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What is it that makes a heart attack fatal? My aunt was in hospital for a routine surgery and the day she was due to leave hospital she died of a heart attack. How can this happen in a hospital?First off, my deepest sympathy and condolences to you and your family for your loss. One of the components of grieving is “trying to make sense” of the event(s) and understand “how” and/or “why this could have happened”.A “heart attack” is a generic term to express that “something significant and life-threatening has gone wrong with the heart”. The heart is (as many know) utterly vital for life to continue. It pumps blood throughout the body, and that circulation provides oxygen and nutrients to every part of the body as well as transporting away carbon dioxide and other waste products. Without the heart working properly, death happens within minutes.You mentioned that your aunt was in the hospital for surgery, but her attack occurred on the day that she was due for discharge. In many hospitals, patients vital signs (pulse, temperature, blood pressure, etc.) are monitored at a frequency appropriate for their current medical condition. For example, within an ICU (where patients are critically ill or injured) patients are connected to machines and monitors that display and record vital signs real-time. Moment to moment, second by second, at a glance, the caregiving team members can know what the patient’s heart rate is, look at that waveform to see if it is normal and healthy, or if it shows signs of odd, dangerous or even potentially fatal electrical activity. They can also see recent/frequent (and even real-time in some instances) blood pressure, respiratory rate, oxygenation levels, temperature, and so on.That sort of monitoring is very comprehensive at the high-end of care, which is what the most sick and injured patients need. As patients recover, get better, stabilize, and heal the need for that level of intensive monitoring (also known as telemetry) becomes less critical. In addition to being information that is less required (at least in a real-time, second by second manner) as the patient “gets better”, they are also more aware of and more likely to be annoyed by the devices that can monitor those vital signs. Each one requires a device to have a connection to the patient, or a probe, or an electrode, and for a patient who is feeling better, it then becomes a balancing act between “checking vital signs at appropriate intervals/levels for how the patient is doing” and the patients comfort/convenience.If (for example) your aunt was recovered and almost ready to go home, I am guessing that she may have been able to get up and out of bed, walk to the bathroom, use the facilities and perform some of her own self-care, hygiene and grooming. That is typical of patients who are close to dischargable status. Having such a patient connected up so that their vital signs are always and immediately viewable/noticeable isn’t as critical as someone in ICU, and it is more along the lines of the level of monitoring they will have when they are at home. That level being “the patient feels that something isn’t right, and they tell someone”. Vital signs are still taken at that level of “acuity” (the level to which they are either sick, well, or recovered) but they are taken far less frequently and are far less invasive in nature. Usually a care-giver comes into the room, asks “how are you feeling?” while they take their pulse, check their blood pressure, temperature, etc.Now, I don’t know the precise details of your aunt’s incident or the facts of her case. Even if I did, I would be making a judgement as to her care and without the facts, that would be inappropriate and improper for me to do. So please understand, I am not going to give an opinion as to your aunt, just explain some important and relevant factors (there are others, as I am sure other answers will demonstrate).What I can say is that if your aunt had the event that was the initial part of her heart attack while in surgery or while in post-op recovery, she would have been connected to and monitored at a far more intense level than she was monitored on the day she was scheduled to go home. At that higher level of telemetry and monitoring, the early stages of a heart attack are quickly spotted and the various ways that a heart attack can occur (as well as progress) her condition would have been treated immediately and according to well-defined protocols.She was however in a state of recovery and getting a level of care that was appropriate for what was known about her condition. That she was “as close to being the same as at home as could be”. And so, those initial changes in ECG waveform, in heart rate, in blood pressure, any of those, there would have been a time difference between those events on an ICU patient and a ready-to-discharge patient. Those differences in monitoring could mean that the first sign of her having difficulties might be either her saying something (such as “I have a pain”), or someone noticing something (such as “I just took her pulse and it’s high, her skin is cold and clammy, and when I asked, she stated that she does feel a little odd”). Again, I don’t know the details, I am speaking in generalities and non-specifics.Even those patients within a critical-care setting, with all