My brother-in-law, Bruce, delivered me on time yesterday morning to St. Mary's Hospital Intervention Radiology department at 8:30 a.m. for the ultrasound guided ablation procedure. A very friendly nurse named Darcy (who had also called me at home the night before to fill me in on details) got me ready with the standard issue gowns, one-size fits-all pants and non slip slippers (an oxymoron?). The I.V. was a breeze because she was able to access my port. I was further informed about the procedure by Kevin, a physician's assistant and then again by Dr. Skrtic himself. All seemed confident of a good result. Feeling incredibly well-informed having it explained to me be nurses, P.A. and the doctor twice, I was beyond ready to go.
There must have been some kind of emergency because I had to wait an hour beyond the scheduled 10:00 operation time. When they finally rolled me in, I was prepped by a nice person named Meghan who offered me a choice of Pandora channels to listen to. Dr. Skrtik came in to pre-visualize the tumor using an ultrasound wand and a giant TV Screen suspended on a gimbal above. I can tell you that a liver is a less gratifying site on an ultrasound display than say, a baby. I really wanted to see what a tumor looked like but it was tough to see anything that looked like an ominous mass. Dr. Skrtic was having a difficult time seeing it to. It was in a really difficult place to visualize, on top of the liver, behind the ribs. Ultrasound cannot see through bone. He had me run through a series of breath-holding options and seemed to have decided to go between the ribs. But then he tried a wedge on my left side so I was at a 45 degree angle with one arm above my head. He moved to the other side of the table and found a position he liked better. It required a smaller "breath-hold" from me and the approach was under the rib cage. Satisfied with this strategy, he then left to make some measurements from last week's CT scan to establish depth. I could see him working oin the corner of the giant monitor.
Three other people with masks came in and began hooking up equipment. One of them must have been an anesthesiologist (although she did not introduce herself) because I felt a cool liquid flowing into my port and felt the effects of the Versed. This was to be conscious sedation and I knew that they would give me enough to feel groovy but not so much as to put me to sleep. I found it no problem to remain engaged with what was going on around me.
There was a big box next to me and all three people seemed to be hooking it up for the first time. They were looking for instructions and trying to figure out where patch cables and a five-channel piece of tubing were supposed to go. Eventually, Dr. Skrtic reentered and joined them in trying to figure it out. It seemed to me that they were struggling with this for about 10 minutes. I was in an altered state but from my angle I could see a slot with five channels where it seemed likely this tube was supposed to be inserted. Eventually, Dr. Skrtic lifted a block on some sort of hinge that revealed the five channels that I could see and everyone seemed satisfied that the mystery was solved. At least that is my spaced-out recollection. It could have been a dream.
When the operation commenced, Dr. Skrtic started with local anesthesia, warning me each time about a "pinch and a burn". Each shot went to a deeper layer of tissue and I found them easy to handle. My strategy for shots is to drive a fingernail into my side with self-inflicted pain distracting the needle pain. The catheter was then painlessly inserted. I tried to watch on the monitor but could rarely see anything that looked like anything. Repeatedly, he asked me to take a deep breath (or a medium breath or a small breath) and he would push in a little farther. These often did hurt, similar to the pain of getting the wind knocked out of you. Deep and unfamiliar. I wanted to tell him to just push a little harder and get it over with. Eventually I felt myself getting a little clammy and wondered if I was in danger of passing out. The shoulder above my head was getting sore and at one point I think I moved my arm for relief and somehow brought it into the operation arena, touching skin. I remember a barked order to restrain my arm and re-sanitize the area.
Then I remember instantly realizing it was over. I must have fallen asleep. No one was working on me and there was only one other person in the room. Somehow I gathered, or was perhaps informed, that they had given up. The tumor kept sliding out of the way whenever he pushed into it and he would also lose site of it on the ultrasound.
Bruce filled in the gaps with these notes:
Before you came back into the room, Dr. Skrtic came and gave me the overview directly after finishing your procedure. He was disappointed he couldn't lance the mass because it moved up every time he poked it, seemingly up and under the ribcage if I understand it correctly. He said the placement of the needle was tricky and though in one attempt he could get approx. 1/2 cm into the mass, it slid back out with normal breathing, as you recall…Back in my recovery room, I was very hungry. I had to wait a little bit and was given some juice at first and then eventually a chicken salad sandwich and some orange sherbet. Bruce was still there, getting details and instructions as evidenced above. I made a few "Facetime" calls and emails and sent Bruce home while I slept for much of the mandatory 5-hour waiting period. Mary and Marlee picked me up around 7:00p.m. and when we got home, Marlee made me some macaroni and cheese while I rested in an easy chair. I took a Vicodin but was not in much pain
He said it was important to know for certain that the placement was perfect before applying the zap, (my meager attempt to remember the term) so that's why they abandoned the effort. He said you did an outstanding job, it was the limitations of the device under the circumstances and normal breathing mechanisms that were a reality… so know you were doing an excellent job throughout… The seven or so times you tried were exceptional, it was simply a mechanical issue -- the diameter of the needle (thick as a ball point pen tube he seemed to suggest, because of the prongs stored inside of it) that kept nudging the mass away.
So then he straightaway said there's two options, and that had he had permission, he would have attempted the pure alcohol ablation, with a much thinner needle which would have more easily made it into the center of the mass; the idea being to then inject pure alcohol in proportion to the volume of the mass and attempt to destroy the tissue. He said that's the effect of pure alcohol on the mass. He also said that had been the standard procedure they all used regularly up till the radio frequency method was developed. So he would have done it yesterday, yet was considering doing that even this week… just needed permission, scheduling, etc., and since you were "snowed" (his word) yesterday, he couldn't proceed.
However, this is interesting - it's possible the delay will likely be the best thing that could have occurred! When you came back into the room, he visited, and again said to you there's two options; one being the alcohol ablation and the other - minimally invasive laparoscopic surgery to ensure plenty of access, the latter being more invasive, but he wanted to consult with Dr. Pimiento (sp). So, a bit later Darcy said they were on the phone, comparing notes and looking at the scans, etc., and then sure enough Dr. Skrtic came back to tell you the laparoscopic method seems best. That's interesting, because Skrtic said while the alcohol treatment is very effective, he didn't seem to say it's 100%, and Darcy reinforced that idea saying it's often possible to re-do the procedure as needed over time… However, in describing the details, Skrtic said the laparoscopic procedure enables them to use CO2 to easily expand the space to work, etc., etc., and with surgery you get more of a guaranteed exact placement of the same radio frequency technique preferred. He also mentioned they sometimes get him up there in the OR to help during the operation as they as really good at assisting with guided imagery technique. Then, Darcy in a separate conversation later said she too knows the RF is preferable -- the fact being that radio frequency technique has much better precision getting a larger area and any "feeders" (her word describing blood supply that is hard to see) and with the extended radius of area covered by the 'zap' you are in much better shape. And she said again, that because you're such a healthy person, and can live fine with some loss of liver, she seemed to suggest 'why not'… and that it's a much preferred solution in her experience.
Again, the emotion is disappointment. All that rigmarole plus a lost couple of days and the tumor is still there, un-burned and growing. Next week, a new doctor and another procedure. Until then, moving slowly.
