HOME BUT NOT HOME

Home is many things.  Part place, part feeling.  A physical structure with an emotional bond.  A feeling of safety, warmth.  Ah, I’m home again.

Kristina is home, but not feeling herself.  A sensation that she’s had before, after previous transplants.  But forgot about.  So it’s ‘normal’ in the scheme of things, but abnormal.  Nothing is ‘wrong’ but still not ‘right’ yet. 

Home, but not home.

When Kristina left the hospital, her care team remarked that she’s on the fewest meds that they can recall a transplant patient needing upon discharge.   Good news.  But as I quipped to her, she’s had practice (sometimes I should keep my dark humor to myself).  She did laugh. 

Her care team is extraordinarily pleased with the progress and the current state of things.  Kristina feels she’s still very shaky, weak, can’t stand for very long and can only walk short distances.  She wants to be better.  The Mucositis is still a thing, with the nausea, but the vomiting has subsided.  Thank goodness for small wins.

Food still tastes like crap, and Chemo has not improved Kristina’s legendary lack of culinary skills.  So it’s getting nutrients into the body to build strength that’s the current challenge.  Between the Chemo induced gun metal taste of everything, weakness, nausea, and the preexisting genetic aversion to cooking, well you get the picture.

Kristina is frustrated by the long gradually lessoning, lingering effects of Chemo.  Yes it’s getting better but oh, so damn slowly.   Progress, but seemingly glacial in speed.  During her visit to the hospital yesterday they hydrated her through an IV and there was an event that did brighten things.

Sometimes we have pity parties that despite our best intentions take root.  Just as the feelings of ‘I just want to get better’ start to grow, there was a single guy one bed over that had gone through a transplant but was fighting Host vs Graft disease.  This ‘first time transplanter’ hadn’t managed himself particularly well and was in pretty bad shape.  Kristina’s negative thoughts about herself shifted to empathic thoughts about this fellow who was suffering.  And gratitude that she was doing as well as she is.

So she’s home, but not ‘there’ yet.  It’ll be a long road.

No signs of  Graft vs Host disease yet, although some rashes are starting to develop – but it’s too early to read much into that. 

Her high school friend Lizie is with Kristina and said that for the first time in a couple of days Kristina got herself something to eat.  Recognition of hunger and having the motivation and energy to grab and eat food is something that we take for granted.  It was a major win for Kristina.

So that’s where things sit right now.  Home, not feeling herself, daily visits to the hospital, watching for any signs of graft vs host disease (if that does occur in any material way, we’ll devote a post to that syndrome) and a first gear, slow grind back to health.

Jailbreak

 The day has finally arrived.  Kristina is feeling a bit weak, but anxious to escape the confines of the hospital.  Her high school friend, Lizie, got in at 1am last night after a series of flight delays.

With Neutrophils well above 1000, she's ready to go home and play out the rest of her recovery.

We'll prepare a post on what the next few weeks look like, but for now it's all about getting out of the hospital and setting up a new routine at home.

As of about an hour ago she was waiting for her final hydration IV, the pharmacy consultation and a visit from her medical team.  Then, if all goes well, she's 'outta there'.

 

Engraftment

 

 

Good news today.  Kristina’s in the engraftment stage.  There’s still the Mucositis and all that goes with it, but the general trajectory is good.  With Cancer you need to grade on a curve, as A+ doesn’t really feel like A+, but if there was a silver lining a few days ago, the good news is clearer and backed my metrics today.

What, exactly, is engraftment?  So glad you asked.  The stem cells have found their way into Kristina’s bone marrow and are doing what they should be doing.  By the process we described earlier, they are starting to make good blood cells. 

Kristina’s blood counts are getting better.  Platelets, Crits, and those crime fighting Neutrophils are all up.  Neutrophils count is 510 for those of you keeping score at home.

She’s also getting prepared to leave the hospital on the 25^th or 26^th.  Her care team is weaning her off the TPN feeding tube (IV feeding that bypasses the digestive system) and getting the ‘ol esophagus back up and running.  First getting food down then keeping it down are the two goals.

They are also converting her meds to oral meds to ease her time at home.

Kristina also needs to build back some strength – walking around when she can.

All this while she’s still fatigued.  With limited energy she’s requesting ‘no visitors’, but in the case there is a visit, only one at a time.  Even talking on the phone takes effort and she needs to harness her strength.  She’s says she’s still pretty shaky.

