Changed Schedules

Friday - August 31, 2012

Today officially begins my 6th round of Hyper CVAD chemotherapy.  The schedule has been altered due to Labor Day.  Rather than having my Rituxan infusion on Monday, Joe and I are traveling up to VCU today for this 3-hour infusion followed by a consultation with my oncologist.  I am scheduled to go into the hospital for five nights beginning Tuesday.  In addition, my intrathecal chemotherapy will come in tandem with my Neulasta shot the Monday after next week's hospitalization. 

So, six rounds of chemotherapy since mid-May.  Ten hospitalizations.  Who knows how many hours sitting in Dalton Clinic waiting for my name to be called.  I can't decide if time has flown or crawled .... It has just been.  Days morph into one another and the summer has passed, the drugs have been absorbed and processed, and my lymphoma is no longer in evidence.  I'll take that!  A summer well spent!  The plan first laid out in mid-May is coming to a close with GOOD RESULTS!  I can draw breath (a bit)....

Looking forward into autumn, my Bone Marrow Transplant looms.  I am thrilled that my second opinion with University of Maryland-Baltimore's Greenebaum Cancer Center has been moved up to September 24.  With this new timing, we will have the opportunity to digest and consider my options.  Then part two of this health challenge begins. 

It's the Small Things ...

Thursday - August 30, 2012

Time to rest up

... that add to the sense of normalcy and calm.  Small things that really can only be achieved at home by the way.  Today my rebounding health has already allowed me to use the electric toothbrush (my mucositis has almost resolved), WALK THE DOGS on my own without fear that fatigue would strand me (or worse, cause me to fall) somewhere in the neighborhood, and even begin to sort through the huge looming pile of mail (weeks worth).

No medical appointments today.  My plan is to continue to rest up, re-energize, and stay away from germs.  And to get through the mail!

An Update from my Transplant Coordinator

Wednesday - August 29, 2012

Late yesterday afternoon, my VCU transplant coordinator called with an update of an Oncology / Bone Marrow Transplant Unit panel meeting to discuss my pending transplant and with a report of the registry search.  I came away from the phone call with a large measure of relief and a slight twinge of panic - quite a conflict and contrast, yes?  In short, the panel wants a "full match donor" for me and the national and international registry search only surfaced 3 potential "8 for 8 marker" matches.  So, out of almost 10 million people on the registry, I match 3.  It's certainly much better than having no matches that's for sure.  Matching DNA and other criteria (size, blood type, etc) is highly involved with so many criteria that must line up in order to minimize the possibility of acute and chronic Graft Versus Host Disease.  Angela, my coordinator, says that the odds of actually harvesting marrow from 1 of these 3 registrants is "not great" - in the single digits - so I will definitely not get my hopes up.  We should have a response within a month.

Nonetheless, a chance still exists that one of these three potential donors is located and then agrees to go through with the donation.  In that case, I will face a procedure that carries a 12-15% mortality rate at VCU (5 percentage points lower than the national average).  That's quite a high mortality rate from my point of view:  10 percentage points higher than the mortality rate from an autologous BMT procedure.  It gives me pause.  Is my central nervous system truly, fully involved in my lymphoma and thus necessitating an allogeneic BMT?  The lymphoma in my head was in my orbits and sinus cavities, not the brain.  The trace amounts found in my spinal fluid in my first lumbar puncture were so slight that my oncologist was unsure that they were from the spinal column itself and not a result of the insertion of the needle.  Is an allogeneic BMT too radical a response or is it the full-artillery approach needed to eradicate my cancer?  That's the Debate: Part 1.

A view of the front yard

Fortunately, as an alternative to a "full match" allogeneic BMT, the VCU panel recommends that I receive an autologous BMT:  In an autologous stem cell transplant, stem cells from the patient's own marrow are "harvested," stored and then returned to the body (engrafted) after the patient receives high doses of chemotherapy and/or radiotherapy conditioning therapy.  Sometimes, the portion of marrow is also purged of cancer cells before being returned to the patient. The goal of transplant therapy is to restore or rescue hematologic and immunologic function following high dose therapy.  The stem cells are of a type that can develop into the full range of blood and immune cells.  I  am relieved to have the OPTION of an autologous BMT.  Many cancers and blood disorders cannot be treated with an autologous transplant and, without a third party donor, the patient must wait and hope that a donor eventually comes forward.  Yes, I have "clean bone marrow" without any trace of lymphoma.  However, this designation is limited by the current state of our technology.  As technology advances perhaps it might show lymphoma cells that are currently undetectable.  Might I be regenerating bone marrow that contains some lurking lymphoma cells?  Will an autologous BMT lead to a relapse?  And then what?  That's the Debate: Part 2.

So much to consider ... and mull .. and debate....  But still time to do it .... And I have that second opinion to help weigh these options....

A bonus to being home

As for today, I am still resting up and guarding my immune system!  I would love to stay home (read: no hospital) through the Labor Day weekend.  It is absolutely fabulous being in my familiar house, cuddling with my wee greyhounds and my lovely husband, sleeping deeply and thoroughly, not connected by yards of tubing to my pump, de-accessed from my port and able to shower at WILL, and enjoying some privacy and independence.  I am very relieved to be here, holed up to protect my few neutrophils and waiting it out.

Hooray for Being Home!

Tuesday - August 28, 2012

Was it my oncology team weighing in after my weekend of incanceration with Acute Medical?  Was it my strong lobbying / explaining that if I was not released last night then due to transport issues I would not be able to get home until dinner Tuesday?  Did they need the room?  Did my static vitals and inert blood cultures make the argument?  I'm not sure exactly what criteria came together to spring me from CCH3 but Joe and I walked off the floor after 8 p.m. last night and I am finally  - finally! - home.  A one hour nap on the couch followed by eight hours of uninterrupted sleep on the tempurpedic have revived me and now I am feeling somewhat ... perky!  My newfound energy could also be attributed to my being "tanked up" yesterday afternoon on 2 units of platelets and one unit of red blood cells or that my "slow but strong" Neulasta response is finally kicking in.  So many questions about my underlying physiology that remain incompletely understood....  My blood levels remain extremely low and, more significantly, I am still "profoundly neutropenic" so I will rest and hole up for the week. 

Big question:  will this fever and hospitalization impact my anticipated 6th round of chemo that is scheduled to begin one week from today?  The answer should come at my next visit to Dalton Clinic on Friday.