of their vital signs being monitored and observed each second, they can have an event or condition that is the first stage of a heart attack, the care-givers can do absolutely everything properly, according to all known best-practices and protocols, and the patient may still not make it. Spotting early signs or indicators are helpful, and they can improve someone’s chances, but that level of monitoring is not a guarantee that they will survive such an event, even if caught immediately, even if everything and everyone was perfect.So, I again offer my condolences for you and your family’s loss, I completely understand your desire to better understand the how, what, why and other aspects of the event, but I don’t know if it is possible for anyone to give you a precise “here’s what happened, here’s what would have made it different, and here’s why that didn’t happen”. I don’t know enough and even the professional experts who were there (with all of the information at their disposal) would be unlikely to give a 100% certain answer to the seemingly simple questions of “why did this happen?” or “how did this happen?”My apologies for being so long-winded, but when it comes to subjects such as this, I don’t know of a way to be brief and still be accurate.

It does not “depend" at all.First off, you cannot diagnose a concussion. You can only suspect you have one.If there is loss of consciousness you absolutely positively need to go to an ER.And in the case of loss of consciousness every hospital I know would require in-patient overnight observation.Close monitoring of blood pressure changes are performed to assist in a diagnosis.Swelling within the skull within the first 24 hours is the greatest danger.Several drugs and protocols are available in treatment.Generally, dexamethazone is administered.The fact people have survived by not doing this has no relevance.Stay home if you enjoy playing “Russian Roulette".

I was very arrogant about my health until recently.At 59, I had never been sick, I’m very fit, and look quite a bit younger than my age. My father is 90 and lives the same lifestyle now as 30 years ago, living in his own home in the Texas Hill Country.I’m a physician and have almost daily occasions to offer health advice, and I have a healthy, thriving practice.I am a fan of Nortin Hadler, MD, who writes extensively on intelligent, informed healthcare, offering facts and studies a healthcare consumer should be aware of before giving or refusing consent to commonly recommended medical screenings and treatments for conditions such as high cholesterol, blood pressure, or glucose; colonoscopy; mammography; PSA screening and more. Lest you think he’s fringy, he’s Professor Emeritus of Medicine at UNC School of Medicine at Chapel Hill, and Harvard and Yale educated. You can see his brilliance and relevance in this PBS interview.For 20 years or so, I’ve seen a wonderful internist yearly, but, would abdicate responsibility for this behavior, saying. “The only reason I have a doctor is I have a wife.”Thank goodness I have a wife.September, the year before last, 2018, I had previsit labs for my annual visit with Rick Earnest, who was Chief Resident during his internal medicine residency at Emory, he’s top notch.My white count was low. Rick’s nurse called and said he wanted another CBC and a folate. White count low; folate normal.Then, I saw Rick in his office and we chatted dispassionately about the neutropenia… WBC was around 2, with 4–12 being normal.He told me he had talked to a local heme/onc that morning and then, he shrugged his shoulders and said, “Looks like you need to see a hematologist…” I agreed.About a month later, I had extensive labs at the local oncology center; met the delightful hematologist, Kavita Nirmal, who recommended a bone marrow biopsy.I knew this was coming and, once again, being very healthy and having no signs or symptoms, I thought serial CBC’s would do.However, after my consult with Kavita, I had no urge to refuse the bone marrow biopsy, and it was done that day.Things moved quickly from there.The next day, Kavita called and said I needed to see a specialist at Baylor. Five minutes later, she called back and said, “You could also go to MD Anderson.”Baylor is two hours, MD Anderson is four.Initially, I balked at accepting an MD Anderson referral, as this meant, in my mind, saying, “This is serious.”Over the next 24–48 hours, I had the strong intuition I should go to MD Anderson.I responded to Kavita’s phone call about my treatment choice in a way I found funny/odd… I said, “I owe it to my family to go to MD Anderson.” I thought, “Wow, Dude, you can’t even take responsibility for your choice to go to MD Anderson.” (It wasn’t a big deal… but, interesting.)My records and actual marrow specimen were Fedexed to MDA; I went there for labs and another bone marrow biopsy; and met with a national leader in leukemia, Naveen Pemmaraju.All this occurred in a very compressed period of time and in a context of general surreality, punctuated by briefs periods of extreme surreality.I had accepted there was something wrong with my bone marrow. I had actually been aware I was neutropenic as far back as August 2016; but, again, arrogant invincibility had me ignore it.In Longview, I was told, based on microscopic evaluation of my marrow, and an estimated 13% blast count, I had myelodysplastic