9. The bone marrow biopsy

Wednesday 24th August, 2013

Well this is not something I was looking forward to. I wasn’t terrified, I just knew it wouldn’t be pleasant.  The doctor who would be doing it had called me the day before to make sure I was happy for it to be done under a local anaesthetic as opposed to a general and to ask if I had any questions.  I was OK, not happy, with a local anaesthetic and didn’t have any questions.

I was being admitted as a day patient for the biopsy which meant I had to fill in some paperwork for the hospital.  As per usual, I left this until the last minute and was filling it in that morning when my cousin Sonya arrived at my house to take me to hospital.  There were a lot of questions.  Now, I need to tell you something about my crazy family; not the wogs, the other side, the Tomo’s.  We have this ongoing competition where we try to make any particular occasion “all about me”. Sonya is usually the best at it but I think I’m winning hands down at the moment. There is also a competition, as you may have gathered from some of the comments, about who is the favourite.  My mum and dad have received many cards from their ‘favourite daughter’ over the years.  They have more than one daughter! The competition is very fierce amongst the cousins, (and their partners who are honorary cousins), in particular.  Everyone wants to be favourite cuz!  My sister took full advantage of me living in a country town for several years, but now that I’m back, I’m gaining on her and may have just overtaken.  The real competition now is to be my favourite, especially with my life insurance policy! I’ve digressed.  On this form that I was filling in for hospital was a question about who was going to look after me after discharge.  This is what I wrote:

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Sonya loved it! A quick photo was taken and sent to my sister and off we went to hospital.  I should add here that Sonya is also single.  Given the pathetic response to my offer to conduct interviews for a date with Christian (only a married woman and a cougar expressed any interest!), I think I’ll just send Sonya and Christian on a date.

I signed the necessary forms at the reception desk and went to the day theatre area where Sonya and I sat in the waiting room.  After short wait, I was called in and Sonya was left in the waiting room.  I was taken to a bed where a nurse took some observations (temperature,heart rate etc) and told me I was next on the list of bone marrow biopsies for the day (4th out of 5 for the day).  She also told me that I wouldn’t need to get changed into a gown. She asked me if I had anyone with me in the waiting room.  I said my cousin was out there.  She said “Oh yes, your favourite cousin.  I saw that in your file.”  I said, “Sonya will be ecstatic that you noticed.”  She then said that Sonya could come in and that she would go and get her.

I wasn’t there for this bit, but Sonya tells me that the nurse went out into the waiting room and called out quite loudly “Favourite cousin Sonya”.  Sonya stood up proudly and the nurse told her that she could go through and see me.  She was grinning from ear to ear when she came in.

The rest of the morning was not so enjoyable.  Sonya left when it was my turn for the biopsy.  I think she wanted to stay to watch but I told her that wouldn’t be necessary and off she went to the shops.  The doctor came over and introduced himself.  He looked about 12.  I must be getting old.  He told me he was a pathology registrar which means he is training to be a pathologist, sort of like an apprentice.  I asked him how far he was into his training and we had a bit of a chat about that.  He then must have seen on my hospital stickers that my title was Doctor and he asked what sort of doctor I was.  “I’m a pathologist”  I said.  I could see his heart sink and he really tried his hardest not to show what he was thinking which I’m pretty sure was “Oh fuck!”  As a registrar, it would be pretty nerve racking to perform a procedure on any doctor, but to perform a procedure on a doctor who is a consultant, or specialist, in the area in which you are training would probably be close to the top of the list of things you hope you never have to do at work.  We continued the chit chat, talking about an exam he would need to do which would probably mean he would need to come where I work to get some specialised training.

He then explained what he was going to do.  In the area of pathology I trained in, there was never a need for me to learn how to do bone marrow biopsies.  I had a fair idea of what it involved but didn’t know the specifics.  I was then asked to roll onto my side and pull my pants down a bit.  The biopsy was going to be taken from the back of my hip/waist, as illustrated in the image below.

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Unfortunately I got a look at the needle he was going to use and it was BIG!  So, pants were down, drapes were placed over me, he put his gloves and gown on then put some antiseptic over the area of interest.  He put the antiseptic over quite a big area and I could feel it going in to my natal cleft (that’s my bum crack for all you non-medico’s).  He then injected some local anaesthetic.  He waited  a while and then asked for another vial of local anaesthetic.  At that point I said, “ooh, special treatment?”  He was putting in extra local anaesthetic as he really wanted to make sure it didn’t hurt.  He muttered something under his breath about every patient being the same and just following the same procedure.