A Floor Apart

Monday - August 27, 2012

An unused communication tool, tucked in a corner

Well, perhaps flexibility and open-mindedness are always honorable characteristics but I confess that I am not incredibly impressed with the attentiveness, speed, and overall communication here on the Acute Medicine Floor and would prefer to be back on Oncology.  I am no longer feeling that flexible.  Just get me back to what I know and where the floor pulses with alacrity and focus.

This morning, I find myself "mad as a wet hen" after being roused at 5 a.m. by a care partner who turned on the fluorescents and announced herself upon entering my door.  I was irritated enough in my just-in-REM state to declare "lights off please" and after her protests (!!!!) voiced that in my 30+ nights in the hospital no other care partner has needed light (unvoiced: to put on a blood pressure cuff, pop an oximeter on my finger, and read a large, brightly lit LED monitor).  I could have gone on and on to expound on previous and amazing sleep-respectful feats from RNs and care partners: hanging and taking down chemo bags, monitoring my blood pressure for two hours the first time I was infused with Rituxan (thank you Gabrielle), and doing regular blood draws as quietly as possible in the depths of the night.  Yes, these are all disruptive but NEVER have the flourescents been tripped in the dark of the night.  NOT cool.  Closing the door (not allowed in my posted "neutropenic precautions" state due to air pressure) was the final straw.  The GOOD news is that I was so exhausted yesterday that this 5 a.m. wake-up has been made palatable by last night's 9:45 bedtime.

A negative harbinger about today's medical news is that my night RN was just in for tonight's second CBC blood panel; my levels are so low and going down (talking to YOU platelets!) that the attending wants them rechecked.  But my temperature has stabilized in the low 99s so can I please just go home?

I am basking in the sun on this beautiful day!

Aside from this egregious start to the day by an inconsiderate care partner, the general communication and attentiveness are not as sharp here on Acute Medicine.  For example, "infusion complete alarms" can take up to 30 minutes for a response; thankfully I disregard the rules and hit the "silence" button to control the shrieking but having to repeat this action every minute when the alarm resets is. a. drag!  I try to maintain my perspective and understand that more critical patients might be occupying my RNs however this delay has gone on 3 evenings in a row and I am no longer so sanguine.  Also, given the fact that my temperature is a criteria for assessment of my current health and a criteria for discharge, my vitals were not closely monitored yesterday.  Joe eventually took up the thermometer and did his own checks  :)

August 2009, Jonathan moves into West Egg    

So, how about some positive news!  I enjoyed a wonderful visit yesterday with Sally and my mother.  Sally brought some terrific Vietnamese pho - just what I needed to sate my appetite without exacerbating my mucositis.  Joseph came later for a dinner and evening visit.  Oh, I am wishing to be home -- soon!  Megan has begun her formal packing for next weekend's move into her new house and Jonathan is in full preparation for his semester which starts today!  Is he really beginning senior year?  It's been such a full and happy experience for him at Virginia Tech. The memory of driving down to Blacksburg in the pre-dawn darkness remains strong: Jonathan snoring open-mouthed in the passenger seat, me listening tearily to the radio.  He was so excited to arrive, move in, and set off for Hokie Camp.  I can scarcely believe it's been three years!

Can't Shake this Temperature

Sunday - August 26, 2012

Another calm, rainy morning in the outside world

Despite negative blood cultures (to date) and steady infusions of IV antibiotics, I simply cannot eradicate this low grade fever.  I am steadily hovering in the mid 99s (37.5) and yesterday spiked up to 101 (38.3) at one point.  From my early morning discussion with the resident, it does NOT look like I will be going home anytime today.  The understandable concern is that if my fever is not responding to the IV infusion of cefepime, then the less potent antibiotics I would use in a home setting might be even less effective in controlling my fever and its underlying cause and I would end up back in the hospital, sicker than now.  My platelets and hemoglobin have rebounded somewhat after 2 units of blood yesterday.  My lovely neutrophils remain elusive and precious - barely existent;  I remain "profoundly neutropenic."  My discharge goal is tomorrow.  In the interim, I am accepting another quiet, rather isolated day and just rolling with it ....

Yesterday was cheered greatly by an unexpected and oh-so-welcome phone call from Kim (!), newsy check-ins from my remarkable children who shared details of their full and exciting lives in California and Blacksburg, calls from all of my wonderful sisters, and a terrific visit from my intrepid Joe who hauled in a sandwich and smoothie to supplement my hospital meals and then emerged victorious from a fierce Scrabble contest (rematch needed today).  Sally also orchestrated a lovely visit from an energetic and pleasant friend who was visiting her father here at VCU, a very nice surprise.  Being admitted to VCU meant that I was bitterly disappointed to miss connecting with Kelly who was dropping Beni off for her freshman year at W&M.  At least we exchanged some texts and certainly have the expectation of meeting up again soon. 

Room 142 on CCH3

Saturday - August 25, 2012

A rainy morning outside VCU's Critical Care Hospital. I did not make it onto the Oncology floor.  Instead, I am up one floor on "Acute Medicine" but inside all seems familiar: the shrill chimes of alarms, the predictable rhythm and schedule, the comforting set-up of the room and its furniture, and the glorious expanse of the huge rain-flecked window. 

After discussions with both my day and my night RNs, I enjoyed a decent night's sleep (5 hours in one stretch!) as vitals and blood draws were consolidated into one time.  More antibiotics and saline seem to have lowered and stabilized my temperature.  As for the instigation for this admission, more red blood cells have not (yet) been transfused ... perhaps today.  Given the time needed for my blood cultures, it looks like I will be here until tomorrow at the earliest.  Yup, I'm in for the entire weekend.  My ninth hospitalization since May 2 AND I am 3 for 3 for hospitalizations after my even cycles of Hyper CVAD.  I am truly and absolutely bummed out.  Maybe feeling even a wee bit blue ....

Time for Transfusions AND a Hospital Admission - AARRGGHH

Friday - August 24, 2012

Well, it's going to be a long, full day ....  My hemoglobin level is very low and my platelets are almost nonexistent so I am here at Dalton for most of the day for transfusions.  Joe has left for Williamsburg, needing to return to work and will come back for me at the end of the day.  I have a good supply of New Yorkers and a semi-charged iPad so I should be good to go!  Not quite the way I envisioned spending the day but flexibility and positivity are key!

