3 stories

NIH, day 4. Easiest day yet. Nothing to do but chemo, and working out how to handle the antibiotic for whatever's going on in my left lung (see yesterday's post).

Showed up at the day hospital just before 10 AM. Very efficient and competent nurse placed another IV, drew some blood without me even noticing, plugged in the cladribine and off I went.

Meanwhile, the sweet but unconfident young med student from Infectious Diseases showed up before we even got around to raising the antibiotic issue. She asked about any new symptoms (none), listened to my lungs, heard nothing. I told her about my fears about Levaquin — tendon rupture, insomnia, leg cramps — and my conversation with Dr. K last night.

Story #1, from her: I'll consult with Dr. B, the attending. She fired off a text message. I think what he will say is that the side effects you describe are very rare and that it's the best option for you. Turns out that Infectious Diseases is a sort of rotation for her; she's trying out different specialties, mainly working on internal medicine. Didn't realize Infectious Diseases would be so interesting. Dr. B makes it all into a mystery. It's fascinating.

A few minutes later, med student returned with NCI Fellow from yesterday. (All without me saying a word.)

Story #2: this time, no hedging. I've prescribed Levaquin throughout my residency. Never had anyone complain about insomnia. The tendon rupture issue is real, but it's more common among children. I told her about the lawsuit against the company that makes Levaquin; 400+ people suing over tendon ruptures over a 10-yr period. But how many people took the drug without side effects? I've never seen a tendon rupture.

The other problem, she said, is that you can take Levaquin orally, but all the other broad-spectrum pneumonia options involve an IV for 7 days. I could see right away that would be a major headache. You can always try the Levaquin, and if you start to develop side effects, you can stop right away and we'll do something else. That made sense to me. I told her I'd try it. Said I'd take it during the day instead of at night, at least hope to avoid the insomnia that way.

An hour later, Dr. B came in, along with med student and NCI Fellow, and a third woman who said nothing and was never introduced. He listened to my lungs for a bit, then motioned med student over to listen while he held the stethoscope in position. This time, she heard it: crackling in the left lung.

Dr. B's from Madrid. Beautiful accent, great manner, great communication. And a really different story. We loved this guy.

Story #3, from Dr. B: first, he confirmed NCI Fellow's line on Levaquin. Fine drug, widely prescribed, and the other options are all combinations of oral pills and IV delivery. But next: We know something's happening in your lung. We don't know what it is. We don't know how long it's been there, how it's changed. Has it been there 10 days, or a month? Is it getting better, or worse? You have no symptoms, no fever, no cough. I nodded and confirmed. So we don't need to treat you right this minute. It's not like you're coughing up blood.

What could be causing this fuzzy spot on the CT scan? It isn't cancer. That shows up as a dark mass, not a fuzzy infiltrate. But it might not be pneumonia either. It's possible that because you're immuno-compromised, some of the bacteria from your mouth — bacteria that are normal there — have gotten into your lungs where they don't belong.

So I say: you're already scheduled for a bronch tomorrow. There's no need to treat right away. Why don't we do the bronch and find out exactly what it is? If it's mouth bacteria, we have a lot of other options for antibiotics.

Now that's a good idea. I'll take it, I said.

The interesting thing here: the three different levels of experience, and the three stories they produced.

• Story #1, inexperienced apprentice: defer to someone else's judgment, but predict that it'll be an attempt to persuade me to stick to the original plan. Don't mention other possibilities (maybe don't know them). Call for backup.
• Story #2, real but limited experience, journeywoman: describe the other available options and explain why Levaquin makes the most sense. Reassure the patient about the unlikelihood of side effects, but acknowledge their reality. Offer one option: try it and see.
• Story #3, deep experience, guildmaster: Look again at the entire situation. Reopen all avenues. Does the patient really need this antibiotic, right now? Is there another way to think about what's going on? Realize that there's an unexplored, but simple and obvious possibility: wait, find out more about the condition, use that knowledge to decide what's best.
  

There's a life lesson in that one, I think.

Out of the hospital by 12:30. Wiped out, back to the hotel for a 1.5 hour nap. Then a long slow walk.

This go-round, without the anxiety of a PICC line (which made me feel like I really shouldn't move much, even though I think the intent of the portable pump was the opposite), I'm focusing on keeping somewhat active throughout the treatment. Circulating the cladribine can't hurt. I want poison to reach every cell of bone marrow. Light exercise will certainly do that better than lying on my back in a hotel room.