The procedure is actually called a BMAT which stands for bone marrow aspirate and trephine.  So, once the local anaesthetic had taken effect, he performed the aspirate part of the procedure.  This involves sticking a needle through the bone of my hip into the marrow, like in the picture above, and sucking some marrow out.  I think he said about 10 ml, maybe more.  He told me I would feel a sharp pain and a drawing or pulling sensation, which I did.  It probably lasted about 5 to 10 seconds.  Not too bad.  The next bit was the trephine.  This involves actually drilling a core of bone out.  He drilled into my bone and I could feel some vibration but not really pain.  He then had to jiggle quite hard, apparently to make sure the core of bone separated and stayed inside the hollow needle.  As he was doing that, he explained that sometimes the core doesn’t come and out if that happened he would need to have another go.  “That won’t happen”, I said wishfully.  He pulled the needle out and I could hear the fear in his voice when he said “It’s happened.  I’ve only got cortex.  I’m going to have to do it again”.  Cortex is the outside of the bone.  He needed to go through the cortex and into the spongy bone of the marrow.

So we went through the process again.  This time it hurt a bit more and the result was the same.  No marrow.  So he had to drill into my bone a third time.  This time it was a bit more painful again.  It wasn’t excruciating but it was uncomfortable.  It was quite possibly the thought (and feeling) of having a great big needle being twisted around in my hip bone and having it go in so deep that it felt like it was going to come out the other side, that was worse than any pain I was feeling.  The nurse looked at me and said “you’re over it aren’t you?” to which I replied “Yep!”  The needle came out and there was a sigh of relief.  “Got it this time”.  He had the core of marrow but he told me it was three quarters hanging out of the needle so he almost lost it again.  I don’t think I would have let him have a fourth attempt.  He put a dressing on and I had to lie on my back with pressure on it for about half an hour.

Whilst I still had my back to him, he asked if I had to have another bone marrow biopsy, would I ask for a general anaesthetic.  I said I probably wouldn’t and I think he was relieved by that answer.  I told him it was probably worse for him than it was for me.  I didn’t enjoy but I think he was VERY nervous doing a bone marrow biopsy on a pathologist.  As he moved on to the next patient I said something to him about coming to my work for his specialised training and exam.  He just scurried away quickly.  I think it was the bum crack.  I don’t think he could look me in the eye professionally knowing he had seen my natal cleft.  I joked with my colleagues that if he did come to our work to do the exam, I would examine him and fail him three times to get my revenge!

Sonya returned soon after that and I gave her a run down of what happened.  Then my haematologist unexpectedly popped in to see me.  I thought I wouldn’t see him again until Monday when I had chemotherapy.  He asked how it was and I told him it wasn’t too bad but certainly not pleasant having three goes at the trephine.  No sympathy of course.  He then said “So your PET scan showed some lymph nodes around the spleen so you’re stage 3”.  I asked him about the bone marrow and told him the radiologist had already called me and told me the bone marrow might be involved.  I can’t remember his exact words but he said something along the lines of radiologists always overcalling it and saying the bone marrow is involved.  I asked if the bone marrow involvement was mentioned in the report and he said it did but he ignored it.  All the while, I could feel Sonya’s eyes darting between us.  She later told me that we were talking “doctor talk” and she had no idea what we were saying but she heard stage 3.  She had thought I was stage 2 because that is what I had told everyone based on the CT scan.  So I was stage 3, not stage 4.  I was pretty happy (perhaps not the right word) about that. The bone marrow biopsy hadn’t been looked at of course but he seemed confident it wouldn’t be involved.  He explained that Hodgkin’s tends to spread in a particular pattern going from lymph node group to lymph node group and I got the impression it would have been more widespread in the lymph nodes in the abdomen before it went to the bone marrow.  I also asked him if lymphoma is in the bone marrow is it everywhere in the bone marrow or could it just be in some areas.  He said no, it’s not everywhere.  Which begs the question.  What is the point of taking that tiny sample of bone from the hip and diagnosing bone marrow involvement based on that?

Anyway, I was stage 3.  Stage 3A to be precise. When the haematologist left, Sonya and I had a conversation that went like this:

  • Sonya: “Oh my God, are you OK?”
  • Me: “Yes. Why?”
  • Sonya: “You’re stage 3”.
  • Me: “Oh, I already had the results of the PET scan and I thought I was stage 4”.
  • Sonya: “You bitch! You didn’t tell anybody” There was probably an expletive in there too.
  • Me: “Well if I told you I was stage 4, you all would have panicked wouldn’t you?”
  • Sonya: “Yes, probably”.
  • Me: “Wel that’s why I didn’t tell anybody”.

I still believe it was the right decision not to tell anybody I thought I had stage 4 disease.  They would have panicked and I wouldn’t have been able to reassure them because I didn’t know how that would affect the prognosis.  The visit from my haematologist was fleeting so I didn’t get the chance to ask him what my prognosis was now that I was stage 3, but I got the impression it was only marginally worse.

For the next couple of days I felt like I’d been kicked in the backside by a rather large horse but the pain was manageable and it was soon a distant memory.

5 sleeps til chemo……..