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Perspective:  A memorial on my Treatment Room door

Saline? No problem.  Platelets? No problem.  Red blood cells? Oops! Problem!  My temperature elevated one degree Celsius in the first 15 minutes of the transfusion so .........  I am being admitted.  They will try another transfusion up on the floor.  Of course, I have requested to go back to the Oncology floor!

Breathless but Better (+ Scheduling Tears)

Thursday - August 23, 2012

I feel that I have turned a corner;  my mouth sores seem to have hardened and allowed more eating and range of movement - hurrah!  It is difficult to eat and talk when you simply cannot open your mouth!  My energy also feels more available, more on-tap.  In fact, after a deep afternoon nap yesterday, I was restored enough that Joe and I were able to enjoy a long sunset walk to the river with the hounds - how long has it been since I managed that simple once-daily feat?!   I am still feeling the effects of an elevated pulse.  Some breathlessness and fatigue.  I am very aware of taking it slow and easy - especially on the stairs!

Today is officially the first day of school for teachers at Matoaka.  Another milestone signalling my current focus:  not on work but firmly on my health.  Nonetheless, I do feel some pangs!  I am going to try to channel some of the vicarious energy from all of those dedicated teachers and staff into some home tasks.  Specifically, more phone calls today to try to hammer out medical appointments.  Yesterday, one of my nurses at Dalton Clinic called worriedly asking why I had missed my appointment.  Huh?  I have never had a Wednesday blood draw on top of my normal Monday / Friday journey up to VCU and had no clue that an appointment was scheduled.  Three trips to Richmond in a week?  I can't see that happening unless there's an emergency.  After she said I was also scheduled for three appointments next week, I pushed back and said I was happy to come Tues / Fri or Mon / Thurs but I was not coming up three times without a specific medical cause / reason - not just for blood draws.  Okay ... resolved that issue....  THEN she mentioned that next Friday's appointment is an 8 a.m. consult with my oncologist and an 11:30 Rituxan infusion that takes 2.5 hours.  Ummmm .... say what?  3.5 hours between appointments?  Yes, life is pretty much on hold due to this lymphoma but my husband (and able chauffeur) would like to devote some time to his actual job.  That's the subject of today's phone calls to Dalton.

As for my medical records, Carolyn made some calls and found the VCU person in charge of last week's request.  The records were mailed (not FAXED as specified by UMD) up to UMD-Baltimore last Friday and have not yet been tracked down on the receiving end.  Another task.  At least I am finally feeling alert and above water enough to find them and schedule this appointment!

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Remarkably, I have shed very few tears these many days since all hell broke loose on December 28th.  Of course, in my pre-diagnosis and chemo days, I had moments where I cried with the intense pain of the migraines.  Since diagnosis and chemo, I have cried in saying goodbye to the children and to my sisters, in leaving my students and classroom for the last time, and once in a moment of abject fear amidst researching the BMT options (these mortality rates are scary).  Today, I cried when confronted with a scheduling clerk up at UMD-Baltimore!  I already had an inkling of a possible issue when warned by my primary admin contact that he would be on vacation for a certain period and that his counterpart would not be helpful if I called.  In previous phone conversations, she has demonstrated poor phone skills and apathy and today, in trying to track down these elusive medical records, she actually said to me, "Well don't think that I'm going to do anything to help you" before abruptly putting me on hold.  I couldn't believe it!  And even more surprisingly, I just BURST into tears to the extent that the dogs both roused themselves and began showering me with kisses.  When she came back on the phone rather than my desired (and primary) contact, I clearly communicated that she had been rude, unhelpful, and not a good representative for her employer.  As she apologized, I couldn't help but pull the cancer card:  I have stage 4 lymphoma, am trying to get info on a Bone Marrow Transplant, and would appreciate not being told when people are completely unwilling to help me.

Then I dried my tears, took a deep breath, and called another contact number for this physician.  Happy energy on the phone from Angela (aptly named) who is currently digging through the mail pile as I post, trying to get her hands on my records.  When I explained that they may be at her address rather than the scheduler's address, she immediately said no problem, she would get them to the other office.  Yes.  Then I can make this damn appointment!  More Angelas in the world; fewer she-who-will-not-be-named (until after my second opinion when I will leave feedback directly for the doctor). 

"Riding the wave"

Wednesday - August 22, 2012

I have been hunkering down - trying to eat, swallow, and maintain a pulse that doesn't result in loss of breath or dizziness.  I see this status as one of unavoidable inertia;  Joe described it yesterday as "riding the wave" - a phrase that I find to be completely evocative.  I'm just going with it - napping as needed, avoiding exertion, working around my mouth sores, maybe even zoning out a bit....  Carolyn surprised me with a delivery from the base store.  How did she even get the phone number? Not an easy feat.  Twenty cups of sherbert to ease my aching mouth  :) 


The BMT second opinion is not yet scheduled.  VCU has still not faxed my medical records;  apparently this task is done by a contractor only on Fridays and she did not get to it last week.  UMD- Baltimore's Greenebaum Cancer Center cannot schedule an appointment until the records are in hand.  Ah well, we are now looking at Sept. 24 at the earliest for the daytrip up to Baltimore.

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A morning outing with Gina was certainly a highlight of this quiet, almost-feels-like-I'm-underwater week!  Today is Gina's last day of summer vacation since tomorrow teachers report to school for meetings and classroom prep.  While Aroma's seems to be one of our standards, this time in choosing a rendez-vous spot my only criteria was soft food!  Success!  So excited for Gina starting her second year! 

Resting up

Tuesday - August 21, 2012

"Peace" and rest sounds perfect!

Ten hours sleep last night has not exactly resulted in a peppy, zippy awakening but I am excited that my fever is down and that my pulse is under control.  I am still ... not ... quite ... right.  Some congestion.  Epic mucositis.  General weakness.  Another gray morning certainly seems conducive to a day of rest and recuperation with my eyes fixed steadfastly on the goal of staying OUT of the hospital.  One significant change about my discharge orders is that I am now taking two prophylactic antibiotics to combat infection.  This protection eases my mind.  I know that although my entire GI track is currently pretty well shredded, my natural E. coli should be confined to its designated locale and NOT cross into my bloodstream (again).

Not feeling quite right ...

Monday - August 20, 2012

What an odd series of days since my hospital discharge.  My temperature has been up every late afternoon and evening.  Yesterday I hit 100 degrees on a number of readings which scared the pants off of me.  I simply have not felt that stable.  Just a little off.  Something not quite right.

