no flashing was necessary for it to get a laugh!  Bum jokes aside (well, nearly!), I did end-up on another antibiotic for whatever it was at the top of my right leg, as one of the doctors prescribed that after taking a look, and that did seem to do the trick, as in a day or two it thankfully started to get better.  I also ended-up on an air bed, instead of the usual hospital mattress, as they are supposed to help with bed sores; I did find the air bed a bit uncomfy and noisy at first, and I'm not really sure whether it helped or not, but either way after a few days I'd got used to it.

Getting back to the infection for which I was admitted, I simply stayed on the same intravenous antibiotics that I was originally prescribed for about a week, as the blood test showed that they should do the trick; The antibiotics were administered a few times a day, which only took about five minutes or so each time, but I was also given saline solution inbetween to ensure that I was well hydrated.  The first day I was on the antibiotics I felt a bit tired (perhaps due to the lack of sleep I got the night I was admitted) and nauseous, but the next day I was fine really, except for the typical and delightful side effect of diarrhea - That gradually got better as the week progressed though.  During that time, I did have a couple of platelet transfusions too, as the daily blood tests showed that they were getting really low, but other than that my stay was pretty uneventful - I'd say the worst part was probably coping with the boredom, but luckily for me the Teenage Cancer Trust recently opened a kind of mini-ward for teenagers and young adults, which is kitted-out with games consoles, laptops, a pool table, a juke box, big TVs with bluray players and several comfy chairs, so that helped keep me entertained a bit!

When I said my stay was pretty uneventful, I did kind of skip over one side effect of the chemotherapy that some people find really hard to cope with: Your hair falling out.  I have to say it doesn't bother me at all, as other than my eyelashes and eyebrows, I'd quite happily have no hair whatsoever; It's great not having to bother shaving!  Having said that, it is a bit of a pain when it first starts to fall out though, as it can end-up everywhere.  I first noticed it was falling out in the shower, as simply running my hand through it was enough for my hand to be covered; Fortunately my hair was short anyway, as after the previous treatments it had never really grown back properly (it was much thinner), so I had to keep it short to avoid it being noticeable.  After I got out of the shower, I just shaved off what was left, which was still quite a bit of it at this point, but it was no use prolonging the inevitable, and avoided me leaving a trail of hair everywhere.

I would have probably completed the antibiotics and been discharged after about five days, rather than a week, had it not been for needing to get a hickman line inserted.  Discharging me earlier would have meant me travelling back and forth between home and hospital a fair bit, as I needed more platelet transfusions shortly before the procedure, and the line redressing a day after the procedure - The other factor was that given my blood test results and that I'd been on antibiotics for an infection, it made sense to stay in that bit longer just so that I could be monitored more closely for any problems.  There did actually turn-out to be a slight hiccup the morning I was going for the hickman line to be inserted, as the platelet transfusions took maybe three times as long as normal, due to the cannula in my arm being on its last legs, so that meant I missed the transport to the nearby hospital where the procedure would take place.  However, in the end that proved to be a good thing for me, as I was taken there and back in an ambulance instead, and that meant rather than waiting for when the transport is scheduled, I could pretty much go when I was ready.

The insertion of the hickman line went fine, so a day afterwards (once it had been redressed) I was on my way home.  I did have an appointment for a few days later to get the line flushed, but other than that I just had to come back in about a week for the next session of the IVE chemotherapy.  I actually ended-up coming in a day early for the line flush, as it had been bleeding a bit, so needed redressing again, and because of the bleeding had another blood test, but the results were fine and everything else went to plan.  In case you're wondering, the line is supposed to be flushed when not in use for several days, as this prevents blood clotting in the line; The flush essentially just involves removing a bit fluid from the line, pushing through some saline solution, and finally inserting enough heparin into the line to prevent blood clotting within it - At the same time as the line is flushed, the connector(s) used to administer drugs etc are typically replaced too.

Tuesday 10 July 2012

What happens when you go for a check-up?

In the past, I've tended to have about one check-up a week whilst undergoing treatment, but the frequency varied whilst in remission: It started at maybe once a week, but gradually the gap between check-ups increased, as the doctors gained confidence that I was on the right path.  When I recently relapsed, which was about eighteen months post-treatment, my check-ups were every twelve weeks.  So, as you can probably imagine, I've been for numerous check-ups over the last few years, hence by now I'm more than familiar with the routine; The routine is pretty simple though, as it essentially just involves a blood test, followed by getting weighed, and finally a chat with a doctor about how I am getting on - It probably comes as no surprise that there's a fair bit of waiting involved too.

The blood tests seem to be much more important during treatment than when you are in remission, as during treatment the chemotherapy affects the levels of various key components of your blood.  When in remission, the blood tests can show signs of relapse, but it seems the doctors rely more on the patient to mention any issues/symptoms etc.  Your weight is just monitored for any worrying trends.