Her childhood friend, Lizie, is coming in on the 25^th and will take the first stint at caregiving.  After she gets home, she’ll still need to visit Fred Hutch every day as they closely monitor her progress.

That’s it for this morning.  More news when there are developments.

 

Kristina texted this morning that her Neutrophil count had climbed to 410.  Surprising, perhaps shocking, but great news.

She's still requesting no visitors.  She does expect to be released from the hospital on or around the 25th and a long time friend from her youth is flying out from the east coast to take over care duties for the first couple of weeks.

She does, however, say she is feeling largely like crap, which, if I dare read between the lines, may be a small improvement.  but not much.  So Mucositis is still very much a thing with all the 'stuff' that goes with it.

Hopefully the symptoms will wane in the next few days as the blood counts improve.

Neutrophil Count at 190 and climbing

Kristina texted -- still no visitors, she's still dealing with Mucositis and all that entails.  Hopefully she'll start feeling better soon.

The good news is that the Neutrophil count is on a climb.  Previously she had warned it wouldn't be linear, but so far it's climbed every day.  A good sign.

Silver Lining

 I got a brief text from Kristina.  Still in the throes of Mucositis, vomiting and all.  But she noted a silver lining.  Her Neutrophil count.  40 on Thursday, 140 on Friday.  So even with all the misery, some positive news.  A silver lining.

Neutrophil Count at 40

 Kristina texted with the update that her Neutrophil count is at 40.  That's pretty low, but significantly better than zero or 'too low to count'.  It's a start.  It's a sign.  A good one.  

When I texted her back "Good start", I got four thumbs up in return.

She's still dealing with "all that other sh$&t" as a result of the chemo and is hoping it magically clears up.  

She is spending her days trying to sleep, but I suspect that's difficult.  

Short update today, but the positive news is that it sounds as if there are the first faint signs of cell recovery.

Tuesday August 15th. The deep dark hole after Chemo

 

Kristina knew the post transplant period could be intense, but I suspect she was hoping to dodge the worst of the complications.  She texted that she didn’t know it would be this intense. 

Right now she’s still fighting the after effects of Chemo with ‘Mucositis’ being one of the primary things she’s dealing with.

Mucositis causes mouth sores and inflammation of the digestive tract.  The symptoms are painful and miserable.  The sores can become an entry point for infection, and it’s already caused her care team to feed her via an IV, getting nutrients into her bypassing both the mouth and the entire digestive tract.

As the side effect is common, there’s a common trajectory that it takes.  It starts, spreads, then creates ulceration and inflammation and finally the cycle ends with healing.  The care team tries to manage pain and keep Kristina fed while the painful cycle takes its course.

Added to the problem was a hard sneeze she had earlier last week with a bite to the tongue.  Without platelets, blood clotting doesn’t happen and, well, it got pretty gross pretty quick.

Then there’s the ‘Chemo brain’ that sets in – the foggy feeling where it’s difficult to concentrate. 

So other than not being able to think clearly, or talk, being fed through an IV, things are, well, about what you’d expect.  She says she’s going through that “deep dark hole of chemo, mucositis, and everything else that goes with it.”

Her care team is confident that cell recovery will begin to take place in the next few days – usually between day 12 and day 28.  She’s at day 14.  Earlier she had hoped that she’d start feeling a little better by today but by the sounds of it, that hasn’t happened. 

It’s too early for graft vs host disease (GVHD), as that may happen when cells start to multiply. 

“GVHD” is where the immune cells from the donor attack the host, Kristina in this case.  It’s not a sure thing she’ll have some version of it, but four out of five non related donor patients are impacted.  The very treatment that introduces life saving and rather magical stem cells also introduces a small army of immune cells who take it upon themselves to attack the very patient that the stem cells are trying to save.  I’m sure that there’s a more technical way of putting it, but with cancer, it seems that every treatment comes with significant side effects that need to be managed.

So that’s where we are today.  At her request there have been no visitors, and for now (unless you hear it from her directly), that holds.

Send prayers and positive energy.

Friday Aug 11th. Still not feeling well

 

The emoji's above were all I got this morning.  Just these three.  I'll hang my hat on the last one.  The battle continues.