This morning brought two big surprises in our (successful) quest for that precious Neulasta shot.  First, the mucositis has taken forceful hold of my mouth and eating is very, very difficult.  Swallowing also remains a (sore) challenge, a discomfort related to the mucositis.  Second, in checking my vitals at Dalton, my pulse was at a new-for-me high of 137.  I was quickly called back for follow-up.  In testing while lying, sitting, and standing my pulse hit 153.  Beeps, lights, and alarms (literally) sounded.  Solution?  Well ... a solution!  I had a 90 minute saline infusion and my pulse came down to 106 before I was released. Unfortunately, with all this unanticipated intervention, Joe was late to a work obligation.  This treatment is all-consuming.  My life is definitely in some kind of suspended state but Joe soldiers on, balancing all of the travel, house chores, and care against his (overly) full work schedule.  It isn't easy ... I am so grateful.

The plan for today is to rest, hydrate, and to try to get in some calories. 

Just Hangin' with the Hounds

Sunday - August 19, 2012

Baxter curled up behind my right shoulder

Resting up and giving in to fatigue is made more palatable when I think of all the contentment that I am bestowing on the sweet animals that share our home with us.  I am a guaranteed cuddle for them -- and Italian Greyhounds love a good cuddle.  As I crash with physical depletion, Baxter and Sadie do not miss the opportunity to snuggle right up to me, demand attention in the form of "belly belly" (Sadie) and full, deep body strokes (Baxter) before curling or splaying out alongside me to snooze.  When we say their names, their skinny Italian Greyhound tails whip the couch like a mallet on a snare drum and they wait with excitement.  What are these humans going to say?  What might be coming next?  "Christine's home!" we remind them and then their tails explode with a rapid flourish of tapping before they can no longer contain themselves and they leap up to share kisses and hugs.  I do indeed believe that the hounds keep my spirits up and help me heal.  Our own therapy dogs!  It must sound insane to people who do not have animals in their lives but these creatures project a steady belief and connection that has certainly helped me weather my recent chemo challenges and change in life / career orientation.  Simply put, they keep me focused externally rather than internally.  They make me smile!

Sadie pushing up onto my lap / computer

A solid eight hours of sleep in my own bed may help to increase my current low baseline of energy.  Yesterday, for two separate dog walks, I went out with Joe and managed to make it around the neighborhood without dizziness or my legs going out on me.  My heart rate was under control and I only got a bit winded.  I'll take that as a success!  As for the dreaded methotrexate-induced mucositis, I feel it coming....  It's certainly already in my nose, throat, and GI track but is just starting in my mouth.  I am tender and sore but no open ulcers yet.  In fact, Joe brought in (spicy) Thai for dinner last night as a real treat to enjoy before the sores really set in and I am back on my smoothie and frozen yogurt diet  :)   An odd and new-for-me sensation is some difficulty swallowing.  Even water seems to meet an obstruction and can cause me to cough.  It's certainly not at the point that I would term it "dysphagia" but I am aware of the issue.  I am going slow, small, and steady - making sure not to aspirate anything - and will discuss this new sensation when I'm next with my medical team ... tomorrow!

Already Tracking a (Mild) Temperature

Saturday - August 18, 2012

HOME!  I believe I have been sleeping since I entered the door last night (hounds snuggled up close next to my hips).  My hour's crash on the couch did not adversely impact a nine-hour evening slumber.  It was absolute bliss being back in my own quiet bed with Joe and dogs snoring alongside.  Yet, I am awake now and still dragging with fatigue.  I must be tired  :)  BUT my agenda is to rest and heal so ... a little tiredness will certainly not interrupt that goal!

Last night did bring a bit of a fever panic as I got into bed.  99.4?  How did that happen?  Would it go up during sleep?   Would it meet the 100.4 "get-to-the-ER-NOW!" marker while I was passed out with hospital-induced fatigue?  Despite craving rest, I was no longer sanguine about the prospect of sleep.  Instead, I stayed up longer to get a follow-up reading (99.2) and then finally (and worriedly) gave in to deep physical weariness.  When I awoke during the night, my temperature was 99 and I was able to relax a bit more.  This morning?  Down to 98.2.  Phew  :)

Discharge Details

Friday - August 17, 2012

My remarkable kidneys have again purged the Tuesday-Wednesday 24 hour methotrexate infusion at record rate.  Yesterday's 4 pm blood draw showed a 0.07 methotrexate level - just a whisker away from the 0.05 level needed for discharge.  During this morning's RN shift change, I requested that the attending physician move up my methotrexate blood draw from its currently scheduled 4 p.m. target to a time that will allow me to be discharged this afternoon.  It's a simple bureaucratic fix and I am sure that it will work out.  Just to be sure, I will make the identical request during today's visits with the resident ... the fellow ... and directly with the attending if she makes makes rounds early enough in the day.  UPDATE:  The methotrexate blood draw will be this morning and I should be home by dinner!  My attending had no problem with this request and happily came in to give me the good news herself.

Yesterday, I tied up the last loose ends on transferring my medical records up to UMD-Baltimore for a second opinion.  Today, I plan to schedule the actual appointment for the week before Labor Day.  We'll make a quick day trip dash, hoping that I am NOT in the hospital with neutropenic fever.  These even Hyper CVAD cycles and the resulting mucositis have been the bugaboo in my efforts to stay at home and heal.  I do NOT take it for granted that I will remain out of the hospital.

However, the good and interesting news about this round of even Hyper CVAD is that I do not yet have ANY mouth sores - none!  Have I escaped this scourge this round?   Just delayed?  No matter - I am grateful for every day without this discomfort.  My finger neuropathy has also dissipated a bit and again I am fortunate to be avoiding any nausea, vomiting, or other gastro distress.  I am still very bloated from the steroids; my face is so round I sometimes don't even recognize myself.  In this next two week interlude between chemo treatments, steroids are not on my medicine list.  Perhaps I will look more like myself :)

Sleep update?  Oh, it was a miserable night in terms of regular interruptions.  Perhaps every 90 minutes someone came in for vitals, blood draws (the regular CBC draw not the methotrexate draw), taking down the chemo bag, giving me oral meds on its strict 4 a.m. schedule, attending to air-in-line alarms, changing the sodium bicarbonate bag....  I was so exhausted going INTO the night that I managed to return to sleep each time but being roused from deep REM so many times has taken its toll.  As I watched the sunrise, I realized that I will need to discuss a "sleep plan" with the Bone Marrow Transplant unit before or upon admission.  4-5 days of hospital-disrupted sleep are manageable; 4-6 weeks of haphazard disruptions and sleep deprivation might be the catalyst to strip me of my positive attitude and disposition.  I shall go mad.  So, I am googling existing documents and programs and mulling over simple (and acceptable) guidelines to optimize nighttime AND daytime sleep.  The latter is certain to involve a door sign; the number of folks knocking and then attending to tasks or checking in during the day is EPIC.  I'll figure it out :)

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So .... I am data driven.  In order to begin crafting a "sleep optimization plan" for my BMT, let's track today's daytime visits (after 6 a.m. wake-up).
NOTE:  RN responses to "air-in-line" alarms are NOT included.  At this point, I can tackle most of these alarms by myself, opening the pump, flicking the bubble up into the tube, tapping it into the vent, and then restarting.  If unsuccessful then I put in a call to my RN.