It seems the blood components that are most closely monitored are:
  • Hemoglobin - It carries the oxygen that you breath-in for use around the body and the resulting carbon dioxide back to your lungs for you to breath-out, so if your level of hemoglobin falls too low you may have symptoms such as feeling weak/tired, out-of-breath on exertion, or trouble concentrating; You are considered anemic when it drops below a certain point (it varies based on age and gender) - A doctor can prescribe a red blood cell transfusion to increase your hemoglobin level.
  • White Cells & Neutrophils - They are both related to your immune system, so as they fall you become more and more prone to/at risk of infection; You are considered neutropenic (either mild, moderate or severe depending on the level) when the neutrophils, which constitute around 45-75% of the white cells, fall too low - You can have injections in the stomach to help raise these levels, and whilst undergoing chemotherapy they may be prescribed ahead of time as part of the treatment, as these levels are expected to drop, so this minimises the period where you are neutropenic.
  • Platelets - They are key to the forming of blood clots, i.e. if you cut yourself it is the platelets that stop you from continually bleeding, and if they fall too low can result in things like: becoming more prone to bruising, having nose bleeds, and red spots appearing on the skin (usually in the lower legs); You are considered thrombocytopenic when it drops below a certain point - A doctor can prescribe a platelet transfusion to increase your platelet level.

The chat with a doctor tends to involve a couple of things: The first usually starts with a fairly open question about how are you getting on, i.e. gives you an opportunity to raise any concerns - I have found that as I got to know some of the doctors it did also become a bit of an informal catch-up on life in general; The second is usually just a quick comment on your blood test results and weight, followed by arranging any medications, transfusions or further tests/procedures, and the next check-up or treatment.  During a check-up, the doctors have sometimes listened to my breathing, and had a quick check for any lumps too - I guess these tests could be specific to my diagnosis though, i.e. Hodgkin's Lymphoma (a type of cancer of the lymph nodes) in the chest.  Incidentally, that reminds me of the first time I was ever checked for lumps, as after the doctor felt the lymph nodes in my groin, under my arms and in my neck, he then not surprisingly washed his hands.  At this point, I was left thinking that perhaps that's not the best order, as now I feel like I should wash my neck!

In terms of the waiting, you can wait for up to thirty minutes (if things are really busy) for a nurse to take some blood samples to send for analysis; The analysis seems to take anywhere between about thirty minutes to an hour, during which time you get weighed and wait to see a doctor.  In the vast majority of cases, you don't see the doctor until the blood test results are back, and even then there is a queue of patients, so you can be waiting a while (especially if one or more doctors have been called away unexpectedly to treat patients).  In total, I think the quickest check-up I've ever had probably took about an hour, the longest maybe four hours, and typical being more like around two hours.

What was the first IVE chemotherapy like?

You may not realise this, but chemotherapy is really just a general term for a type of cancer treatment, so when different people say that they have had chemotherapy it is entirely possible that they have had completely different drugs to one and other.  There are about sixty different individual chemotherapy drugs, and regimens are typically made up of a few of them, hence there are quite a number of possible combinations; However, in reality there is a much smaller number of regimens than theoretically possible - Coincidentally, there are also about sixty.  The different regimens are used for different types of cancer, but factors such as your medical history also come into it.

Note: The individual chemotherapy drug and regimen statistics are based on counting those currently listed by Macmillan Cancer Support, and their lists are not exhaustive, but even so they do help to illustrate the point that chemotherapy is not just one drug.

The chemotherapy that I am having for this particular treatment is a regimen called IVE, which contains three chemotherapy drugs: Ifosfamide, Epirubicin and Etoposide.  If you were to read the list of possible side effects of those chemotherapy drugs, you would likely be looking for the nearest emergency exit.  Fortunately, there are medications that help alleviate some of the side effects (most notably, anti-sickness drugs); However, as much as they might help, it is still likely to be an unpleasant experience - The reason I say likely is that the side effects do vary from one person to the next, both in terms of what side effects they get, as well as their intensity.

The previous times that I was treated for Hodgkin's Lymphoma I had always had different chemotherapy regimens, and although one of those regimens did include Etoposide I still didn't really know what exactly to expect, as when taken with different chemotherapy drugs the side effects do vary; Obviously I had some idea, but I also knew that each of the regimens I'd had up until then had affected me differently.  All of the chemotherapy drugs that I needed for this regimen were administered intravenously (via IV) - In other words, dripped/injected directly into the blood stream.

The first chemotherapy drug that I had in this regimen was Epirubicin, which involved two syringes of a red coloured fluid being slowly injected (each over five or so minutes) into a cannula in my arm.  However, this did not exactly go smoothly, as the small veins in my arm did not take too kindly to the experience: about halfway through the first syringe the veins in my arm started to swell-up quite a lot, due to an irritation/reaction - The nurse finished the syringe really slowly, but then had to stop to seek advice about how to proceed; It appears the irritation/reaction was unusual, as a number of nurses were curious and came to have a look before a doctor looked and decided that I would need a femoral line inserting for the remainder of my chemotherapy - The reason being that the femoral line goes into a much bigger vein, and when combined with a drug to help prevent reactions the remainder of the chemotherapy should be problem free.  In case you are curious, here are a few pictures I took:

Epirubicin reaction (Close-up near vein)
Close-up near wrist
Epirubicin reaction (Close-up near elbow)
Close-up near elbow
Epirubicin reaction (Full area view)
Full arm view

The remainder of the Epirubicin was injected into the femoral line, and that went fine, so other than the Epirubicin making my urine turn red for a bit, I couldn't really attribute anything else to it for certain.  Next up was the Etoposide, which came in two one litre bags, each of which takes an hour to drip through; by the end of the two hours, I was starting to feel really nauseous.  Finally, or so I thought at the time, was the Ifosfamide, which came in three one litre bags, each of which takes seven hours to drip through - A drug called Mesna is also administered at the same time, as the Ifosfamide can irritate the bladder: the Mesna helps to prevent the irritation from happening.  The nausea seemed to lessen whilst the Ifosfamide was administered, which was definitely welcomed.  To my surprise though, I now had a further two doses of both the Etoposide and Ifosfamide, hence another couple of days went by before it was all finally wrapped-up with a litre of Mesna, which took twelve hours to drip through.  During this period, the level of nausea was up and down a fair bit, and I was sick too, which is never a pleasant experience even if you do feel a bit better afterwards.  I also felt quite tired at times, probably due to the chemotherapy, but also because it can be quite hard to sleep in the hospital, as mattresses aside the nurses need to regularly check your blood pressure, temperature, pulse and oxygen saturation, as well as disconnect and connect the different chemotherapy drugs.  The only other noticeable side effect was loss of appetite; I lost over half a stone in a few days.

In total it took around five days to complete the IVE chemotherapy, and I got to go home pretty much straight afterwards - The femoral line had to be removed before I could go home.  That meant I had a couple of weeks or so to recover before the next session of chemotherapy.  In that couple of weeks, I just had to: come back after about a week for a check-up, i.e. to have a blood test and to talk to a doctor about how I was getting on; and shortly before the next treatment go to get a hickman line inserted, which would hopefully be used for the rest of my treatment, and make things easier.  If you could see all of the bruises on my forearms after just a week of blood tests and treatment, you would fully understand why I say that - I've not taken a picture, as we all know what bruises look like!

When discharged from the hospital, I was given a bunch of medications: Ondansetron (anti-sickness), Co-trimoxazole (anti-bacterial), Aciclovir (anti-viral) and Fluconazole (anti-fungal) being those that are typically prescribed.  Also, because this was my first session of chemotherapy in this round of treatment, I was also given some Allopurinol tablets to help my kidneys with the side effects of the chemotherapy.  If that wasn't enough, I was also given a week's worth of Filgrastim (G-CSF) injections to help boost my immune system, as the chemotherapy pretty much kicked its ass!  You may now understand why I have to take all of those tablets for fighting infections - My immune system is essentially compromised, so infections that it would normally just handle without any real fuss can now be a much bigger deal.  This is also the reason that it is recommended to avoid certain foods, as well as takeaways, and just to generally be extra vigilant about hygiene.

All of the medications and injections are no problem really, but I must admit I do always hesitate a little before injecting myself in the stomach - It's not that it particularly hurts or anything; It's just the idea of putting a needle in to my stomach makes me stop and think a bit.  The only thing that is worth mentioning about the injections is that you do sometimes start to feel them kick-in: you feel a kind of pulsing pain in the centre of your lower back.  With the Filgrastim injections, it has never really been that bad for me, perhaps because they are lower doses over a number of days, but I have also had Pegfilgrastim, which I assume is essentially just a single larger dose, and then the pain has been really bad; Patients have been known to go into accident and emergency departments with it, and despite being given strong pain-killers such as morphine not feel any better - Surprisingly, paracetamol is actually really effective though, which you would likely never even consider if you felt it yourself.  The pain seems to be triggered by moving, and it does ease dramatically if you stay still, but it is not that easy to stay still, as it really does hurt, and your instincts are telling you to move.  It did once kick-in whilst I was visiting one of my cousins, and I think she was pretty worried, as she could see how much it hurt - I could hardly breath let alone speak as she carefully drove me home!  Once I laid down on my bed, after taking some paracetamol, I felt much better after half an hour or so.

At home, after the IVE chemotherapy, I still felt nauseous, and I was a bit tired, but it was more that I was easily out of breath than anything; for example, the next morning after a few minutes in the shower, I had no choice but to sit down, as it felt like I was about to pass out.  I apparently looked pretty shocking too, as there was a lot of black around my eyes.  However, over the next few days, I gradually improved and was eating and drinking a lot better.  It was probably about five days though before I could simply stand still for more than a few minutes without feeling exhausted and needing to sit down.  The next day, things didn't go so smoothly though, but that's a story for another post...

Saturday 7 July 2012

What are cannulas, PICC lines, femoral lines and hickman lines?

In order to administer drugs intravenously (via IV) you need to have some kind of thin tube inserted into a vein, so that the port(s) on the other end of that tube can be connected to a syringe/drip, thereby allowing the drugs to be inserted into the vein; It is also possible (sometimes at least) to use the same tube to remove fluids from the vein, e.g. to extract a sample of blood for testing purposes.