syndrome (MDS), something I was familiar with when a fellow staff psychiatrist told me he had it. It was a significant health scare for him, but that was in the 90’s and he and I were in touch for at least 10 years after that, and to my knowledge, he’s still fine today… (we both moved on from that mental health center years ago).Then, as I was going through the process leading up to seeing Dr. Pemmaraju, a nurse who was checking me in and reviewing my chart, was reading out loud to herself… as I listened, it was all quite routine to me as a health care provider, until the letters “AML” came out of her mouth.They weren’t intended for me; she was just one of those people who reads out loud when they read. Perhaps she thought I knew. Perhaps she didn’t know she was reading out loud. It is a cancer center…I can’t think of an adequate adjective to put in front of “stunned” and “frozen” to adequately express that instant as the biggest WTF! of my life rang out in my mind…“It’s leukemia?! I have leukemia?!!!” My mind was reeling with that shock…It was quite a mental shift, in an instant, unsuspecting, unprepared, from MDS to AML.I suppose it was helpful to have the time to be past that initial reaction later, as I sat in one of Dr. Pemmaraju’s exam rooms, waiting to see him. He burst into the room almost as enthusiastically as Kramer on Seinfeld. He was young, energetic, positive and extremely enthusiastic.There I was, sitting face to face with one of the finest allopathic physicians… a hematologist/oncologist who only treats two types of leukemia and MDS.It was a briefly challenging/confronting situation on a philosophical level.You see, I’ve been writing, Power Without Pills: A Curious Psychiatrist’s Guide to Healing and Growth in the Modern World since Googling John Sarno, MD in February 2006. And, I have talked some trash about modern medicine. Not irresponsibly or inappropriately… but, trash talking nonetheless.I was challenged with substantial, in-my-face cognitive dissonance.I resolved it for myself quickly.I had been throwing the baby out with the bath water.I had been all “mindbody medicine is where it’s at!” and, then and there, I realized I had been going to an extreme.I once heard a man say, “You’re just as half-assed no matter which cheek you got.”So, I decided, “Alright... I like this guy... I trust this guy... I’m going to roll with this, and I’ll handle the mindbody part... and he’ll handle the traditional medicine part…”Both cheeks were suddenly firmly in place.He told me they have a clinical trial, using the CLIA protocol, where they’re getting upwards of 90% complete remission rates in frontline AML.All three drugs are FDA-approved for AML, but no one is using all three together. “We are gonna rock this thing! We are going to crush it together!”, he said, beaming.He told me I’d need some preliminary tests, like an echocardiogram, to qualify for the study... a formality.Then, I would be admitted, given five days of chemo, be in isolation, and have a total of around 28 days inpatient before being discharged to outpatient treatment where I would receive five consolidation rounds of the same three chemotherapy drugs every 28 days.He said I’d be in complete remission by Day 28.That conversation was on the Friday before Thanksgiving. He told me to go home and spend time with family... my wife was there in that initial consult and throughout, but I hadn’t seen my father in Austin in a while... it was a wonderful, deeply meaningful break/visit with close family before I went inpatient… ostensibly 28 days, in isolation.On the eve of Thanksgiving Day, I was admitted to the Leukemia Specialty Care Unit at MDA, at around 7 pm, and began chemotherapy that night.How I’ll be bathing in isolation for the next 3–4 weeks…My wife and father-in-law visit me in the square bubble…This woke me up in the middle of the night, tickling my nose…Going…Gone. My hair didn’t survive.It went exactly as he said; except I had a Day 21 bone marrow biopsy in the hospital. The next day, the attending on the service strode briskly into my room, smiling, and said, “Go home. You don’t need to be here any more.”My blast count had gone from 30% to 4%, complete remission, in 21 days.I said, “Uh… I’m not ready.” (My wife was four hours away and expecting me to be discharged in about a week).I went home the next day, six days early, for good biological behavior.I was in complete remission.There was suspense though. I was told through some magic called flow cytometry, they could give a measure of prognostication, MRD, Measurable Residual Disease. With MRD, they could find traces of leukemia, the presence of abnormal blasts, “down to levels of 1:10,000 to 1:1,000,000 white blood cells (WBCs), compared with 1:20 in morphology-based assessments.”