by Christopher Graham
The other big part of the treatment for peritoneal mesothelioma, in addition to trying to remove all of the big, bulky disease you can see on the inside, is heated intra-peritoneal chemotherapy (HIPEC) in the OR, pumped through the belly, while they place you in different positions throughout that part of the case so it can all mix around in the belly. The idea is that the surgery removes all the big visible stuff, and the chemotherapy is to address the tiny, microscopic cancer cells that we pretty much know are there, but can’t see. It’s heated so that it’s more effective at actually penetrating into the cells.
The medication they chose for the HIPEC was called cisplatin. Anything with –platin in the name is a platinum based chemotherapy agent. Those basically bind and crosslink DNA molecules in cells in an attempt to activate the normal cell-death pathways[ref]Cells have built-in check points to make sure that DNA replication and cell division are going okay. In cancer cells, at least some of those pathways have been damaged and aren’t working. So the cell divides when it’s not supposed to. But if you can get the cell to recognize the DNA errors, maybe you can activate one of the other checkpoints that will tell the cell to kill itself, a process called “apoptosis” or “programmed cell death.” This happens all the time in your body, actually, and when the process doesn’t work, that’s when you get cancers.[/ref] in cancer cells. One of the things they teach you pretty early on in medical school is that cisplatin is well known for trashing people’s kidneys, too. We didn’t know it at the time, but that’s exactly what was happening during the HIPEC portion of the case. We wouldn’t find out exactly how bad it was for a few days, actually. It was pretty freaking bad, but we’ll get to that, too.
The last thing they did, before they closed me up, was to put in a couple of “Jackson Pratt (JP) drains.” Those are the drains that look like there’s a little hand grenade on one end. You squeeze the air out and then hook it up to the drain tubing, and the negative pressure inside the bulb sucks all of the secretions and post-op juices into the bulb. Then we can measure the output day to day. Once they stop getting a bunch of stuff out, we can just pull them out through the skin. But between the mediport devices – which they left accessed with a needle in each one – and the JP drains, I had four tubes sticking out of my belly.
That’s not to mention the other tubes and lines I had when I woke up, too. There was a tube up my nose going into my stomach, a nasogastric (NG) tube. There were at least four IV lines, two on each side, and some of which were very large bore needles. I was glad that they were kind enough to put me to sleep before starting those big honkin’ IVs. They had also placed an arterial line (“a-line”) into the radial artery of my left wrist. Right in the part of the wrist where you feel for your pulse. That allows them to monitor your blood pressure in real time, basically. And it felt exactly as pleasant as it sounds, to have a catheter going right into one of the arteries in your wrist.
The last, and perhaps most fun tube of all, was the Foley catheter. That’s the kind of catheter they use to drain your bladder, and there’s only one really good way to get into the bladder – the urethra. The thing you pee through. I can honestly say that I never thought I’d have a plastic bladder tube sticking out of my Johnson at the age of 32. Thankfully they were kind enough to wait until I was asleep to place that particular device.
So the number of the day, that day, was eleven. Eleven lines and tubes going in and out of my body. The arterial line, four IVs, two intra-peritoneal ports, two JP drains, an NG tube, and a Foley catheter. It could have been 13 things, it turns out. I just avoided getting chest tubes. Chest tubes are things that go between your lung and your chest wall to suck out air in that space. If you have too much air between your lung and the chest wall, the lung can collapse. I’ve heard that those are very unpleasant, and that it basically hurts every time you breathe when you have chest tubes in. Thankfully, I can’t actually tell you what that’s like.
But, after the HIPEC and subsequent closure, the case was finally over. It was time to go to the “post anesthesia care unit,” or PACU. We love acronyms[ref]Yes, Mr. Smartypants (or Dr. Smartypants) – some of the examples I’ve given you are initialisms. Initialisms are a subset of acronyms which are pronounced using the letters, not as a word like a regular acronym. “FBI” or “EGD” or EUS” are initialisms. “PACU” or “SCUBA” are acronyms. And, yes, if you really want to be a pedant, words like “scuba” and “radar” – which are pronounced as their own words now – are more precisely called anacronyms. These are the sorts of hair-splitting technicalities for which radiologists live.[/ref] in medicine, as you may be gathering by now. In the PACU they make sure you’re waking up from the anesthesia. Once you’re awake enough, they take the breathing tube out of your throat. Then they monitor you really closely for a while before sending you where you’re eventually headed to. There’s a really big push in medicine to get people out of the hospital as fast as possible, mostly because people do better when they’re not in the hospital. So for a lot of things that used to get you admitted, you now just go home. Laparoscopic hernia repairs or gallbladder removals are good examples. If you’ve had something a little more serious, like perhaps a bowel resection, you might go to the regular floor. For people who have had brain or heart surgery, or a big open abdominal case like mine, the intensive care unit is usually where you’re headed.
I can’t tell you much about my time in the PACU – I actually barely remember anything about it. I think I informed my nurse that I was really tired and going back to sleep, and she told me that was just fine. And that’s really all I remember from the hour or so immediately after surgery. And, after all the stuff they had done to me, there was no way I was going anywhere except the intensive care unit.
Read the previous installment by Christopher Graham here: Chapter 2 | Part 4: So What Happened During my 12 Hour Surgery?
Christopher Graham is a radiologist who was diagnosed with peritoneal mesothelioma in early 2016 at the age of 32, two months after he was engaged to his now-wife. He has since undergone two major surgeries, intra-abdominal chemotherapy, and has had many significant complications as a consequence of his treatment. He currently lives in Columbus, Ohio with his wife Nicole and their two dogs. Christopher plans to finish residency and fellowship after treatment, and he and his wife are trying to get their lives back to something resembling normalcy after dealing with such a devastating diagnosis.