This is the simplest and most common method used, and typically involves inserting a small needle into a vein in one of your hands (on the back) or forearms (underneath - usually near the elbow).  If the veins are not very good there, then it is also possible to put them in your feet.  Once the needle is in a vein, a thin tube is slid into the vein and the needle removed.  The thin tube is connected to a small plastic port (at the other end) with what looks like a wing on both sides; The wings lay against your skin, and help with dressing the cannula, as thin strips of sticky tape can be placed over them to hold it in place.  Once secured, a dressing is placed over the area (leaving just the port(s) exposed) to keep it clean and help prevent infection.  It may feel a bit odd at first, but you soon forget about it.

If the idea of having a cannula inserted in your foot freaks you out a bit, then it may comfort you to know that despite the veins in my hands and forearms being hard to find these days, after all of the treatments that I've had, and that I've long lost track of how many cannulas I have had inserted in my hands and forearms, I've yet to actually have a nurse/doctor try to insert one in my foot; They have looked at my feet on a couple of occasions, but never went any further - I must admit, I was quite glad about that, as I don't really like the idea myself, and I have heard they're not very nice.

There are different sized cannulas for different sized veins too, so even if you have quite thin veins, it is still possible to have one inserted.  In case you are wondering, they are inserted without any anaesthetic, as you don't really feel it (certainly not enough to warrant local anaesthetic) and what you do feel tends to be over in less than a second.  As the nurse/doctor inserts the cannula, they will most likely warn you that the needle is about to go in by saying something about a "sharp scratch".

Cannulas are intended to be temporary, and will probably only stay in for anywhere between a few minutes and several days, depending on for what they are being used; The longest I've probably had one in my arm is around five days, after which it was starting to not work very well, so if it hadn't been for my treatment finishing at that point it would have likely been removed and another inserted.

Removing a cannula simply involves taking off the dressing, and pulling out the thin tube whilst covering the area with a small piece of gauze and applying some pressure to help it stop bleeding.  The gauze is then usually swapped for a clean piece and sticky taped down for a bit - It can be removed not long afterwards, e.g. normally you will be asked to take it off in fifteen minutes or so.



I have had a couple of PICC lines in the last few years; although they are intended to have much longer life spans than cannulas, in both cases mine were removed after about a week.  The first was removed due to getting infected, and the second was removed as it was only ever intended to be a temporary measure until a hickman line could be inserted.  When the PICC line got infected, you could see a kind of red line on my upper arm (following the path of the vein), and my upper arm felt quite hard; It didn't really hurt or anything, so at first I just assumed that was normal - I was wrong.

PICC actually stands for peripherally inserted central catheter, so it may come as no surprise that it is inserted in your arm (peripherally), but the thin tube for the line actually goes all the way up your arm and back down into a big vein near your heart (central); In both cases, mine were inserted on the underneath of my forearm near the elbow, which is fine except that it does tend to limit your arm movement, so it can be a bit awkward - Had mine stayed in longer, I might have got used to that.

Inserting a PICC line involves first using a cream that numbs the area where the line will be inserted; it is similar to having a local anaesthetic only it takes about thirty minutes to kick-in and you don't get any kind of stinging sensation.  Once the area is numb, you will lay down on a bed (if you have been admitted to a hospital ward, then probably just the bed you sleep in), your arm will be draped in those blue sheets you have probably seen in the movies, the area will be cleaned, the actual PICC line itself will be inserted, the area will probably be cleaned again (it tends to bleed a bit), and finally a transparent dressing will be placed over the top to keep it clean and help prevent infection.

The nurse/doctor inserting the PICC line does have to guess a bit whether the line is in the right position when inserting it, so an x-ray is necessary afterwards just to make sure it is positioned correctly.  Essentially, the line may need pulling out or pushing in a bit, or it may have taken the wrong path, e.g. gone up towards the brain instead of down towards the heart - A doctor did once tell me that you can kind of feel whether the latter is the case.  In terms of guessing the line length, it is calculated based on your height.  In the vast majority of cases, the x-ray will show the line is fine.

The PICC line itself looks like a tube going into your arm, which connects to a sticky plaster with the port(s) attached to it; I assume the sticky plaster is intended to prevent you from accidentally pulling on the tube going into your arm.  It does feel a bit odd on your arm at first, but you do start to forget it is there, and the white sock they give you to cover it all over does help take your mind off it too.

With the veins in my arm not being very good, it did actually take three separate attempts from different medical staff before my first PICC line was successfully inserted.  The first nurse tried in both arms, one of which was without the cream for numbing the area (it hardly felt any different), but was unsuccessful in both and was pretty gutted about it; to be honest, I almost had to console her!  The second nurse tried for quite some time (my arm must have been going blue), only this time with the aid of an ultrasound scanner, but she was also unsuccessful; to be fair, I think she had only just trained to do it, as a more senior colleague was helping her.  In the end, a doctor inserted the line without much fuss really; whether it was skill or luck, I guess I'll never know, but it was the same doctor that inserted the second PICC line several months later, and that went in first time too.