6:20    night Care Partner "just checks in" to see if I need anything
7:00    vitals
7:30    RN shift change / bedside meeting
7:55    oncology resident visits (with assessment)
8:10    sodium bicarbonate changed by RN
8:20    oncology attending visits
8:25    daytime Care Partner "just checks in" to see if I need anything
8:30    RN rigs tubing in preparation for the 10 a.m. cytarabine infusion
8:35    breakfast delivered
8:55    RN does her formal assessment (heart, lungs, pulse, edema ....)
9:10    "food and nutrition" takes my dinner order (none!   I'm going home!)
9:25    my morning meds are delivered
9:30    "food and nutrition" takes my breakfast tray
9:35    tech checks the tags / expiration dates on my pump (2nd time this check has been done this week)
9:45    housekeeping visits to empty garbage
10:00  housekeeping returns to clean floors
10:20  Care Partner comes in to "check on me" and I say I will probably be trying to nap today (read: please don't check on me again although I know you mean well and I think you are very, very kind)
10:25  RNs hang my last dose of cytarabine and use blood return check to draw blood for methotrexate leveling
10:40  housekeeping supervisor comes in to survey me about housekeeping standards and effectiveness
10:45  RN returns to collect my chart (left inadvertently in room)
10:50  resident checks to see that the blood draw for methotrexate has been done
10:52  RN brings me some oral meds

WOW!  I knew that visits were frequent but this exercise is illuminating!

11:05  resident reviews my at-home meds and checks on any needed prescription refills
11:15  volunteer offers magazines and books (very nice service; 2nd visit this week)
11:40  technician changes out "sharp disposal box"
12:05 "food and nutrition" brings lunch
12:20  team of three visits to determine location of new cardiac monitor (10 minutes)
12:50  vitals
1:10   "food and nutrition" collects lunch tray
1:20    chemo bag runs dry and is taken down
1:45    Daisy the therapy dog comes to visit!  Hurrah!
2:15    RN team visit for monthly bed sore inventory (I'm clear!)
2:45    RN delivers FABULOUS news that methotrexate level clears me for discharge
3:20    physio retrieves bike
3:35    RN does assessment
4:00    resident visits to confirm that discharge orders are in and should be ready by 5 pm
4:10    RN responds to "infusion complete" alarm
4:15    "food and nutrition" double checks my lack of dinner order
4:40    RN responds to "infusion complete" alarm

JOE ARRIVES!  Let's de-access me and get me out of here!

4:50    "food and nutrition" checks again about my lack of dinner order
5:05    one member of team of three moves post-it showing location of new cardiac monitor (away from gas line in headboard area)
5:20    RN presents discharge orders; I sign
5:30    2 RNs de-access my port and I AM FREE!

Red (Blood Cells at) Dawn

Thursday - August 16, 2012

Good visit-planning with my night R.N. and great luck avoiding sodium bicarbonate "air-in-line" alarms resulted in a much better night's sleep:  6.5 hours with only one significant disruption.  My blood work came back showing a hemoglobin drop so, just before sunrise, I locked down a decent night's sleep and woke up to meet with the physician and sign my consent (again) for a transfusion.  This hiccup will not disrupt my second dose of cytarabine that is due to be hung at 10 a.m.;  my chemo schedule continues as planned.  I hope to be discharged tomorrow afternoon IF /WHEN my (remarkable and much-appreciated!) kidneys purge the 24 hour methotrexate infusion to an untraceable (<0.05) level.

Everything is moving with clockwork professionalism and friendly customer service.  It's going to be another productive day of lymphoma-poisoning here on the Oncology Floor :)

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Discovered by Jonathan.
Foraged and delivered by Joe.
Perhaps envied a bit by Megan?
Enjoyed by me!

What a fabulous Burger Bach dinner picnic with Joseph here in room 132!

New-Zealand organic beef?  Delicious!

Company and effort in getting me such a special meal?  Extraordinary!

Maybe the best burger since Jackson Hole in NYC ....

"3 a.m. and All is Well"

Wednesday - August 15, 2012

Mr. Cow waits for morning

Vitals?  Blood draw?  Alarms from my bubbling sodium bicarbonate drip?  The IV steroid that has been pushed twice today to pair with my methotrexate infusion?  The rhythm and subtle grind that characterizes the sound of the infusion pump?  The sound of the floors being cleaned by that whirring / purring / humming ride-on machine that does circuits in the halls every morning between 3 and 4 a.m.?  (WHAT does it look like?  Someday I will just have to scope it out.)   Who knows why I am up in the wee hours - alert and ready for the day to begin .... The BBC World Service keeps me company with in-depth reports about the housing crisis in the U.S., drought in Western Nebraska,  disabilities in the Ukraine, and today's bomb in downtown Damascus ....  Hmmmm ..... Maybe it's time to queue up "Thistle and Shamrock" or Pandora and try to nap ....
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Success?  I suppose .... Two more hours of deep / delicious REM sleep disrupted by two  interruptions - one air-in-line alarm and one wake-up to get my vitals.  Uncle!  I'm getting dressed .... Sleep in the hospital is precious and elusive.

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Happiness is getting the bike back in my room :)  

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... but true contentment is having Joseph visit at the end of his long day at work.  Joe feeds, walks, and loves our affection-craved hounds (hysterical yesterday at the sight of Jonathan carrying bags into the garage!) and then hops in the car for the 50 minute drive to Richmond to spend some time with me.  He must be exhausted.  Every chore is falling on him, he is working a demanding job with much personal interaction, and he is my calm and comforting companion.