[1]A few nervous days later, at my first outpatient follow up, I was given the news, “You are MRD negative.”A Senior Coordinator of Clinical Studies, Department of Leukemia, MD Anderson Cancer Center, Rabiul Islam, who’s worked there since 2003, gave me that wonderful news, and he added, “I have never seen an MRD negative patient at Day 21.”As I have said, I highly value and practice mindbody medicine; parts of that are a positive mental attitude and faith in the healing propensity of the body and the intelligence of life.And my positivity and faith had been rewarded at every turn (even developing leukemia, which I would not have consciously asked for); but it was never the kind of faith and positivity that produced a reaction to, “You are MRD negative,” of, “Well, of course, I’m MRD negative.”I cried when he told me and it brings tears to my eyes now as I write this. I am deeply grateful.And, along those lines, I have taught mindbody medicine concepts for over 20 years and was pleased to find nothing changed with being diagnosed with an illness that has a 25% five-year survival rate. I found, not surprisingly, I walked the talk. Yet, you don’t know how solidly your ship is moored until there’s a storm.As interesting foreshadowing, for years, as one approach to mindbody medicine, I would discuss the hypothetical situation in which someone was diagnosed with a type of cancer that had their physician say, “The 5-year survival rate is 5%.” I would then say, “I wouldn’t say, ‘Oh, no! Those are terrible odds!’ I would say, ‘What did the 5% do?’’’ (My apologies for the complex, and possibly incorrect sentence structure.)I have had many profound blessings in the powerful life lesson leukemia brought to me.To address the question:The leukemia was caught on a yearly routine blood test before I was symptomatic.I am young and healthy, with no comorbid illnesses, and I really stood out on the Leukemia Specialty Care Unit because of my youth, fitness, and lack of comorbid illness.I got the best cancer treatment in the world, I assert.I’ve had an excellent attitude throughout.I never fought the leukemia. I was never inclined to. At the local cancer center, the narrative was everywhere about fighting cancer; even the wifi password had that rhetoric… yet, I could not abide by that narrative.I’m not suggesting that people not adopt that narrative; it’s fine with me if they do; it’s just not for me. I’m not going to start a “Fight Fighting Cancer!” campaign.I do want people to know there’s more than one narrative to adopt in the face of cancer. Pick according to your gut.I’ve said thousands of times: “What you resist persists.” I would not fight. I would listen.I viewed the leukemia as a messenger, and my job was/is to get the message.I have enjoyed Louise Hay’s work, and was aware of the fact she gave meaning to particular illnesses.I thought, “Leukemia is a childhood disease…” Hmmmmmmm…I had started guided journaling at What is Self Authoring? many months earlier, and had started with the Past module (there are also two for the present and one for the future… starting with the past made the most sense to me…) but, I quickly fell into procrastination…One obvious message was, “I wouldn’t do that if I were you…”, meaning, I got one message as, “Don’t keep putting off deep work.”Now, acute myeloid leukemia is relatively rare with about 20,000 newly diagnosed cases a year. That’s an incidence of 0.006%. It’s rare.But, things would likely be much darker (which sounds weird to write, because I can’t say they’re dark (though I can admit if one looks at the five year survival rate for AML, one would be inclined to say they’re dark… but, that’s a statistic, and part of good mindbody medicine is not being negatively influenced by stats…)) if I hadn’t been getting yearly routine labs.TLDR:Get yearly routine labs like a CBC and complete metabolic panel.The risk/benefit ratio argues for it.Think of it as insurance… you definitely want to have it, even though you don’t want to use it.Extra credit edit:So as to exclude as few readers as possible, I am adding an important point…I have used the word, “blessing” more than once, and said that there is meaning in this life challenge/lesson, thereby asserting/strongly implying it’s not random; we don’t live in a strictly mechanical Universe, in which we humans are machines that break and consequently go to doctors that intervene on our behalf and restore us to health.I was ultimately convinced of that mechanistic worldview until the age of 23. I no longer believe in or inhabit that worldview… but no matter…I’m working on a reply to the gentleman’s comment in which it’s asked what I think caused the leukemia.My reply involves logic I learned from my mother, an adept at logic. She changed her worldview late in life with logic.She told me one day, she had done a thought experiment in which she made a matrix of cells… the particulars will be in the reply when I post it.It is the particular thought exercise that’s relevant here:Let’s say you can’t abide by the notion of an actual blessing, or the idea there’s meaning to be mined in a disease, especially a life-threatening one like leukemia, you can still potentially get the value of that system/belief through this exercise:Let’s construct a matrix of four cells: 2 rows, 2 columns…I’m blessed really/I’m not actually blessedI believe I’m blessed/I reject the possibilityThen stand in each cell and look out at the world as if those conditions are so… what do you see? Is that possibility empowering?You see, it isn’t the truth that I was blessed and it isn’t the truth there is meaning, not randomness, in the leukemia… it’s a powerful place to stand.For the strictly “If I can’t see it in a lab, it doesn’t exist,” Do you want to be empowered, or do you want to be right? Or, if your health isn’t good, do you want to be healthy, or do you want to be right?Consider everyone is a house with four rooms: physical, mental, emotional and