Tuesday, June 1, 2010

Hoping for the Best, Worrying about the Worst.

Tomorrow I go to have definitive surgery for my melanoma. If you have a strong mental constitution read on to find out my mental ramblings during this time.
 I am scheduled to arrive at Froedtert at 6:30 AM when I will be checked in for Day Surgery. Then I have an appointment at 8 AM in Nuclear Medicine where a radioactive protein will be injected into my melanoma lesion on my arm along with methylene blue which is a dye. Then I am told that it will take about an hour and a half for these substances to migrate up my arm from the lesion to the lymph nodes under my arm. I am not sure if they follow this migration with a probe or detector or whether they take nuclear images to follow it. I will know more about this after it is all done. The anesthesiologist called this afternoon to get my medical history from me personally; he has my preop and all my preop labs in front of him. He told me to hold all meds except to take my Bystolic (a beta blocker) and the 10 mgm of prednisone with just a sip of water before I leave. I am also to take only half my usual dose of Lantus the night before and no short acting insulin the morning of the surgery. He explained the anesthesiological procedure carefully to me. My surgery is scheduled for 10 AM. I will get undressed, be put on a gurney, and an IV will be started by an anesthesia resident. Then I will be wheeled into the operating suite and a mask will be put over my face with lots of oxygen. I will be put to sleep through a medication injected through the IV. Then when I am asleep I will be entubated and monitored closely throughout the procedure. He told me that they would probably be checking blood sugar about every hour during the surgery and recovery times. The surgery is scheduled to last 1 1/2 hours. Then I will be awakened and extubated when I am breathing on my own, and moved to recovery for about 1 to 1 1/2 hours. After that I will be sent to Day Surgery to further recover for about 1-2 hours. So I will probably not be released until mid afternoon.
     This afternoon, after a call from Freodtert OR Nursing to confirm that this is all to take place tomorrow, from the anesthesiologist, and from the surgeon's office to confirm that everything is ready to proceed, It is difficult to put this upcoming procedure out of my mind. I have never had a general anesthetic before so this will be a new experience. It brings to mind the spiel that a neighbor and friend who was an anesthesiologist used to present at parties. He would pretend that he is doing a preop visit to a patient in the hospital the night before their big surgery. At that time there were very few outpatient day surgery procedures so he was usually visiting the patient in person unlike now when this is all done over the phone. This effect of his spiel in person was highly impressive for party guests but it is not very effective when now years later I am going through with a general anesthetic procedure. Now there is nothing to laugh at. His spiell went something like this:
     "Hello, I am Dr. Smith. I will be your anesthesiologist during tomorrow's surgery. I must get your medical history and will be asking about 100 questions about your health history and various symptoms that you have. We need to know all the answers to these questions because you life will be very delicately in my hands during that surgery tomorrow. We will be monitoring you very closely because lots of things can go wrong during anesthesia and surgery. We could have trouble helping you breath; you could have bleeding during the procedure or afterwards, you could react adversely to any of the many drugs we need to give you, you have an increased risk of stroke, heart attack, and other major medical complications during anesthesia and during the surgery. Our tube that we place in your throat could cause damage to your teeth, tongue, throat, voice box, and breathing tube." (Nowadays  and in reality I can vouch for the anesthesiolgist who I just spoke to and he said all these things, not quite in this blunt a fashion and he interspersed with multiple statements that these complications are all very rare now adays with the degree of monitoring that is done during modern surgery. But he said them). But Dr. Smith would have gone on: "Basicly what we will be doing is putting you into a coma utilizing several drugs and we hope and plan that it will be a reversible coma and that you will wake up." How would you like to sign up for this after this spiel? Scary isn't it? Well now that I am going through this tomorrow I can't help but remember this party stunt carried our frequently by our neighbor.
     Unfortunately, also this afternoon with my mind on my disease, I have  been reading on the Internet about melanoma, its staging, the characteristics of melanomas that are high risk to return, and what can be done to prevent such a recurrance. I have learned that treatment for melanoma that gets away from the original lesion is very inadequate. Normal chemotherapeutic agents don't work very well, and even radiation is not very effective. There are sometimes indications to use a drug called interferon which is a body product that is artificially produced and injected daily at first and then three times a week. This treats the cancer cells with your immune system. This substance is like the body product that occurs with flu illnesses and so it produces flu like symptoms and in the large doses needed tends to be very very toxic. Many people can not take the full dose due to the severe side effects and symptoms, liver toxicity and general toxicity. It is given for a year. And still with all that there is controversy in the studies whether it really helps survival. There seems to be some indication that disease free intervals are prolonged by maybe 9 months or so. Wow that isn't very much! This means that if I have a high risk melanoma -- thick in original depth which we can't even determine in my case, or having already spread to the local lymph nodes (which this surgical procedure is designed to determine) -- I have to decide whether to make myself sick for a year to try to reduce my chance of having metastasis and local recurrances or I do nothing and just take the chances that the disease will metastasize in which case other treatments are not very efffective at all and you die. Really bad idea to read all this this afternoon  before my surgery though being a doctor I knew some of it anyway.
     I am still vacillating between hope for the best, believing that this lesion isn't all that big and so it shouldn't have gone anywhere else in my body, and then the fear that it has already spread. One tends to arrive at a state of mind that you are prepared but hopeful. But this state of mind is very fragile and it doesn't take much to start a spiral of dread again. For example, my surgeon had said that we would decide on a referral to an oncologist who would recommend regarding the use of this interferon -- we would decide on this after my surgical results were known in a week. We would then know if the tumor had spread to local lymph nodes which makes it a high risk that it will recur elsewhere. But I received a phone message while we were gone on our trip from the Cancer Clinic at Froedtert Hospital that said they had received a referral from my surgeon that he wanted me to make an appointment in follow up with the oncologist. That scared me! Dr. D had said we would decide about that later but now he has made a referral. Does he know something I don't know? Does he already think that it has spread? Seeing an oncologist puts this in a whole new level of concern. No longer is this just a shallow skin lesion that needs removal and will be cured, with sentinel node biopsy being done just for safety; an appointment with an oncologist would be cancer follow up. I am tipped off my fence and my fragile positive state of mind is destroyed for a while. I need time and have to build up my dose of hope again to get through the next week of waiting for the test results. Wow, this is shitty!!!

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