Joe is pulling heavy duty these last 8+ months dealing with my crashes and fears in response to debilitating pain and loss of vision, helping to ferret out a diagnosis, and now shouldering all of the household issues.  With my BMT, my function will be even more proscribed and Joe will pull in the slack.  I wish I could do more but the reality is that I simply cannot.  I have to rely completely on Joe.

30 years together and with this new challenge we fall back on our strong core, our friendship, our amusement in one another, and our love.  I am one lucky woman.

Lovin' Room 132

Tuesday - August 14, 2012

Jonathan moves me into the Critical Care Hospital

Getting the ball rolling is always the trickiest part of a chemo admission.  Medicine orders do not get submitted to the pharmacy until the patient actually enters the room and is "green banded" with an official admissions bracelet with medical record number.  Then you wait.  The start time for the chemo is critical because it dictates the waves of chemo to come; each round is spaced out at a specified interval from the time that first bag of chemo is hung.  For this even round of Hyper CVAD, I begin with a 24 hour infusion of methotrexate which must be purged from my body (untraceable in my blood) before I can be discharged.  Getting this methotrexate hung and dripping into my port is the goal ... and it usually takes about 4 hours after I arrive before this chemo ball rolls.  As I post, I have been settled into room 132 (my third visit in this bright room!) for two and a half hours and am still waiting for the RNs to arrive, covered in protective clothing, eyewear, gloves, and masks and carrying the chemo bag that will soon slough off the cells in my digestive track.  Bring it on, pharmacy!  Release the drugs!  My port is accessed, the sodium bicarbonate is dripping, my pH is perfect, and I am ready to go!

I do love being on the Oncology Floor.  Not only am I in a familiar space with a wide, bright window but I also know so many of the staff that it feels like a comfortable and nurturing community.  I have worked with both of my (amazing!) RNs for more than a few days and Dawnett - today's Care Partner - might have been paired with me on each of my five admissions to this floor.  Hugs and catching up with today's team, boisterous visits from staff assigned to other rooms who have seen that I am back for treatment, cheery notes from some night staff saying that they will see me later this week - what a lovely welcome!  What an incredible community!  I am so lucky to be here at VCU, benefiting from the expertise, caring, and connection with such a remarkable staff.  Good energy reaps good karma. Blessings abound.

After driving me to VCU and settling me into my room, Jonathan drove back to Blacksburg to begin his autumn semester at Virginia Tech.  We will miss him like crazy having been spoiled with a week of easy company and relaxed time with our wonderful boy.  I hope that all four of us will manage a quick rendezvous when Megan comes east from Davis in mid-September.  Until then, we have phone, internet, and Skype!

PET Scan Results (!) and Pre-Admission Procedures

Monday - August 13, 2012

Jonathan is coming with me to Richmond this morning for my pre-admission Rituxan infusion and intrathecal chemotherapy.  Gosh, this whole dance seems pro forma at this point.  We have the rhythm and the expectations down! Still, I always have a baseline concern that I will need blood ... or ... platelets ... or saline ... or something completely unexpected before they let me come back home for my last night before hospital admission.  Fingers crossed!

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Well, that was a LONG day:  9 hours door to door with port access ... and blood draw ... then chemo pre-medications ... followed by 90 minutes of a Rituxan infusion in the not-private-Rev.Jim-roaming-treatment room ...  then more waiting room time before a lumbar puncture with intrathecal chemotherapy ... and finally 30 minutes of flat-on-my-back rest to disperse the medicine.

A LONG procedural day highlighted by Kevin bringing me the very best of news!      The results of Friday's PET scan are in and they are ALL that we had hoped for:

 "Complete Response" to the chemotherapy!  Hurrah!  "Marked interval improvement of lymphomatous disease without discrete foci of abnormal radiotracer uptake, consistent with positive treatment response."

I'm not quite sure that I have fully absorbed this amazing news;  my head is still future-focused on the upcoming Bone Marrow Transplant and consolidating this gain.  Bottom line:  the Hyper CVAD protocol has purged the detectable lymphoma from my system.  My bones, liver, lung, and orbits are all clear.  This PET pathology report reads like a text rather than May's inventory of SUV numbers cluttering up the pages.  Now, we need to double down.  Diffuse large b-cell lymphoma is aggressive and due to this very aggressiveness, it responds well to treatment.  However, its aggressiveness also causes it to recur even after "complete response."  A Bone Marrow Transplant will (probably) seal the deal and forestall a recurrence (but put me at risk for graves-v-host disease and other dangerous conditions).  What kind of BMT?  How do we maintain this progress?  At what physical cost do we consolidate this victory over lymphoma?  My mind continues to debate the options .... Time for a second opinion!

Jonathan escorted me throughout the morning and brought me out to celebrate the fabulous PET scan news.  He may have tracked down the best hamburger in Richmond (if not Virginia)!  AND, in anticipation of my upcoming hospitalizations and home-incancerations, he was so sweet to clarify the take-out menu and procedures.  Our thoughtful boy!

Boxing Up and Sorting Out

Sunday - August 12, 2012

Some shelves are staying intact  :)

This weekend's mild energy level has allowed me to continue to get organized and to feel somewhat productive in prepping for my anticipated BMT-induced sabbatical from home-living.  Joe has pointed out that if we are indeed still moving to San Francisco in mid-June (and this option remains highly tentative) then my schedule, location, and health may not provide much opportunity to help him get ready for the move after I begin the bone marrow transplant process in mid-October(?).  When that treatment begins, I will be living in the hospital, then in Richmond, and then (probably) on a futon in a short-term rental in New Kent County somewhere around exit 214 -- closer than Richmond to Joe's work and within 30 minutes of my mandated tether to VCU.  Perhaps I will make it back into our Williamsburg house by early spring but even then who knows what my energy level will be like....  AND, with my complete lack of immunity brought on by the BMT, I will still be prohibited from any cleaning / interaction with dust.  No cooking, laundry, cleaning etc.  In fact, Carolyn has researched bio-cleaning / crime-scene services to prep the two short-term rentals and our Williamsburg house before I move my immune-compromised self into each space.  Deep cleaning from experts will help me stay clear of infections.  As the BMT lead physician explained, I will be like the "girl in a bubble" until I am able to receive my "baby shots" (MMR, polio, etc.) next summer.