spiritual.In the modern world, you risk falling prey to the paradigm, the physical level of reality is all there is… It’s all matter and energy… if you can’t see in the lab it doesn’t exist.That worldview may be true, and obviously, it may not be.If you hold yourself as a house with only one room, physical, which gives rise to the illusion of the other three rooms and that’s not the case, there may be a dear price to pay.EDIT (April 16,2019):I can’t say I’m about to add materially to my answer of the question; however, I can see how the reader might be curious as to what’s up as of today… I don’t remember when I wrote this; I see my last update was February 16th.There have been three excitements and one very sad loss since I last updated. I’ll end with the loss.About six weeks ago, after receiving a unit of red blood cells, an infusion which took about two hours, I drove home and sat on the couch. I started to feel cold and hot at the same time. Cold won out and I got underneath an electric blanket and turned it on. Very shortly I was having hard chills.My instructions from MDA since my December discharge were, “Go to the ER if your temperature hits 101 or more.” I didn’t have to take my temperature. My wife drove me to the ER. It was a Friday afternoon and the ER was packed. Getting into the ER was fun; because I have staff privileges there, but the staff up front and the triage nurse don’t know me from Adam. So, I went in the back doors of the large ER, bald, with an overnight bag slung over my shoulder and said, “I’m Dr. Murphy. I’m in treatment for leukemia and I have a fever.” Most of the dozen or so doctors, nurses, technicians and unit clerks behind the counter stopped what they were doing to stare at me. I stared back at them. Eventually, a nurse broke the deadlock. “17 is open,” she said stepping out to escort me.I was deathly ill. All the routine things… blood cultures, chest xrays, etc. were done, looking for a possible source of infection.For the next three days I lay in the dark, sleeping as much as I could. They left me alone, which I thought was odd, but appreciated. At MDA I don’t think they would have let me lay in the bed 24/7, and didn’t even when I had RSV (another story).Monday rolled around; nothing had grown in the blood cultures; and, I had started to feel better. About 11 am, having enjoyed a great rapport and relationship with everyone there, I said politely to the nurse, “Um, I’m going to be discharged. I just need to know whether it will be AMA or not.” 10 minutes later I was signing routine discharge orders, and I went home. I felt like crap.In retrospect, the most likely explanation was a non-hemolytic transfusion reaction, something that occurs in about 1 out of every 1,000 RBC infusions. This can occur if WBC’s stow away in a batch of inadequately washed RBCs. They cause a cytokine reaction, the kind of thing that makes you feel awful when you have the flu.Gradually, over the next few days, my energy came back.The second excitement was going back to MDA on a Friday, my chemo rounds always start on Friday, and had labs in the morning to prep to see Dr. P, who would then order the 3-day round of chemo.My WBC was below 1,000, even though, due to circumstances, I was on Day 35 of a cycle. Being in a clinical trial at MDA, there are protocols and guidelines and chemo was off; it couldn’t proceed.Once again, Dr. P predicted the future. He said, “We’ll do a bone marrow biopsy; you’ll still be in remission. You’ll go home. Have a great weekend. Come back Monday morning. We’ll do labs and give you a shot of Neupogen Monday and Tuesday mornings, and we’ll restart your chemo on Wednesday.”That was an exciting weekend; because, while the blast count was likely ready Friday afternoon, no one was there to read it. And, while I mentioned a couple of potentially arrogant sounding behaviors around febrile neutropenia hospitalization; I’m not the type to be inclined to try and get the results before Monday.I was able to think positively throughout most of the weekend. I did allow my mind to think about a recurrence, but not to dwell on that possibility. I wasn’t in denial; I knew the results of the biopsy could be bad news staying alive-wise. But again, I mainly stayed in positivity and continued to visualize my 90th birthday party (my father, Stu’s 90th birthday party is next month) and to affirm, “I am so happy and grateful now that I’ve released the patterns that gave rise to the leukemia.”Monday morning, after having had my labs, I was sitting and waiting in the 8th floor leukemia waiting area, waiting to be called back for an injection of Neupogen, my cell phone rang. It was Dr. Islam. “Your blast count is 2%.”I cried with joy, once again, as I did when he told me, “Your MRD is negative. I have never seen an MRD negative patient at Day 21,” months before.To be continued… fatherhood calls at the moment…there’s more coming… and… 95% of what I write on Quora is via iPhone… somewhat constraining…My two older sisters and I with our father at his 90th birthday party last month, May 2019. He’s a huge inspiration, and not just because that’s his house we’re visiting and he’s had CLL for ten years and has only accepted monitoring of it.I’m coming up on 6 months complete remission. There’s much more to write; and, my commitment is that what I write make a difference for you.And, as promised