Removing a PICC line is a very similar process to removing a cannula, as it really involves the same steps, it is just that the tube is a lot longer (you will be surprised how long), and the dressing placed on afterwards needs to stay on for a while longer, just to give it a bit more time to stop bleeding.

Femoral Line


The femoral line is probably the most uncomfortable line that I have had, which is perhaps not too surprising given that it is inserted in the groin, but the actual insertion itself is a fairly straight forward procedure, and can just be done on a hospital bed, i.e. you don't need to go into theatre or anything.  I have had a couple of femoral lines in the last few years, and I have to say that the first one was much more uncomfortable than the second; With the first one, I kept managing to knock/pull on the line/stitches, which hurt a little (not much) and tended to make the line bleed.  To be honest, the second one was much better and didn't really bother me at all; It was positioned slightly higher-up, which probably meant that I was much less likely to keep catching it when walking etc.

Inserting a femoral line essentially involves draping the area with those blue sheets mentioned earlier, cleaning it to reduce the chances of infection, administrating the local anaesthetic, inserting the actual femoral line itself, and finally a couple of stitches to hold it in place.  The only thing that you feel is the local anaesthetic going in, which is just a slight stinging sensation.  With the femoral vein being somewhat bigger than those in your arm, it does tend to bleed when inserted, so the area needs cleaning before the dressing goes on, and you will likely need to clean around the dressing afterwards too.  You are covered over during the procedure, so only the top of your leg is exposed, hence you do get to maintain your modesty, so to speak; It is probably a good thing, as if you have had a fair bit of treatment, you may know the doctor quite well, so that avoids it being a bit awkward.  One thing I would say though is that it is definitely worth getting the area shaved (if necessary) before starting, as otherwise when the dressing comes off later on you are in for a not so pleasant waxing!

Removing the femoral line is similar to removing the PICC line, only: the stitches need to be removed before the thin tube can be pulled out; the gauze needs to be held on for a bit longer and with more pressure, so that the bleeding stops; and the dressing placed on afterwards is a bit more substantial, as it needs to stay on for longer due to the greater chance of some bleeding later on.

Hickman Line

I have had a couple of hickman lines inserted, one after my first relapse and the other just a few days ago after my second relapse, and whilst it does involve going into theatre for a minor procedure, which may make you feel a bit more anxious, I would much rather have my treatment this way than any of the other methods; the hickman line is neither uncomfy nor awkward, and it avoids the need for nurses/doctors to struggle to find my veins for retrieving blood samples or giving treatment.

The hickman line is a type of skin-tunnelled central catheter, and is in some ways similar to that of a PICC line, in that a thin tube is inserted and the end of it is in a big vein near your heart; The main difference is that instead of it being inserted in your arm it is inserted in your chest (just below the shoulder) - It is sometimes inserted in the lower neck, if it proves tricky inserting in the chest.

The procedure does take place in a theatre, but it is still only done under local anaesthetic, which is all it really needs, as other than feeling the local anaesthetic go in, and some prodding/tugging, you don't really feel anything - It is by no means painful.  With the procedure taking place in a theatre, due to the potential (albeit low) risks involved, you do have to sign a consent form before it can take place; one of the doctors will talk you through the potential risks to make sure you understand them, but it is really just a formality, as complications are rare, so you should try not to over think it.

The procedure begins with you laying on a bed (in a not so flattering hospital gown) that is tilted such that your feet are higher than your head, as this ensures that the blood is more in your upper body than lower body and consequently when any incisions are made the blood is more likely to come out of the incision, rather than air go into it.  Once in the correct position, the area is thoroughly cleaned with the yellowy brown fluid you have probably seen in the movies, and the area is draped with the blue sheets mentioned earlier; The blue sheets completely obscure your vision of what happens from here on in.  After the local anaesthetic has been administered, the insertion of the hickman line involves making two small incisions, one in your chest (just below the shoulder) or perhaps in your neck, and another a few inches further down your chest; the thin tube is tunnelled under your skin such that it comes out of the latter incision, and the former incision is ultimately stitched-up once the line is successfully in place.  The area can then be cleaned, have two dressings applied: one over the stitched-up area, and the other over where the line comes out of your chest.

Once the procedure is complete, you are taken to a post theatre room for maybe half an hour, where nurses can closely monitor your blood pressure, heart rate and oxygen saturation to ensure that you remain fine.  Also, just like with the PICC line, an x-ray needs to be taken to ensure that the line is positioned correctly; Again, in the vast majority of cases, the line position is fine, so you are soon on your way home (if you're an out-patient) or back to the hospital ward (if you are currently admitted).

About a day after having the line inserted, you do need to get the dressing that is over where the line comes out replaced, as it is does tend to bleed ever so slightly, or perhaps a bit more if you do anything too strenuous (you should try not to do much).  Also, after about seven to ten days, the other dressing and any stitches should be removed.  After that, any aching/tenderness should have long worn off, but you may still be able to see some bruising caused by all of the prodding/tugging etc.