The team thinks the tide will turn on day 14, August 15th.  Hopefully then, just 4 days from now, she will start to feel better.

Wednesday am August 9th - still feeling pretty miserable

At Kristina’s request, we held off posting as she was feeling pretty miserable.  She felt a ‘wee bit’ better on Monday, but the last couple of days have been rough.  Monday night was ‘super rough’ and this morning (Wednesday) she was feeling absolutely miserable and requested no visitors.

All of this wasn’t totally unexpected.  She had hoped to avoid some of the worse impacts of Chemo and transplant, but that doesn’t appear to have happened.  So worse than what was hoped but (very generally) about what could be expected. 

She’s being fed now via parenteral nutrition (TPN) which bypasses the stomach and introduces nutrients right into the bloodstream. 

This too isn’t atypical.  AML patients undergoing stem cell transplants are subject to malnutrition caused by cytotoxic therapies.  There’s that word again, Cytotoxic.  Cell killers.   Wreaking havoc on the digestive tract.  So they’re bypassing it to give her nourishment.

So the two asks today are to again check out the go fund me site and to simply send her prayers and positive energy.  If she doesn’t get back to you, it isn’t for a lacking of wanting to, it’s just that she’s feeling miserable and really doesn’t have the ability to talk.

Sunday am 8/6. Not feeling good. And some more history.

 

Most of these posts are vetted by Kristina.  Usually she’ll call and we chat, I write up a post, she reviews and edits it, then I make changes and post.  Today is different.  She’s not feeling well this morning and is having trouble concentrating.   In all likelihood this is normal.  Miserable, awful, and feeling absolutely sicker than hell, but, if we can call it that, the “normal” aftermath of chemo and a transplant. 

Yesterday she did exhibit the symptoms of C Diff, but the tests came out negative.  We don’t have to cover the details, but chemo wreaks havoc on the digestive system and those effects are, simply, miserable.

So that’s all I know this morning is that she’s way under the weather, but this was a well forecasted storm.  If there is news later today, I’ll post it. 

So, taking a sharp u-turn back into history, here’s a bit more on how modern chemo therapy was born.

In an earlier post, we mentioned that the roots of Chemotherapy were laid in WWI owing to the German army’s use of mustard gas.  What I missed was the nexus of why that lead to further research on any possible medical benefits this would have.  And it gets pretty interesting.

While the Germans used mustard gas during WWI, it was actually American made mustard gas during WWII that led to the research.  Americans never actually used the chemical agent, but 80 years ago this month, President Roosevelt signed off on a secret mission to get mustard gas over to the European theater in 1943 in case they’d need to retaliate against German’s usage of the gas.  No formal plans to use it, but a contingency plan if it was used against allied forces.

The SS John Harvey, a liberty ship, carried the secret cargo of gas and was to off load in Bari, Italy in December of 1943.  The captain of the ship, Elwin F Knowles, wanted to expedite the unloading, but secrecy prevented him from telling anyone about the deadly cargo.  The harbor was packed with ships and he had to wait several days for offloading.  Meanwhile the Germans staged an air raid on the harbor and during the attack, about 1,000 people were killed and 28 ships were sunk, including the SS Harvey.

Blogger’s note:  A few years ago I did some reading on WWII and was aware of this occurance.  The US tried to keep it secret, but issued a statement in 1944 admitting to the incident (there were too many witnesses to keep the secret).  It wasn’t until 1959 when the US declassified the records on the attack and it wasn’t until 1976, when a book came out on the incident did it get more widespread coverage.

In the immediate aftermath of the attack, there were hundreds of military personnel and likely more civilians suffering from the effects of mustard gas but prompt remedies were not provided as the medical personnel were initially unaware of what they were dealing with. 

Stewart Francis Alexander, a doctor and expert in chemical warfare, was dispatched to the scene and surmised that the offending agent was mustard gas but the symptoms he was seeing were different than what was observed during WWI.  The difference?  In WWI the soldiers inhaled the gas.  During the WWII incident the soldiers were swimming in the water and the mustard gas agent mingled with oil from the sinking ships and were absorbed through the skin.

It was the follow-up autopsies of the WWII incident where the lower white blood cell counts were recorded.   Autopsies of the victims suggested that profound lymphoid and myeloid suppression had occurred after exposure. In his report, Dr. Alexander theorized that since mustard gas all but ceased the division of certain types of somatic cells whose nature was to divide fast, it could also potentially be put to use in helping to suppress the division of certain types of cancerous cells.  (that last part was cut and paste).

