The bone marrow biopsy

I am back! I need to apologize to the one person following my blog for not keeping up with the posts. I know how frustrating it is to find someone who seems to share something in common and then to be left hanging, not knowing the outcome. I bet my follower wondered if I was still alive. I know I have had that thought when I see a year or more pass between blog posts. I promise dear follower I will not let so much time pass again.

Ok so where did I leave off? Oh yes my visit with hematologist number 2. By the way, I am now up to hematologist number 3 and 4! So much catching up to do!

So heme number 2 changed my diagnosis from ET to PV and advised me to get my name on a bone marrow transplant list before I became too old. I was 54 at the time and never really thought that I was old. My husband and I left the office with plans to call Dana Farber Cancer Center and make an appointment with a specialist in myeloproliferative neoplasms. And so I did. An appointment was scheduled for the first week in September. It seems all doctors take multiple vacations during the summer which makes scheduling appointments a bit of a hassle.

The next day I got a call from heme number 2 asking me to come back to the office, he had some thoughts to share with me. I agreed to meet him again. This time the visit included the very experienced hematologist who I was originally scheduled to see. She is the doctor who cared for my mother in law years ago. Heme 2 apologized for mis-speaking about the bone marrow transplant. He told me he spent many hour researching my disease and consulting with his mentor and the other docs here in the practice. His mentor advised him to keep me far away from a bone marrow transplant team because they will find a reason to do a transplant and 'kill me'.  Ok now! 

He continued and said he can do a bone marrow biopsy here in the office and give me so many drugs I will not feel a thing. Both heme 2 and Dr. G, the experienced heme, could tell I wasn't buying it. I said again NO. Dr. G commented that it would be very simple to perform a bmb on me because I am so skinny.  She said it would be a piece of cake.  I composed myself and quietly pointed out that while it might be a 'piece of cake' to you, I will forever have the sound of the bone cracking etched in my brain! At that moment Dr. G jumped up, clapped her hands and said ok. It will be done in the hospital and she was off to make the arrangements. 

A week later the bmb was scheduled for the operating room at the local hospital. I was given my pre op instructions and told when to arrive. My hubby and I arrived at the out patient area of the hospital where I was greeted by the nurse responsible for my pre-op care. She handed me a hospital Johnny and directed me to the bathroom and what to do with my street clothes. I asked her if she needed a urine sample and she said no. Back at the bed she asked me the usual list of questions about medications and health history. Then she looked at my chart and commented on my age and casually said Oh you don't have periods any more. Surprise! Oh yes I do! I assured her I was not pregnant but she insisted I try to produce a urine sample. Unlike my dog who seems to have an unlimited supply of pee on demand I said I did not think it was possible right now. Please try she implored. Half an hour later there was a knock on the bathroom door. How are you doing? No luck I said. I even tried the potty training trick of running water in the sink! Back to the bed to wait for the operating room nurse.

So this is a male nurse who had been given a brief over view of my medical history by the pre op nurse. He looked at my chart and made a comment that bone marrow biopsies are generally not performed in the operating room. Is there anything he should know about me? The look on his face told me he was really wanting to know if I was a psycho case who would spaz out on him! I replied No there is nothing more to know, I am just a big baby when it comes to pain. I am not a good patient and I will not apologize for it. So I am lying in the bed waiting to be wheeled into the operating room with my male nurse still looking for clues in my chart for something about my mental state. Suddenly I hear a female voice. Mary, do you have golden retrievers? Startled that this indeed was the voice of God I looked around to find the source. The privacy curtain separating me from the patient in the next bed opened. There was a friend of mine who had just had a procedure and was waiting to go home! She recognized my voice. We instantly brought each other up to speed on our health issues. My male nurse had left my bedside but returned with a hand written note asking me if I wanted to move to another spot to protect my privacy. No I assured him this was ok.

Finally I was wheeled into the operating room. My doc Heme number 2 was waiting for me in his scrubs.  He looked as though he felt out of place. Perhaps he did. Hematologist only perform one procedure, a bone marrow biopsy, and as we all know these are not generally done in the operating room. Just in the doctor's office. So I bet he did feel out of place. 

The anesthesiologist introduced himself to me and asked me about that pee sample I was not able to produce. I reassured him I was not pregnant! Just in case, he continued, what would I do with the pregnancy? I couldn't believe he was asking me this, here and now! I repeated I am not pregnant! This entire experience was becoming just a bit too bazaar!

I don't remember what happened next, but I was back in the pre-post op area wanting to go home!

Two weeks later I am back in the exam room of heme 2. He reports that my bmb shows evidence of an over proliferation of cells. The only treatment I need at this time is a daily baby aspirin. Go out and live my life and come back in three months. 

