Abbreviations

Toby is back in the hospital.

Chemotherapy's impact on the bone marrow and other organs typically reaches its maximum effect 7-10 days after a cycle. It is at this point when blood counts reach their lowest and when fever and the risk for infection is greatest. Toby is now 10 days out from cycle #7 of chemo. His white blood cells are low, i.e., neutropenia (N) and almost on cue, he spiked a fever (F) last night, guaranteeing an automatic admission for I.V. antibiotics for what doctors call "F/N."

Toby also has pretty significant nausea (N) vomiting (V) and diarrhea (D). One of the chemo agents he got, irinotecan, is known to cause diarrhea, but because Toby has so few white blood cells, which normally ward off infection, the diarrhea and vomiting might be a sign of a bad infection of the bowel wall commonly seen in post-chemo neutropenic patients called typhlitis. For this reason, instead of the usual one or two antibiotics for F/N, Toby is on three antibiotics just in case he does have typhlitis. A mainstay of treatment for typhlitis is bowel rest, with minimal to no food. Toby's gut actually sounds like it's "working" so while his doctors aren't allowing him to eat anything (he doesn't have much of an appetite according to Mooki) they are letting him have a clear liquid diet (CLD). Because Toby isn't in the mood to eat he has to get nutrition somehow else. The two options are either nutrition via a tube that is snaked through the nose into the stomach (an NG tube) or nutrition directly through the vein. Because of the N/V/D, feeding Toby via an NG tube isn't the best option, meaning that unless he makes a quick recovery, he'll need I.V. nutrition, known as total parenteral nutrition (TPN).

As you can imagine, Toby's pretty wiped out and lacking in energy. He received a blood transfusion today and hopefully that will help a little, but the constant V/D is extremely draining and fatiguing. The retching associated with vomiting is painful and the frequent diarrhea is irritating both to Toby's body and to his spirit.

Toby will be at Sloan until his blood counts recover, he is fever-free, without an active infection, and able to eat and drink on his own. He is scheduled for another round of re-evaluation scans (CTs, MIBG, MRI, blood tests, and bone marrows) in a couple of weeks to see how the neuroblastoma responded to this most recent round of chemo. Let's hope that Toby has a speedy and uneventful recovery, that he makes it home before he has to endure the next barrage of testing, and that he doesn't encounter anymore abbreviations.

Yoram