So, NOW is the time for me to brave the dust and to sort through the accumulation of three years of full, stimulating, and busy Williamsburg living!  Time to tackle the graduate school materials and all of my classroom resources.  Time to weed out the children's possessions and ready them for shipment to their new independent locales.  Time to organize, pare down, and sort out.  As a bonus, this focus is keeping my mind happily occupied with cheery memories of people, accomplishments, and challenges and giving me a project!  ... And, of course, I can work alongside the quiet company of Joe and Jonathan as we hang out and relax on a grey, steamy Virginia weekend.

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And I did indeed manage to get much organizing done!  Bundles of recycling into the blue bin.  Resource materials boxed and readied for future use.  Children books inventoried and stored away.

However the highlight of this happy Sunday was getting out of the house for brunch with Gina, Savannah, and Jonathan!  "Nearly normal" feels terrific!

"Weekends don't count ...

Saturday - August 11, 2012

Ele-phonse: being pointless

... unless you spend them doing something completely pointless."  ~ Bill Watterson (Calvin & Hobbes)


This last weekend before chemo round #5 of 6 (two-thirds done already!), I plan to shepherd energies and strength, readying for next week's 24 hours of methotrexate infusion (and the ensuing mucositis), bracing myself for another 5 days / 4 nights in the hospital, and just enjoying the company of Jonathan and Joe.  While I remain a bit hamstrung by physical fatigue, I need to sate my "get-it-done" bent and achieve something completely tangible this weekend.  In this case, my goal is to organize and finish packing up my teaching materials and graduate school texts.  And to rest up ...

The Fundamental Importance of JOY!

Friday - August 10. 2012

Yesterday, Jonathan drove me to Matoaka so I could retrieve the “joy” from my former classroom.  Yup - literally!  We went on over to clean up some loose ends and to pick up my “joy!”   Many years ago, RSCP mom Jamie Leonard used the thumbprints of our many preschool students to create a sinuous, evocative Chinese dragon, curled into the word “joy.”  At Rock Spring, I worked in the front entry of the school, guarding the door perhaps and certainly remaining within earshot and instant access to any of my classrooms;  I had no real RSCP office to display my “joy” so this happy dragon peered down on me from my home office.  It seemed to me that it was waiting for circumstances to align in such a way that I could fulfill my decades long goal to return to an elementary classroom, to share my joy as an instructor rather than as an administrator. 

I LOVE how this joyful dragon is a composite piece, created from so many tiny thumbprints, assembled into a meaningful and lovely whole.  I love how that one word – JOY – embodies so much of what I feel in the classroom and what I hope to share, nurture, and preserve in education. This joyous dragon waited patiently on my shelf a long … long … time and gave me many smiles through the passions and tensions of preschool work, the stimulating demands of graduate school, and the natural concerns that perhaps a 50-year-old aspiring first-year teacher would not have such an easy time finding employment.   Last August, bringing this lovely RSCP gift into my new Matoaka classroom felt like I was linking my past educational experience and comfort to my new challenge.  “Joy” and excitement!  Happiness all around!  I loved having this dragon overlook my first grade classroom throughout the year and how some students made spontaneous connections with either the (difficult to read for a first grader) letters or the fact that it was indeed a (Chinese!) dragon.  And what exactly were all those dots?  Sunflower seeds?  Acorns?  Smarties?

So Thursday, when we returned to retrieve this “joy” - temporarily – from the classroom to return it to its place here at home, it felt like more of a finalization of my wrenchingly-abbreviated teaching tenure than simply handing in my keys.  Ah, there was a strong sense of finality in that moment and I did indeed feel some twangs … but I feel confident that – at some point – my “joy” will be back up in a classroom once again.  In the meantime, I will savor my “joy” – once more - at home … while I heal ....

HAPPILY – and in an amazing stroke of chance – I was fortunate enough to meet up with many colleagues during our brief trip to Matoaka.  Most importantly, walking down the dark hall, Tama and I ran into each other.  In the building at the same time.  In the hall at the same time.  No previous communication about plans.  What absolute luck! I was so excited to be able to introduce Tama and Jonathan.   I felt completely energized by her hugs, her positivity, her smiles, and all of her support and help.  How fortunate I have been in having Tama as my cooperating teacher during my student teaching and then down the hall for company, laughter, and mentorship during my first year of teaching.  Yes, it has been an odd and unexpected year but I have not lost sight of all the blessings and joy that Matoaka and its community have given me.  Tama is atop that list.

Today I am up at 3 a.m. - once more well before dawn.  Most pressingly, I continue to be anxious about understanding and addressing Jonathan's weight loss.  It is also an important medical day on my lymphoma journey.  Jonathan is driving me up to VCU for a follow-up PET scan.  This scan will provide a contrast to my initial PET scan in mid-May that identified and measured the lymphoma “hot” activity spots scattered throughout my torso and abdomen.  The final report should come in next week.  Compare and contrast.  Venn diagram, anyone?  Let’s hope for  MANY differences.  I want to see a dark PET scan!

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Our four hours at VCU encapsulated the classic rhythm of waiting and waiting and waiting at the hospital for my name to be called, for tests, for results, for consultations.  It's the standard.  It's the expectation.  Just accept that the system takes time to process correctly and accurately, pick up The New Yorker or The New York Times on iPad, and just settle in for the wait.  Today we bopped between venues for the PET scan (results next week) and the bloodwork (strong all around!) before we finally sprang out into the sunshine.

How best to reward oneself for hospital duty and to enjoy some special time with your Napoletana-certified pizza connoisseur son?  Stuzzi!   For the record, while Jonathan may have voiced a slight preference for D.C.'s 2Amy's, this authentic pizza is absolute bliss!  A fabulous meal with my wonderful boy  :)

My Best non-Hospital Weeks?

Thursday - August 9, 2012

Refilling my pill box.  Can you believe it?

Yes, I am knocking wood like mad as I type out these fate-prompting words  ... but as Joe mentioned last night, I am certainly weathering these last two post-chemo weeks better than my three previous intervals.  Most obviously, I have NOT been readmitted to the hospital with neutropenia as I was after each of my even Hyper CVAD rounds.  In addition, the debilitating physical weakness and crushing fatigue of my first round of odd Hyper CVAD have been absent these last two weeks.  Even my sleep patterns are so much improved over what I expected during this steroids-heavy week.  Bravo! 

But why?  Can I replicate this success for the upcoming 2 rounds or is it just a fluke over which I have little control?  Oh, everyone knows how I enjoy having a role / some control and the thought that I might be able to influence my physical response to this chemotherapy protocol is tremendously appealing.  So what's been different?