It was that report that prompted the defense department to enlist two pathologists to explore any medical benefits of mustard gas and the initial focus was on Leukemia.

An interesting side note on how chemotherapy came to be.  Yes it was the Germans who initially used the gas, but it took the Americans secretly getting a stash of a weapon they never actually used and a horrible attack with unforeseen consequences that led to a sharp doctor surmising that perhaps there may be a beneficial side to the weapon.

None of this has anything to do with Kristina – except that it has everything to do with Kristina and a nod of the head needs to be given to the past suffering, coincidences and curiosity that lead to modern treatments. 

I would find all of this fascinating were it not for the fact that a dear friend is lying in a hospital bed feeling desperately ill.  Send positive thoughts to her.

Saturday August 5th - Morning Post

 

Cytoxan (aka Cytarabin)

Kristina got her last dose of Chemo yesterday , a drug called Cytarabin (or Cytoxan)

What is Cytarabin you may ask (or even if you didn’t, if you care to read on, we’ll tell you).

Here’s what the literature says.  Cytarabine is the most effective cytotoxic agent in the treatment of acute myeloid leukemia (AML).

Cytoxan.  Cytotoxic.    Any time the word toxic is used in something you put into your body, it’s gotta be good.  Toxic?  Yummy.  May I have two please?  (Did they really think changing the suffix from ‘toxin’ to ‘toxan’ would work?

Let’s break down the word cytotoxic.  Two words.  Might as well put a “Mr Yuk” sticker on the second one but the first one is Greek from the Greek word Kutos, or ‘vessel’.  From the word vessel but means ‘Cell’ (as in cytoplasm).  So Cytotoxic.  Cell Killer.  Trained assassins that seek out mostly cancer cells with collateral damage to cells that act like cancer cells (sounds like poor policing, but I digress).

In the early 1950’s, cytarabine was discovered as a nucleoside (containing arabinose sugar) within a species of sponges (cryptotethia crypto, if you really want to know).  These buggers play a role in DNA synthesis. 

According to my research (over coffee, pursuing journals) I found a guy who claims that “Cryptotethia Crypta, possibly one of the coolest sea sponges ever, possess two very interesting free state elements”.. then goes one to use way too many syllables and after he uses the word ‘cool’ he wanders off into scientific speak that my partially caffeinated brain can’t understand.

But the essence is the chemical in these sponges inhibit cell growth by attacking the cells DNA replication cycle.  If you’re not replicating, you’re safe. Any cell that replicates becomes the target.

In what is a clear copy paste with little understanding of what this actually says, here’s the formal description:   Cytarabine is incorporated into DNA, it blocks DNA synthesis by inhibiting the function of DNA and RNA polymerases. The most essential step in the AraC activation is phosphorylation into the monophosphate form, which is catalyzed by deoxycytidine kinase (dCK).

Personally, I like the fact it comes from the coolest sea sponge ever. 

Blogger pauses, sips coffee, ponders the larger world. 

Chemo, as we learned a few posts earlier, has roots in the German Army’s use of mustard gas during World War One.  Now we find out that one of the specific chemicals used for AML comes from Sea Sponges.  Medical discoveries all within the 1900’s and further refined over the past several years to offer hope and a life saving gift to Kristina, currently lying in a hospital bed benefiting from these medical discoveries and advancements.

Kristina slept most of yesterday afternoon, a reprieve as the side effects of these medical wonders kicked in. 

Kristina is now entering a critical phase.  As much as the meds and new stem cells are doing their thing, there’ll be a shift to her own body’s creation of healthy blood cells.  But she’s got to ward off infection which is now the most acute risk between now and when healthy blood again courses through the body.  .   With a highly compromised immune system, it’s infection that becomes public enemy #1.

She texted this morning.  Yucky coating in her mouth and no real appetite.  She’s forcing down a ‘wee bit of food here and there’.    She’s using some stuff Leigh gave her for dry mouth and it’s helping a bit.