above, there’s more to the story and I will flesh out what I believe made the difference in the face of a potentially terrifying disease…Today, my hair, like springtime blossoms, is sprouting again… a sign of the life force, irrepressible, pushing up through the cracks in the sidewalk…Here’s to New Life……and again, more to come…Edit: July 4th, 2019Today, the 4th of July, enjoying Life. I’m 60 now… my hair’s sprouting… the sprouting started this Spring after the chemo was finished… I gave that timing meaning… Springtime… new life…I intend to share more about this experience, and yet, I’m not sure this is the place to do that given the original question.So far, it has been a pleasure to have this forum to share my experiences with leukemia and everything related. If you have a suggestion as to a better forum/platform to share my knowledge, experience and hope with regard to leukemia, let me know.EDIT Saturday, July 27, 2019:I had surgery Thursday to have a myringotomy and tympanostomy tube placed in my left ear. It went perfectly.Fluid filled my left middle ear during my last hospitalization (for febrile neutropenia) in April. There were two complications from that hospitalization, I presume from high dose IV vancomycin and cefipime… a sudden and persistent left ear effusion and neuropathy of my distal feet bilaterally.The tube has all but resolved the effusion (it’s present in the morning, but drains within and hour or two). And the neuropathy, which consists mainly of the sensation my socks, no matter what their fabric, are filled with sand in the toes, and there is pain at times, increased initially with hard shoes and jogging. However, the jogging actually seems now to be a force for its resolution.I set a goal of running a 10K by September 29th, a goal RunKeeper helped me to decide on. Thanks to my varsity tennis playing son, Elliot, for that app tip.I had preop labs Tuesday, and coincidentally, two month followup labs for my heme/onc, Kavita Nirmal, on Wednesday. Not surprisingly, they were both very close…WBC 4.1Hgb 16Platelets 157,000It’s all good.EDIT Thursday, September 12, 2019:Reporting in for the curious…My post above starts with the yearly routine labs I had done September of last year, 2018. That’s cool, and relevant to the question.I’ve had two haircuts since my nuked hair decided it was OK to start growing again. Gone is the childhood fear of the barber or stylist getting it too short.I’ve run 5 days a week since July 21st, and I am registered in Texas Oncology’s Celebrate Life Survivor’s 5K on the 28th.There are two big benefits of running 5 days a week.One is the health and fitness benefit which is enough on its own.The other is, who I am for myself today is larger than who I was when I was saying, “I need to start running again,” for SEVEN years. (I was shocked about 4 months ago, in a moment of self-clarity, I caught myself running that line of bullshit past myself, and I stopped and asked myself, “When was the last time I exercised regularly?” …2012. Damn, Dude. You’ve been saying that to yourself for SEVEN years.)About 3 months ago, I started making the bed if I were the last one out. I’d heard Dr. Jordan Peterson recommend this one before solving any of the world’s problems. “Make your bed.”About a month later, during breakfast with my varsity tennis playing son, I downloaded an app, RunKeeper, he’s using to log his many runs.It started pressuring me to run a 10K in a month. I reacted, “I’m 60 years old. I’m not running a 10K in a month… I’ll run one in two months,” and on July 21st, I started running 5 days a week.Another recent shift in who I’m being in the world is manifested by the fact that I’m writing again.UPDATE: September 30, 2019I beat my oncologist in a 5K this weekend! Sorry, Dr. Nirmal. Good run!Not that long ago, my hemoglobin was 7 and I got winded climbing a flight of stairs. Now it’s 17 and I can run a 5 kilometers!UPDATE: October 25, 2019:It just occurred to me it is getting close to the one year mark that I went to MD Anderson for the first time and I don’t think I’ve adequately acknowledged them.To me, and probably by objective measures, MD Anderson is the best cancer treatment center in the world. It must be one of the largest with over 20,000 employees and over 15,000,000 sq ft of space. Yet, it is one of the best run organizations I’ve ever seen of any size. That’s important. But, not as important as the care and concern I saw everywhere. The ethos there is healthy, upbeat, nourishing and inspiring.In particular, I want to acknowledge and thank to a depth appropriate to one given to someone who participates in literally saving a life. Naveen Pemmaraju, thank you for saving my life. I am the father of a now 3-year-old, precious boy. I am also the father of two other boys, 19 and 17, who shouldn’t lose their father, either; yet, the biggest save was saving the life of the father of this precious 2-year-old boy.December 13, 2018 - Just discharged from MD Anderson’s Leukemia Specialty Care UnitThis is what I’m talking about, Naveen. This is such a huge gift. Words aren’t adequate to express the depth of my gratitude. Thank you.Rabiul Islam, thank you for your relentless close support and encouragement. You repeatedly went above and beyond calling me on my cell and keeping me informed. And, the moment you told me I was MRD negative is one of the happiest