Thursday 5 July 2012

What are the heart, CT and PET scans like?

Heart Scan (Electrocardiogram & Echocardiogram)

The heart scan is pretty straight-forward really, at least from a patient perspective, as you just have a few sensors connected to your chest that read your heart rate etc (electrocardiogram), and at the same time an ultrasound scanner is used to look at your heart in action (echocardiogram) - The relevant data can be recorded for later review, e.g. by a doctor.

All you really do during the heart scan is lay in a certain position on a bed, and when requested change position or control your breathing in a specific way, e.g. take a deep breath.  It is probably all over in 5 to 15 minutes.

You don't really feel anything during the heart scan, other than: the gel they put on the ultrasound scanner feels a bit cold when it first touches your skin; the pressure from the ultrasound scanner being pushed against your chest can be a bit uncomfy; and if you have a hairy chest then you are in for a bit of a waxing when the sensors come off!

CT Scan

A CT scan can vary a bit depending on the area of the body being examined, but in a nutshell you lay on a bed that slides back and forth through a quite thin donut shaped scanner (you're unlikely to feel claustrophobic), and is probably all over in 5 to 15 minutes.  It works by essentially taking lots of x-rays from different angles, so that they can all be combined on a computer into a 3D model; the end result being a much clearer/more detailed view than that possible with a simple/single x-ray.

I have only ever had the Chest, Abdomen and Pelvis type of CT scan, with the exception of the first time when I also had the Head type of CT scan, so can really only speak to that in terms of the full experience, but for me it has always involved a few things that I've not mentioned yet:

  • I needed to drink a bit less than a litre of contrast fluid, so that a clearer view could be seen on the CT scan.  The contrast fluid looks a bit like a white washing detergent, and has a similar consistency; Having never tasted washing detergent, I can't say for sure, but the contrast fluid probably doesn't taste much better, even though it does seem to have had a bit of an orange like flavouring added to it.  I did once get a different contrast fluid that was more like water in consistency and I think colour too, which did taste better, but was still not exactly something that you'd order at the bar.  There are a couple of things to keep in mind with the contrast fluid, one is that you get about thirty minutes to drink it, so you better be thirsty, and two is that you really need to make use of those thirty minutes; I once downed-it quite quickly, and lets just say as laxatives go it is quite an effective one.

  • During the CT scan, I needed a contrast dye to be inserted intravenously, so that a clearer view could be seen, hence I needed a cannula in my arm.  I was on one occasion told you may feel the contrast dye when it goes in, as it is at quite high pressure, but having had several CT scans I've only ever felt it once; although, I must admit, when I did feel it, it was more uncomfortable than expected, but it was over quickly so was nothing really.  The one thing I have always noticed though is that when the contrast dye goes in, you get a kind of warm sensation go down your body, a funny taste in your mouth, and it feels a bit like you just wet yourself!

  • During the CT scan, you are occasionally asked to take a deep breath and hold it for a short period; It's only a few seconds, but it can sometimes feel longer.  It's similar to being asked to stay still during the CT scan, as it's not really a problem staying still for a few minutes, until you suddenly start to imagine that your nose is really itching and desperately needs scratching!

Once the CT scan is complete, you are asked to wait for around fifteen minutes before the cannula is removed from your arm, just in case you have some kind of allergic reaction that requires treatment.  I have never had a reaction myself, nor have I ever seen any other patients have one whilst I have been waiting, so I assume they don't happen very often.  Anyway, once the cannula is removed, you are free to go.

PET Scan

A PET scan is similar to a CT scan in that you lay down on a bed that slides back and forth through a fairly thin donut shaped scanner (you're unlikely to feel claustrophobic), but it does take longer, i.e. 15 to 45 minutes, and it works in a very different way.  It relies on a radioactive tracer being added into your blood stream, and as that tracer decays the scanner can detect the resulting radiation and pin-point its origin; This is helpful as the cancer cells tend to absorb more of the radioactive tracer than normal cells, hence the cancer cells show-up as hot spots (areas of higher activity) on the PET scan.

In order for a PET scanner to work effectively, you are not allowed to eat or drink anything except water (of which you may have to drink plenty to ensure that you are well hydrated) for roughly four to six hours before being scanned, as this ensures that the sugar levels in your blood are not too high; your sugar levels will be tested before proceeding with the PET scan.  Assuming your sugar levels are fine, then you are given the radioactive tracer into a cannula in your arm, after which you need to sit still and remain quiet for around an hour, as this enables the cancer cells to absorb the radioactive tracer - If you moved around and talked, normal cells would absorb more of the radioactive tracer than they would have done otherwise, which would lead to the cancer cells not showing-up as well (if it all).