Hematologist #2

It is now August 2011. I have been coping with the concept of being diagnosed with a rare life threatening incurable disease for about six months. I am in denial and really not handling it well. My GP is not happy that I haven't seen a hematologist since February so he suggests I see another. The appointment is scheduled for a Tuesday during the first week of August. Late in the day for my husbands schedule. I am in the blood draw area with the phlebotomist/nurse answering questions about my health history and medications. She weighs me, takes my blood pressure and draws about 8 vials of blood. This practice runs a paperless office, scanning all records into the computer. There is no paper chart that I can see. I glance at the screen and notice my name with a doctor's name next to it. The doctor is not the one my GP requested I see. This is not the doctor who took care of my mother in law so many years ago. I recognize the doctor's name from the office website and remember that this guy joined the group two months ago, right after completion of his hematology fellowship. I asked the nurse if i was seeing the doctor my gp requested. She gave me what was obviously a standard line in this practice and said 'we have three hematologist, a nurse practitioner, and a physicians assistant. You may be seen by any of them during your visit.' I was furious! Another newbie. I thought about leaving and going home but i decided to give him an hour. I figured he couldn't do any harm. The first thing I notice is this guy doesn't make direct eye contact. He speaks with his gaze averted in a non-confrontational manner. I do know that he studied school psychology prior to becoming a doctor so I thought this behavior may have been a part of his counseling bag of tricks. He asks why I am there so I tell him about the ET diagnosis and my reluctance to have a bone marrow biopsy with just Novocain. He has the records from the first hematologist and tells me I don't have ET. He says I have PV, polycythemia Vera. Why I ask? Well you are jak2 positive. He then tells me I should get my name on a bone marrow transplant list before I become too old. It may take some time to find a match. He also wants to do a bone marrow biopsy. I am shocked! I am not surprised he would have a different diagnosis. The two are related and I do have symptoms of both. But no where in the limited research I have done did the research suggest a bone marrow or stem cell transplant as a standard treatment protocol. Quite to the contrary! I repeated that I would not allow him to do a bone marrow biopsy without some sort of sedation. We left knowing that this guy did not have a clue of what he was doing and knew even less about this rare disease. I planned to call the Dana Farber Cancer Center in Boston the next day. I desperately needed to speak to someone who knew what they were talking about.

The hematologist

So I am trying to play catch up with my diagnosis during the past year in order to get to MPN current events. Let's see how far I get. After the bloodwork my GP ordered showed elevated platelets he told me to see a hematologist. The cardiac testing, echo cardiogram and stress test were both normal. My first appointment with the hematologist was somewhat uneventful. He was a very young doctor who happened to teach advanced placement biology courses before medical school so I thought he might be someone I could relate to. He was very nice and did I mention very young? Well my husband and adult son were with me for this visit. That alone was awkward because they never come to appointments with me. The heme looks over my CBC results that my GP had forwarded and compares them with the labs completed in the office. My platelets are definitely elevated, hanging out in the 650k range.the other blood counts appear to be normal. At the high end of normal. I am asked questions about symptoms and lifestyle habits. Do you smoke? No. Have you ever smoked? No. Do you have any itching after bathing? No. Unusual bruises? No. Nose bleeds or problems with bleeding teeth? No. But I do have chronic low grade headaches, tinnitus, and very heavy periods. I ask if any of that is related. No, he says. I mention that my GP said the hematologist would probably want to do a bone marrow biopsy . So I tell him I am a huge baby and do not want to do that. He says we can take a step by step approach and may not need to do that. He wants me to have another battery of bloodwork and come back in a month. He mentions something about a myeloproliferative disease as a possibility. I am beginning to think this doctor is not very interested in my headaches or any of my complaints. When I return he wants me to have a test for a genetic mutation called Jak2. I have read a bit about that and understand that it is an acquired mutation that is seen in myeloproferative diseases of essential thrombocythemia, ET and polycythemia Vera, PV. This test will take a couple weeks for results. In the meantime he asks if I have had a colonoscopy. I am scheduled for that this month. The weeks pass and finally I get a phone call from the hematologist. He is sorry to tell me that I am Jak2 positive. This alone confirms that I do have an MPN. Which one I ask. He thinks for a moment and say ET, yes that's it, ET. He would like me to have a bone marrow biopsy, t my convenience. He is going on vacation, so no rush. I am just short of freaking out. I do not want a bmb and ask if he can do it while I am having the colonoscopy and under sedation. Unfortunately no, his malpractice insurance wnt cover him outside his office. Can you do it in the hospital under anesthesia? No your insurance won't pay for that. But we can give you Valium to calm you down. That's what you think. I decide it is not convenient to have that bone marrow biopsy. No now. He is not concerned with my complaints of chest pain and headache. He just wants to drill into my bone. I am not going back! Five months pass and I am scheduled to see my GP again to check my blood pressure. Even though I am on two blood pressure meds it is still in the 130/85 range. My GP is not concerned. My bloodwork is similar to the past results with my platelets around 650k. I notice my hematocrit is creeping up to 46-47 percent. About 5 percent higher than the top of the reference range. I tell my doctor of my experience with the hematologist. That I do indeed have a hematological malignancy, ET, and the Jak2 mutation. My doc knows nothing of this. The hematologist has not shared this information. I tell my doctor that I am not going back and refuse to have a bmb performed with just a couple shots of novocaine. He suggests I see another hematologist. He assures me she is quite good. She also happens to be the same doctor who cared for my mother in law twenty years ago whe she had non-hodgkins lymphoma. I agree to see her. Next post, hematologist number 2.