And the final bit of news is that they’re checking for C diff again.  Results should be back by end of day.  This is one of many infections they’ll be looking for.  The challenge is that some of the side effects of the chemo can be very similar to C diff.  The C diff bacteria emit a cytotoxic substance, so tests are needed to discount the C diff possibility.  In an abundance of caution, her visitors will need to gown up until that possibility is discounted, which should be later today. Edit 9:08pm.  Results came in negative.  Whew!!!

Friday August 4th.

 

Well, the well forecasted storm has hit.  Kristina is hoping to avoid the worst of it, she’s been there before.

She slept in a little and felt a bit spacy, then waited as various body parts checked in, most were moving and confirmed they were still in reasonably good working order.

Today at noon she started her last round of Chemo – Cytarabin, which in the past has given her a rash on her lower extremities.  There was a bit of nausea this morning and as a write (11:45am) the dry heaves have begun. 

While there was a momentary crack in the veneer yesterday (oh this is really happening) the cancer, chemo and other stuff haven’t disabled the sense of humor.  It remains strong. 

So today will likely be a bit rough but she’s still hopefull she can avoid the more severe side effects of the chemo.  Time will tell, let’s all send her positive energy.

CHEMO -- a brief history and what's about to happen

 

This is going to be greatly simplified, but Kristina reviewed and said ‘post it’. 

We all know that Chemo has massive side effects, but the question that popped into my head was ‘why’.  What was the history of Chemotherapy, how does it work, and why are the side effects so miserable?

Surprisingly (to me at least) the roots of ‘Chemo’ date back to and begin with Germany’s use of mustard gas in world war I.  After the war two pharmacologists from the Yale School of Medicine were tasked by the defense department to see if there were any beneficial uses of these chemical agents and they made the link between derivatives of this terrible battlefield weapon and their ability to kill cancer cells.

The specific cocktails involved in Chemo have evolved quite a bit and are varied in their approach, but they work by killing fast dividing cells.  Most cells our bodies don’t divide particularly fast or regularly.  Cancer cells divide quite rapidly, so if you send in an agent that seeks out and kills fast dividing cells, it’ll attack the cancer cells and most of our healthy cells that don’t quickly replicate are left unharmed.

But there are a few categories of healthy cells that do replicate quickly and those are the ones that become collateral damage with Chemo’s onslaught.

The key cells that divide quickly are found in your mouth, blood, digestive system and hair follicles.  So hair loss, mouth sores, and all sorts of digestive tract distress are the side effects.  The blood levels plummet and there goes the immune system.  Infection risk is high.

So after chemo your digestive tract goes to hell, nausea threatens expel food one way and the other end, and the plumbing that lead to it, doesn’t work well either.  Nothing tastes good, your mouth feels rotten and any germ that feels like it can attack you without risk.

Chemo also creates a fog in the brain.  “Chemo Brain” becomes a phrase that’s well known to those that have undergone treatment.  Add to that the side effects of the drugs that are controlling nausea and other meds and, well, it’s not a walk in the park by any stretch.

So while some of us are looking forward to SeaFair and the air show over Lake Washington, Kristina, having gone through this before, is awaiting these side effects to fully manifest themselves. 

Using  sailing as a metaphor, picture yourself on the ocean without any port to run to.  A well forecasted storm is headed your way and you can’t outrun it.  You are going to have to shorten sail, make sure everything is securely stowed and dog the hatches tightly shut and simply take it, hoping that all your preparation will keep you safe.  Miserably uncomfortable, but safe.

This morning I asked Kristina how she felt on a scale of 1 to 10, where 1 is lousy and 10 was pretty good all things considering.  She said 7 or 8.  On the plus side no stuttering or shakes so far this morning.  But her appetite is gone and while she can’t quite put her finger on it, she says ‘something is brewing’.  She doesn’t feel completely ‘right’.  Storm clouds are gathering.  Yesterday she mused that Saturday would be the day she’d start to feel much worse, perhaps it’s starting a day or two earlier.

Take a moment and let’s hope our collective positive energy flows her way.

DIP and the rocky journey

 

Ok, it's a bit juvenile, but the graphic above captures the curvy and erratic journey of a transplant patient.  There are little and big things lurking along the way that vary from irritating to annoying to frightening.

Sometimes it helps when things are explained.   It may not make the symptom go away but at least an explanation can take away the worry that accompanies a symptom.  

Take her stuttering speech, the inability to walk well and her shakiness and tremors.  Annoying and frustrating.   But explainable as her doctor did a couple of hours ago.