moments of my life. You didn’t have to add, “I have never seen an MRD negative patient at Day 21.” But, you did and that made a deep, profound positive impact. It has been some of the best medicine mentally and emotionally, and probably physically and spiritually. All boats rise with the tide. What a profound gift. Thank you.Michael Andreeff, thank you for who you are personally and professionally. You were my first inpatient physician contact, and it was, interestingly, on Thanksgiving Day. You walked into my room with an entourage of residents and fellows and said, “Who are you, and vot are you efen doing here?” (Sorry, that’s my recollection of your delightful German accent.) I loved our banter. When I told you I was a psychiatrist, you told me, “I vanted to be a psychiatrist, but I vound up being this.” You were part of the development of flow cytometry in the early days in Heidelberg. Flow cytometry told me the leukemia was gone down to a resolution of 1:1,000,000 WBC’s compared to 1:20 resolution possible with a microscope alone. Thank you for the quintessential physician that you are; and, thank you for having me look forward to witty banter every morning at morning rounds. What a delight.Zeev Estrov, thank you for who you are. Two memories stand out. You came into my room the morning after my Day 21 bone marrow biopsy and said, “Go home. You don’t need to be here anymore.” And, after I started to recover from the seeming near death experience from RSV, I perked up for your morning rounds; and, you and your entourage of residents and fellows came in. I had finally had a good night’s sleep and told you so. You turned to your students and said, “That! will tell you more than any lab test.” To me, such a brilliant moment of teaching. In medical school, I remember the lesson of one of my professors, “You treat the patient, not the labs.” You are another star in the MD Anderson firmament.To the staff of the 12th floor Leukemia Specialty Care Unit and to the nurses who inserted my PICC line, I cannot say enough to thank you and express the gratitude I have for my treatment there. It is a difficult thing to be a young man, otherwise healthy, diagnosed with a life threatening disease and facing an uncertain future, knowing it included, at the least, chemotherapy and weeks of isolation. I don’t think I’ve told anyone this because it sounds weird. When Dr. Estrov told me to go home on Day 22, I was disappointed. That’s partly your fault. Good job. I’d say, “Keep it up,” but that would be silly. It’s who you are.To the 8th floor Leukemia Clinic and staff, thank you for always being friendly, upbeat, professional but not dry or stiff, and always being a well-oiled machine. Wow. You and your clinic and lab are part of the reason that the thought occurred to me, “This is the best run organization I’ve ever seen of any size.” Amazing. Thank you.To my individual nurses, inpatient, outpatient and chemo, because all of you were so extraordinary in skill, compassion and presence, I got to be right every time about how great MD Anderson is, every time. Every contact. Thank you.To the nurse who put in my PICC line, when I was the most alone and scared, Wednesday night, alone before Thanksgiving Day, thank you for your flawless insertion of a central line, your calming bedside manner, and thank you for telling me you had multiple myeloma years before and remain disease free. (The only thing that could have made the whole experience better, for the next patient, consider leaving out the part about your PICC line getting infected. :) ) Thank you.There are so many people to thank. Right now I am acknowledging you, MD Anderson. Thank each and every one of you. I am weeping now in gratitude as I get in touch with the magnitude of the gift and how you gave it. Jackson just turned 3. He will thank you one day. For now, I thank you on his behalf.Oh my! There are so many people to thank!To be continued…EDIT: January 7, 2020An interesting “problem” is arising here… the longer I live, the less appropriate the word “recently” in the opening line of this answer is… in December, less than a month ago, I went back to MD Anderson for my first checkup since July. All is well and my MRD continues to be negative over a year after entering remission. Thank you, Dr. Pemmaraju and all of you at MD Anderson.And, as I mentioned above, there are many more to thank. I will address two of you now:To Nortin Hadler, MD, of UNCSOM. Nortin, your startlingly deep compassion and ability to read between the lines of what I was saying moved me to tears. You heard me asking things I didn’t know I was asking. Your clinical acumen and profound compassion were so intense at times it was hard to be with. You encouraged me at a deep level. Not long before I was diagnosed with AML, I wrote you to thank you and tell you how much your work has meant to me as a physician and reader. I didn’t expect a reply, let alone one of such thoughtfulness. Then, during my struggles with leukemia, you shined as a lighthouse of steadfast personal and clinical wisdom. Thank you for hearing what I didn’t even know I was expressing and addressing it.To Steve Derdak, DO. My sister, one of the finest physician’s I know, refers to you as the smartest physician she knows. That’s quite an endorsement. I still remember visiting you when you were in medical school and thumbing through your Harrison’s Principles of Internal Medicine to find it thoroughly highlighted. Years later as an intensivist at Brooke Army Medical Center you brought your vast clinical experience to me personally in a very frightening and challenging time. Thank you for being there. And thank you for your sweet, personal bedside care of Marty at our home during her final days.And thank you Quorans for your views and upvotes. I deeply appreciate it!More to come.Edit: June 21, 2020Went back to MD Anderson a couple weeks ago for a routine followup. Results were all good except MRD.CBC great. Bone marrow aspirate showed 1% blasts (normal is < 5%). All very exciting. 