The Immediate Future

Here is the schedule of impending events. It will perhaps explain my sudden absence from cotillions, State dinners, ice cream socials and UN Security Council meetings.

Day Zero (Monday)

I receive a toxic dose of Melphalan. I've never been exposed to this particular drug before, but I've been exposed to drugs of its class. It is technically an alkylating agent, distantly related to mustard gas of World War One infame. It bonds alkyl groups across DNA base pairs, making it impossible for the cells thus affected to reproduce (many, in fact, commit a kind of cellular suicide upon the discovery that their DNA has been in effect glued shut). I've already done the ABVD protocol, and one of its drugs worked in this fashion. Nobody can really say how unpleasant the side effects will be. On the one hand, the side effects of ABVD weren't incapacitating. Unpleasant, sure, but I managed to keep working and as long as people didn't mind seeing me shuffle when I walked, I could generally get around. On the other hand, though, I'll be getting a monster dose of Melphalan - seven times the normal dose is the number that I remember. It could be bad, and it could be very bad. At the conclusion of this, I will be discharged and sent home.

I will also start daily courses of two antibiotics, an antiviral drug, and possibly an antifungal drug.

Day One (Tuesday)

I report back to the hospital for the reinfusion of half my stem cells. This is a precisely scheduled proceeding. My stem cells are currently frozen (not just frozen, but cryofrozen) and only remain viable for about ten minutes after they're thawed. The bone marrow team aims to have them infused within about three minutes of being thawed. Basically they get you all set up for the procedure with everything in place but the cells, then they rush the cells up from the vat of liquid nitrogen and put them in a special thawing device (kind of like trying to defrost a turkey in a sinkful of cold water on Thanksgiving morning, I imagine).

The greatest risk during this reinfusion is having a reaction to the DMSO that the cells were preserved in. Here's where having a good stem cell harvest pays off. I was able to produce over five million stem cells in two sessions of apheresis, so they only had to use two doses of DMSO to preserve my cells. People who have to go through many sessions of apheresis to get enough cells end up getting many doses of DMSO, and have a higher risk of having a reaction to all that DMSO. The doctors speculate that my main reaction will be to develop a garlicky taste in my mouth and garlicky DMSO breath. (Chemo almost always gives me a strange, unpleasant metallic taste in my mouth, so this might be refreshing for a change, though I do wish they could develop a class of chemo drugs that gives one a pecan pie taste in one's mouth.)

Day Three (Thursday)

My immune system finally fails. My white blood cell count will begin to decay immediately after the Melphalan, but it's on Day Three that the count basically bottoms out and the risk of infection becomes very serious. I'll go on full anti-infection measures Sunday night, before the Melphalan, but it'll be on this day that such measures will become seriously important. My red blood cell and platelet counts will also bottom out and I may need occasional transfusions of such cells, though that remains to be seen.

Day Five (Saturday, I think)

By now the stem cells have found their various ways to my bone marrow and have begun to colonize the area. On this day I start to receive daily injections of Neupogen, which stimulates the stem cells to divide even faster. They will also begin to differentiate. A stem cell is basically an undifferentiated cell that can turn into either a red blood cell, a white blood cell, or a platelet, and as they multiply and differentiate, my blood cell counts will slowly rise.

Neupogen is no picnic. While I thought Neulasta caused worse and more sustained bone pain, Neupogen isn't any fun either. Every part of your skeleton that contains marrow hurts. For me, it was concentrated mostly in my pelvis, the long bones of my legs, my spine, and my forehead ridge. Many people say that the worst discomfort is felt in the sternum, but HA! I fooled them; I had my sternum sawed in half and wired back together a few years ago and it has thus far not caused any pain from Neupogen. Maybe there's no marrow in my sternum any more.

Day Twelve

They expect my blood cell counts to return to more or less normal by Day Twelve. My immune system won't be normal by any means, but at least it'll be sufficiently rejuvenated that the greatest threat of infection will be over.

Meantime, if the President or the UN General Secretary want me, I'll be in bed maintaining a dutiful arm's distance between me and the rest of the world.