Holy crap Batman!

I am fortunate to have good health insurance and make the effort to do all those routine screenings that doctors advise. Well most of those screenings.

So early in January I had my annual physical scheduled with my general practitioner. I had been keeping a list of my nagging little complaints, mainly a chronic low grade headache that I mentioned each year, but also an interesting chest pain that occurred during intense physical activity. I also needed to complain about how long it took to actually schedule this appointment - seven months! For a long established patient!

I expected this physical to be pretty routine just as all my exams have fortunately been. After *nicely* expressing my frustration over the scheduling of the appointment, my doctor decides to re-take my blood pressure. 190/95. Wow! I had noticed a trend over the past few months in exam rooms, my blood pressure was routinely about 150/85. None of the doctors mentioned any concern, I am sure they attributed it to 'white coat syndrome'. However I never felt anxious at routine medical exams. So I began tracking it at home. There it was typically 140/80. Certainly not normal. But 190/95??? Ever Mr. Cool, my doctor simply says, 'that's too high' and writes me a prescription for a blood pressure medication and tells me I can expect to be on this for the rest of my life.

He then tells me he wants me to have a cardiac stress test - the tread mill test - and a cardiac ultra sound. He hands me a lab slip for a complete blood workup and says his nurse will be right in to do an EKG and that I should come back in a month to review the test results.

The cardiac tests were both scheduled at the hospital conveniently on the same day. I even had the blood work completed that day too.

Back at my doctor's office - the cardiac tests are reviewed, treadmill test and echo cardiogram, both normal, just as I expected. However, the next conversation was a bit of a surprise.

Doctor - I want you to see a hematologist. Do you have anyone you prefer?
Me - Why?
Doctor - Your platelets are high and have been for a while.
Me - What??? Remind me please what platelets do.
Doctor - Your bone marrow makes red cells, white cells and platelets. Platelets clot the blood.

Next stop hematology.

Welcome to my life!

2011 is quickly drawing to a close and I am struck by the changes that have occurred in my life during the past year. I had been a happy boring patient with just a handful of routine medical visits per year. Now I am an exotic patient with a rare hematological malignancy and a bevy of specialists. Where do I begin?

September 2010
My summer vacation has ended and I resumed my work as a middle school counselor. Middle school - grades 6, 7 and 8. Roughly ages 11 to 15. I have a caseload of 300 students. I like to live dangerously. One day I heard an announcement over the building PA system, the school nurse was conducting annual vision and hearing screenings. Teachers were to bring their classes to the health room for each student to be screened.

I noticed recently a persistent ringing in both ears known as tinnitus and that more and more of my students seemed to mumble. Teachers too, especially women, loved to speak to me by simply moving their mouth. I guess I was suppose to read lips. I was growing weary asking people to repeat what they just said. I decided to pop into the health room and ask the nurse if she would do a hearing screening for me.

Nurse Kelly was very eager to accommodate my request. She brought me into her back room and had me put on a headset, then she fiddled with some nobs and told me to raise my hand when I heard a tone. In just a few minutes she had the results plotted out on a graph. There was a noticeable loss of hearing in a specific frequency in both ears. She recommended that I have it checked out further with an audiologist.

Fast forward through the next few months. I was seen by an ENT - ear, nose and throat specialist - who ruled out any physical problems and ordered a complete hearing test by his audiologist. These results were remarkably similar to the quick screening the school nurse completed. The ENT told me I had a sensori-neuro hearing loss usually seen in patients who have been endured chemotherapy or loud gun shots. I had experienced neither. He offered no thoughts on what could have caused the hearing loss but he assured me it was not the result of my daily exposure to hundreds of screaming middle school students in the gym or cafeteria.

So what did this all mean for me? The doctor said hearing aids would be too annoying. Only a very limited frequency was affected and the devices would amplify the sounds I can hear well. The doctor said I would have difficulty with soft voices, women and children, people with accents and conversations with background noise. He suggested I avoid those situations or try to minimize the distraction and come back next year for a follow up exam.

And so I began my journey on the MPN fast lane.