6 days out a notification popped up on my phone that Dr. Pemmaraju wanted a telephone appointment with me.That was not welcome news, and I couldn’t wait until the next day to find out why. I called his PA, Rodney, and learned the news. My Measurable Residual Disease is now positive. I am in morphological remission, but not at the level of resolution provided by amazing technology.Dr. Pemmaraju’s recommendation is 3 rounds of venetoclax and azacitidine (VEN/AZA). Mild chemo… he used the analogy that the previous chemo is like a bomb and the VEN/AZA is like a Predator drone strike.He said my MRD will turn negative again. And he referred me back to the Stem Cell team.No problem seeing the Stem Cell team again for a consult but I was dead set against it.My thinking was why would I sacrifice feeling great for the devastation SCT is?And I’ve already created this narrative of how powerful mind/body medicine can be…It wasn’t an easy choice at all. And at one point in the last 16 days of wrestling with my circumstances I decided to do SCT but from a place of fear. (There’s a powerful distinction between choosing and deciding worth taking a look at.) Then I decided against it.At some point I looked at the scientific research and statistics on it; then I watched some inspirational videos by successful recipients and using the rhetoric from one of those people, switched to viewing SCT as an investment in my future. And I went back to my matrix of 4 cells and considered each possibility it boiled down to which mistake I would rather make…Have a stem cell transplant when I could’ve done well using mind over matter after allorNot have a stem cell transplant when in fact I needed one to prevent death by AML progression?Decision is derived from the root word “cide” or to kill off. In a decision the circumstances and considerations determine the selection… you have a pro list and a con list and the selection is based on which list is longer. The alternative is killed off by the considerations.Choice: To select freely and after consideration.Initially I decided no. Then I decided yes. All of that occurred in a field of fear and suffering.At some point I chose SCT and a feeling of peace came over me.I am at peace with the choice and the outcome.Once again, I think I will fare exceptionally well and I know that isn’t a given.I realize one outcome is death by overwhelming infection, organ failure or graft vs host disease.That is out of my hands. I accept my fate. I choose it.And I am happy to share the journey ahead.Edit: August 3, 2020Day 1 Cycle 2 of venetoclax and azacitidine. Mild chemo. The first cycle of this had few side effects and no hair loss. It was surprisingly hard on my kidneys… the cycle is Monday through Friday every 28 days (if possible) and my creatinine spiked to 1.5 on that Friday. It returned to normal and a nephrology consult concluded it was a reaction to the venetoclax. Dr. P concluded it was an idiosyncratic reaction and doesn’t think it’ll happen again.Edit: November 3, 2020Getting Busulfan at MD Anderson this morning in preparation for a stem cell transplant.I am quite well and continue in morphological remission. My MRD turned positive in June for the first time since December 2018. I’ve accepted MD Anderson’s recommendation for a SCT. It’s been their recommendation all along, but until June insurance wouldn’t pay for it and I didn’t want it. However, confronting a dead canary down here in the mine, two thoughts persuaded me.I have three boys, the youngest is four. In that context I look at this as an investment in the future; and, I’d rather have it and not need it than need it and not have it… I met a wonderful man in his early 70’s, John, in an infusion room last year. Delightful. I got to talk to him at length twice. Delightful man. He looked well to me. However, his chemo had never gotten him into remission and he died very quickly. His death hurt deeply. I grieved his death and I could feel the pain of it much more acutely than my mother’s 8 years ago, something I think odd. Perhaps it was the reminder of my vulnerability.I remain optimistic and grounded in my choice and commitments.Today is the first day the thought, “I am a writer” occurred so consonantly. Perhaps the dawning of the reality of death, not necessarily of its immanence, but of its ultimate reality, shifted my audience from what others think to what I think. I’ve a story to tell. It’s for me and that others may benefit.“The ill person who turns illness into story transforms fate into experience…” —Arthur Frank, from The Wounded StorytellerFootnotes[1] Minimal/measurable residual disease in AML: a consensus document from the European LeukemiaNet MRD Working Party