Once the radioactive tracer has had time to be absorbed by the cancer cells, you will shortly be taken through to the PET scanner.  I have only had a couple of PET scans myself, but I was always walked through to the toilets first, as given I was well hydrated it was best to go then, i.e. before spending around thirty minutes in the scanner where you need to lay still.  The thing I remember the most about the whole PET scan experience is that the person that walked me to the toilets asked me to walk at least a metre behind him, presumably because I was essentially radioactive due to the tracer added to my blood stream - I was a bit unsure whether he was joking at first, as I was thinking how radioactive can I really be, but I soon found out he was quite serious when I got too close to him as he opened a door for me.  That brings me to an interesting point actually, as after a PET scan you remain slightly radioactive for several hours, so they recommend that you stay away from children and anyone that is pregnant, due to their higher susceptibility to the radiation - This can pose a bit of a problem though, as if you use public transport to get home, and a woman sits down next to you, it can be a bit awkward to ask if she is pregnant, especially if you are hoping to avoid getting slapped!

If you are interested in more detail of the science behind it all, then in the vast majority of cases the tracer is a radioactive sugar, specifically fluorodeoxyglucose (FDG).  As the radioactive tracer decays, which is quite quickly as it has a short half-life (time for half of it to decay), it emits positrons (the antiparticle counterpart of an electron) and when those positrons collide with an electron, they annihilate each other, and that results in gamma rays firing in opposite directions, which the scanner can detect to pin-point their origin - The annihilation will take place very close to the position of the decay.

Some of the PET scanners are actually combined PET and CT scanners, and this is useful as it enables both scans to take place simultaneously, and in doing so allow for the PET scan to be overlayed on the CT scan, so that it is easier to determine where exactly the hot spots are in the patient's body; If the scans are done separately, then the patient may be in a slightly different position, which makes the scans harder to overlay.

Monday 2 July 2012

Draining a Pericardial Effusion (Fluid around the Heart)

Once I arrived at the Cardiac Monitoring Unit (CMU), I was connected up to a heart monitor (just like with an electrocardiogram) by one of the nurses, and a doctor came and performed a quick echocardiogram to see how best to insert the drain.  The doctor asked one of his more senior colleagues to join him, after a quick look with the ultrasound scanner, as it turned-out that the normal entry point for the drain wouldn't be possible, as the path from there was obscured by the cancer, so instead of going in the centre of my chest (just below where the bottom of the left and right rib cages meet) it would need to go in my left side (between the ribs at a similar height); Once that had been decided, I was moved down to the Cath Lab to have the drain inserted.

The Cath Lab looks pretty cool, a bit like something you'd see in a sci-fi movie, as there are: panels of monitors, an x-ray machine that hangs from the ceiling (it can move around the room on tracks), and other assorted gadgets; However, it did amuse me that with all of that technology, the biggest problem was arranging it so that I could lay on the bed at around a 45 degree angle; there was an appropriately sloped cushion that I could lay on, but it would just gradually slide along the bed, so in the end, after trying a few things to hold the cushion in place, the not so high tech solution was to sticky tape a bag of saline solution to the bed so the cushion couldn't slip past it!  It was at this point that the Cath Lab lost some of its cool sci-fi look and feel!

Armed with the sticky taped bag of saline solution, the drain could now be inserted under local anaesthetic, and other than feeling the local anaesthetic going in, which is just a slight stinging sensation, I never felt a thing; To be honest, I wasn't even sure when the procedure actually started.  The drain itself is nothing special really, as it's just a thin tube that is inserted in to the pericardial sac (a wall of tissue around the heart), so that the fluid can slowly drain by itself over a number of hours into a bag connected to the other end.  I did seem to have a bit of an audience in the Cath Lab, as I got the impression a number of people hadn't seen it inserted in that position before, and I think it was even the first time the doctor had inserted it there too, as one of his colleagues explained the process to him in detail.  Anyway, once a sample had been taken for analysis, and the area had been cleaned and dressed, I was back on my way to CMU.

In CMU, I was reconnected to the heart monitor, and placed on bed rest whilst the fluid drained.  The fluid drained relatively quickly at first, i.e. most of it came out within a few hours, but the drain is left in for longer to make sure the fluid stops coming; I'm not sure what I was expecting, but the fluid looked a lot like a urine sample!  In fact, even one of the nurses confused it for one, as when I asked about going to toilet, she brought me a bedpan, and when I then awkwardly explained that that wasn't what I was meaning, she looked at the bag of fluid and started saying "but..."; Incidentally, it turns out that peeing in a bottle when you are not allowed out of bed is not all that easy, so I'm glad I didn't need to use that bedpan!

About the only thing you can do in CMU is try to filter out the noise of the heart monitors going off all of the time: It seems like the sensors are a bit sensitive, so when people move around the heart monitor loses the signal and starts bleeping to alert the nurses that it can't get a reading - the nurses know which bleeps to listen out for, and mostly ignore the others.  The heart monitor was going off quite a bit for me, as my pulse is a lot higher than normal (due to the cancer it seems): even at rest it is around 120bpm, whereas it should be more like 70bpm; unfortunately, the heart monitor bleeps like crazy when you reach about 130bpm, so all I had to do was move around a bit, e.g. try to sit up slightly to go to toilet, and off it would go!