It's related to the nausea meds.  The Dr explained there's a tie between those meds and cognition.  It's a thing.  

While the Dr didn't use this exact term, there's a condition called DIP.  Drug Induced Parkinsons.  No, she doesn't have Parkinsons.  But the symptoms are not unlike Parkinsons and should subside with the cessation of the meds.

Kristina was really feeling those effects today but the doctors explanation eased at least that worry.

AUGUST 2nd. That shaky feeling the day after

 

Well yesterday got away from Kristina.  Like platelet transfusions there’s a sedative involved, but more this time.  There’s a preservative in the stem cell stew and they sedate you in case there are any reactions – so just as the transplant started, the sedatives took effect and, well, the rest of the day was pretty much lost in the fog.  She woke up and thought that it was 2:30 in the afternoon but the clock said 7:45pm.  The clock was right.  An odd, weird day.   But a good one with the long awaited transplant done.

This morning she reports that she’s feeling pretty good, but a bit shaky – stuttering and stumbling over words, not walking right, etc.  Largely it’s a repeat of her earlier 2 transplants.  She thinks that sensation is due to the antiemetics she’s taking – the drugs to combat nausea.  She’s frustrated by it, but she knows what’s coming – the delayed impact of the chemo. 

She’s expecting that by Saturday she’ll be laid pretty low by the after effects of chemo.

Today’s news:  Her Liver Enzymes shot up.  Way up.  They’ve shot up before, but not to this degree.  There may be some med related impacts.  Her doctor said it was like she went on a huge drinking binge last night.  Which she didn’t.  Or at least doesn’t recall (maybe yesterday’s singing nurses returned for a party?  Probably not).  A short term spike that’s med related isn’t a huge concern and the meds are being changed up to deal with it.  They are closely monitoring and hopefully they’ll go down in the next few days.  For now, it’s not a huge deal.

The short story is that all of this is largely ‘normal’ and things are going as expected – with the possible exception of the liver enzymes.  So for now, ‘so far, so good’, but by the end of the week or the weekend, she expects to be hit by the after effects of the chemo.

She’d love to have visitors.  Check in with her first (can’t have too many at one time) but in the formal language of one set of my grandparents, “She’s receiving visitors”.

Random Updates on August 1st

 

Stem Cells have arrived

So I'm getting some texts from Kristina and will add to this page through the day.  She had a rough night last night, but sounds pretty excited now that the process has begun,

First, the pre-transplant ceremony.  Complete with a 'happy cell day'  card.  It's a transplant thing.  So this just happened a few minutes ago:

Complete with card!

Really nice touch

And so it starts

Kristina says you can actually see the tiny little golden stem cells!

Stay tuned.

 

So now that the transplant is done, what’s happening.  In a word, Haematopoiesis.  It’s a Greek word formed from two other Greek words.  One meaning ‘blood’ the other meaning ‘to make’.  Making blood.

Using stem cells.  The ones that, as I type, are being introduced into Kristina.

Fun fact:  The healthy adult human makes between 10 billion and 100 billion new blood cells each day (no wonder I’m tired).  Take a nap.  You’ve earned it.

What sorcery is at play?  Stem cells.  Haematopoietic stem cells.  Or, as my spell checker likes, Hematopoietic stem cells.  These cells have the unique ability to give rise to all the different mature blood types and tissues.  Some that stay in the bone marrow, some that flow through the blood and others that in tissues. In laymens terms, the main ones are red blood cells, white blood cells, and the platelets.

But (of course) it’s more complicated than that.  Stem cells can create a wide variety of cells, but do so through another layer of cells called  ‘progenitor cells’.  The progenitor cells are only slightly less cool than stem cells.

Stem cells can live indefinitely and create progenitors, but progenitor cells can only create certain specific cell types and can only replicate so long before they expire.  As long as the stem cells are good, the creation of the progenitors and subsequent cell types can go on for a long time. 

So what type of cells do stem cells create?  They have big fancy words and different levels of creation.  Picture a big family tree with two diverse kids more diverse grandkids and great grandkids each with special powers all originating from a single parent (don’t dwell on that analogy too long).  But it’s fascinating how these stem cells organically know where to go (the spongy bone marrow) and how they replicate into myeloid progenitors and common lymphoid progenitors which in turn create another level and type of blood cells, some of which then give rise to still other types of blood cells. 