• Extra week of recuperation and healing following the one-week postponement of chemo round #4 due to my E. coli infection and hospitalization.
• Two courses of prophylactic antibiotics to combat potential repeat of such an E.. coli infection.
• MUCH less interaction with the world.  I have been hunkering down in the house in an attempt to ward off another hospital stay.  NOT what I want to do but has it been a successful route?
• Avoiding naps has resulted in fuller nights of sleep.  Last night, I was out for more than eight hours with only one wake-up!  Hurrah!

I also am curious about what this improved sense of energy and health might herald going forward.  From mid-May's very first week of treatment, my restored vision and lack of migraines evidenced the chemotherapy's immediate positive effects in my left orbit.  Is my current improved physical state a reflection of the purging of lymphoma in the rest (less obvious and visible) of my cancer hot spots?  Tomorrow's PET scan will tell the tale.

"Animal Kingdom" ...

Wednesday - August 8, 2012

The hounds got me out and MOVING!

... (as Joe puts it) certainly has its pros and cons.  The hounds fill our days with connection, personality, and perpetual attempts to communicate their understandings and also their needs / desires / requests.  They really structure our days with walks, feedings, and delicious cuddles.  Dusk's interactions with us enjoy a less mutual give-and-take; we definitely serve him and his demands are often relentless and delivered in a less than polite manner.  This morning, Dusk had somehow remained in the house overnight and emerged to yowl at me and paw my head, awaking me from precious slumber at 6 a.m. - that was good news!  I had about seven hours sleep on my last day of steroids!  After chasing a very noisy cat away from the bedroom and downstairs towards his soon-to-be-filled food bowl, I started the day with a Dusk-induced energy rush, some shortness of breath, and a readiness to start the day.  I am functional, relatively alert, and ready to heal up, process my chemo, and get ready for next week's round #5 of 6.  Oops! First things first - I need to clean up the salamander parts off the kitchen floor - thanks Dusk  :)

Today is a relatively low obligation day.  No physician appointments for ANY Ammiratis.  Just a time to rest up and regroup.  Tomorrow, we return to the PCP for an initial read of Jonathan's early bloodwork and an EEG.  Friday is a red-letter assessment of "Partial Response" to my two months to date of this Hyper CVAD protocol.  I will have blood work followed by a PET scan that will then serve as a point of comparison with my initial, pre-treatment PET scan from mid-May.  Before and after.  How MUCH has the lymphoma activity declined (or disappeared) and where have these changes occurred?  We should have the results during my upcoming August 14th 4-night hospital admission.  I am clearly eager to see the results.

A Sense of Success to Start the Day! (and THEN another ER visit)

Tuesday - April 7, 2012

I conquered yesterday's late night wake-up and have returned to a more-rested, more-manageable, more-familiar, early morning start!  I feel great!   Little large-muscle fatigue, no lower-back twinges, and perhaps a slight decrease in the finger neuropathy that has been a constant presence since my first round of odd-round Hyper CVAD (wow!  That's a nice surprise!).  Could this week be officially deemed a "good" week?

Joe, Jonathan, and I continued a pattern of restaurant dining with a dinner at Second Street Bistro that included some great draft beer samplers.  I have medical go-ahead to enjoy some wine and beer (yay!) and must confess to being happy about returning to the occasional mealtime pairings. Now if Joe and I could only track down our corkscrew, I could enjoy that great bottle of Chardonnay I have chilling  :)

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Well, we are all home and healthy now but what another rollercoaster hospital interlude this morning!  Our 4th trip to our local Sentara Hospital ER this summer!  Enough!  Good health all around for the Ammiratis, please!  No more avulsions, potassium issues, infections, or fainting spells / seizures.

Today was Jonathan's turn in the health spotlight.  Our routine (but urgent to me) sick visit to determine why Jonathan has dropped 35 pounds off his already slender frame resulted in his blacking out during an empty-stomach blood draw with some shaking that the phlebotomist thought might be a seizure.  Coupled with a low pulse rate, the doctor sent him downstairs to the ER where we spent 4 hours before getting the all-clear.  I am tremendously relieved that a full EKG and long-term monitoring did not surface any issues that would corroborate a seizure.  The ER physician diagnosed vasovagal syncope but advised that Jonathan have an EEG when he returns to the doctor's on Thursday for consultation about his blood work and next steps to discover the cause of his dramatic weight drop.  With a clean EEG, the word "seizure" will be purged from Jonathan's medical record.  Jonathan was a hungry but cooperative patient; it was a long morning!

Moonlight Chores (and Lunch with Jonathan!)

Monday - August 6, 2012

So when the moonlight is streaming brightly through the living room windows as I bite the bullet and come downstairs, it signals my earliest steroids-induced rise-time yet: 1:40 a.m.  I was NOT pleased to be up so early.  What happened?  No naps yesterday and a 9:40 bedtime crash are obvious culprits to be avoided in the future.  I will also move my steroids earlier in the day.  Tomorrow's goal?  Back to my 4 a.m. normal wake-up would be fine  :)   On the upside, just now I was able to take advantage of this found time in the lovely moonlight with a strong surge of physical energy.  Mini-chores that eluded me during the sunshine somehow got done in these wee hours so I am feeling some sense of accomplishment.  Laundry, dishes, garbage, restoring the living room to its pre-back spasms state ... small steps.

Today's bloodwork check at Dalton will bring a special treat;  Jonathan will pick me up in Richmond and drive me back to Williamsburg.  After dropping me at VCU, Joe can get back to his regular work schedule and depend on Jonathan for the return trip!  What a welcome surprise!  Jonathan has a short interlude between his month of Orientation Leader work in Blacksburg followed by his volunteering at the ATP tennis tournament in DC and his upcoming obligations at his fraternity and Hokie Camp at Virginia Tech.  We are lucky to claim as much or as little of Jonathan's time as possible and I am particularly happy to see him at home rather than during a hospital week.  Home time is always more relaxed and offers more options for everyone.

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Released without transfusions of any kind!  Hip, hip hooray for a 4.4 white blood cell count!  It rescued me from a platelet infusion that was exactly the same as Friday's number (28).  Jonathan arrived (!) and drove me back to Arlington where we celebrated with a DoG Street Pub lunch before returning home to rest and Olympic Live Streaming (Track and Field).  I am dragging with fatigue and will certainly go down for a quick nap in order to try to re-set my evening sleep pattern.  Here's hoping!