My response to the drain was fairly typical really, as the area around it ached a bit after the local anaesthetic wore off, and I also later got what is known as pericardial rub, which is when the heart rubs against the pericardial sac and causes some discomfort, presumably until the body adjusts to the new levels of fluids around the heart; At first, I was given some paracetamol for the discomfort, as it was just enough to stop me from sleeping, but that didn't really help, so I was then given some ibuprofen and that - or just being even more tired - helped me drift off to sleep.

The morning after having the drain inserted I was allowed to move around a bit, so I went to the bathroom to get washed etc, albeit still connected to the heart monitor, which was obviously bleeping like crazy for the duration; a nurse did ask if I was alright, but although my pulse was pretty high, due to moving around a bit, it was only about 10-20bpm above my resting heart rate, so I was fine really except for being a bit out of breath.  Shortly afterwards, a few doctors "doing the rounds" turned up, had a quick chat with me about removing the drain later on in the day, and listened to my heart; The most senior doctor among them was keen for the other doctors to listen to my heart, as it apparently had quite an interesting sound, due to some inflammation.

Later that morning, a nurse disconnected me from the bed-side heart monitor, and connected me to a small wireless one, which you can easily carry around (in a not so stylish man bag); when I say wireless, I mean it wirelessly reports your heart rate etc to the nurses station, i.e. it still has wires connected to your chest (it's not that clever).  The small wireless one was a lot better to be fair, as it meant you weren't stuck in bed, unless of course you were worried the man bag would do too much damage to your street cred; that was something I didn't really have to worry about, because as bad as the man bag might look, carrying around the bag from the drain had pretty much already put the final nail in that coffin!

The drain was removed late on in the afternoon, after a doctor performed another echocardiogram to check all of the fluid had gone; The doctor asked how much fluid was drained in the end, and I could tell just by the look on his face when I said about 850ml that that was a lot - I asked the doctor how much fluid is normally around the heart, and he said about 10-20ml, so it was obviously quite a bit more than normal!  The removal process itself is pretty simple as they essentially just remove the dressing, slowly pull the tube out (it is surprisingly long), and finally redress the area; No anaesthetic is required for the removal, as you don't really feel anything, so if you had a local anaesthetic that would most likely be the worst part.  Once the drain is removed, your time at CMU is over; All that is left is for you to remove the dressing in a couple of days, and it should heal-up fine.

Sunday 1 July 2012

What happened on the first admission?

When I was admitted on to the Haematology ward, I didn't know a great deal about what exactly would be happening or how long it would take, as due to the circumstances the hospital hadn't really had an opportunity to properly discuss things with me yet; Essentially, what I knew was that the Hodgkin's Lymphoma had relapsed and there would need to be some more tests done before starting treatment.  So, the plan was for a doctor to explain everything to me, so that the "fun" could begin.

After a discussion with a doctor, I knew the first step was for me to go straight for a kind of heart scan (an electrocardiogram and echocardiogram), as the CT scan from earlier that week showed what looked like a worrying amount of fluid around my heart, hence a closer look was needed to see whether that would need to be drained, and if so how that would be best achieved.  A PET scan had also been booked for the next day, which would go ahead as long as a drain wasn't required, otherwise it would be cancelled/postponed; the PET scan is used to determine where the active cancer cells are currently located, hence by doing a PET scan before treatment and another midway through treatment the two PET scans can be compared to check whether the treatment is working.  Next up was starting chemotherapy, which in this case was a regimen called IVE, of which I'd need three sessions each starting three weeks apart, then finally, provided that I responded to the chemotherapy, a stem cell transplant (from a donor).  The preparation for the stem cell transplant also requires a session of another chemotherapy regimen, possibly followed by radiotherapy (total body irradiation).  If everything goes to plan, then the treatment should be all over in about five months.

Anyway, I went for the heart scan, and shortly after getting back a doctor informed me that the fluid did need to be drained, so the PET scan was cancelled, and I was moved from the Haematology ward to the Cardiac Monitoring Unit (CMU).  At the CMU, the drain was inserted, left in for around twenty-four hours, and removed once all of the excess fluid was gone.  With the excess fluid drained, I was then moved back to the Haematology ward, where the next day I could start the chemotherapy.  The surprise I got the next morning though was that they needed to do a bone marrow biopsy before starting the chemotherapy - I was secretly hoping I wouldn't have to have one, as they can be quite an unpleasant experience.  Next up was the chemotherapy, which took place over about four or five days.  I also had to have an x-ray shortly after starting the chemotherapy, as the doctors wanted to check that the pleural effusion (fluid around the lungs) on my right side (about two litres worth) had not got any worse, as if it had or it began causing me to feel out of breath, then it would need to be drained; The hope was that once the chemotherapy started to work its magic that my body would naturally sort out the excess fluid.  I finally then got to go home for what would be about two weeks to recover enough from the chemotherapy to start the next round - I just had to come back in to the hospital in a few days for a quick check-up to make sure my blood counts etc were fine.

So, that was a quick overview of my first admission for this round of treatment, and the next series of posts will cover in more detail what the tests, drain and chemotherapy were actually like, otherwise this post would turn in to a book!