The progenitors mostly live in the factory – the bone marrow.  But the cells they create go forth and do the real work throughout the body, delivering oxygen and fighting off invaders.

And while we’re at it, let’s ponder for a bit just how new this process of transplanting stem cells is.   It started in the 1950’s, the decade into which I was born, right here in Seattle by the very hospital where Kristina is getting her transplant – the Fred Hutch Cancer Research Center (which is now just the Fred Hutch Cancer Center).

Dr. E. Donnall Thomas was the primary driver of treatments for blood cancers in the 60’s at the Fred Hutch and received the 1990 Nobel Prize in medicine for his ground breaking research.  Most of which was done right here in Seattle.

Fascinating process and Kristina’s in the right place at the right time in history. 

Transplant Day

 It’s transplant time

 Today is the day.  Kristina had her first total body irradiation (TBI) yesterday.   3 minute test, then 6 minutes on the front, 6 on the back.  She’s feeling a little fried after the session – like a day in the sun.

Today they’ll ‘pre med’ Kristina in preparation for the transplant.  Then the stem cells are thawed.  They’ll be a honey colored golden liquid in two bags and over the course of two hours they’ll be inducted via the hickman, and as stem cells are naturally programmed to get to the thicker bones, they’ll start to be absorbed into the ‘spongy bone’ and engraft themselves into the marrow and begin to populate new stem cells.  Hopefully they’ll multiply.  Kinda like rabbits.  If everything goes as planned, they’ll create different sorts of cells and get her bone marrow back to healthy blood generation.

We all know what ‘transplant’ means, but here’s a quick tutorial on how it works.  Yes, it’s way simplified, but your humble blogger is a simple guy. 

First the donor.  We’ve been through the matching process, but when Kristina says ‘the donor is being harvested’, gruesome pictures pop into my head.  It’s unsettling.  But when Kristina described the process, it’s pretty simple.  It’s not unlike giving blood.  There are some preparatory steps, but the actual ‘harvesting’ is pretty simple.  Take blood out of one arm, run it through a centrifuge to spinoff the stem cells and then put the left over blood back into the other arm.  Freeze it, and courier it to the patient.

If getting the stem cells out of the donor is relatively easy and fairly risk free, the process of getting them into the patient, Kristina in this case, is a bit more complicated.  With a wide range of side effects.

Chemo, and in Kristina’s case, radiation is involved to lower the immune’s system to battle the new stem cells.  The very treatment that allows the body accept the good stem cells greatly weakens the bodies ability to fight other infections.  Then there’s GVHD (Graft-versus-host-disease).  This is were the donor cells attack the patients body.  Even if the match is ‘perfect’, this can happen. 

GVHD comes in two forms – acute (within the first 3 months after the transplant) and chronic (after the first three months).  The acute form can cause rashes, diarrhea and jaundice and a whole bunch of other things.  Her care team will monitor and meds may be required to block the donors ‘T’ cells which are attacking Kristina’s cells.

The chronic form is more insidious and can be life altering owing to organ damage.  It’s nowhere near certain any of this will happen, but it’s a possibility.  Another thing to worry about.

Kristina is about to battle on several fronts.  Already weakened from the earlier round of Chemo as well as the ‘one two’ punch of the lumbar puncture and ‘maintenance’ round of chemo, she’s about to be further beaten down with the pre transplant chemo and radiation.  The risk of infection is going way, way up.  Even if everything is done correctly and all precautions taken, infection of some sort is likely.  Add to that the potential of GVHD which can wreak havoc.  So many unknowns, but she’s ready to push forward.

Two last requests – care giving is going to be a thing.  Kristina has asked her ‘tribe’ to sign up to be backups.  With a primary and a back up for each day, she’ll feel comfortable.  Take a look at September 17^th as well as there’s a coverage need.   That’s the non-financial ‘ask’.

Then there’s the financial ask.  Take a look at the go fund me page.   ‘Nuff said.

The next few weeks are the critical weeks. 

As a side note, her night time oncologist is a warm, intelligent engaging professional who affirmed the questions Kristina has asked have saved her life.  She affirmed that Kristina’s active engagement in her care have produced positive results, even going back to her two earlier bouts with this disease.