graft failure

ahhhhh. today is friday! and i am not working. yay for not working fridays!

i worked the last three days. and, as always, it was interesting. sad, challenging, frustrating, but interesting nonetheless.

here's the update (and an explanation about why my heart hurt this week): the nurse patient is sick. she is 34 days past her transplant date and she still has no white blood cells. what that means is, her transplant failed. we call it graft failure. and it is very rare. people die on our unit frequently; but it is rarely due to graft failure. deaths on our unit are due to infection and/or graft versus host disease. but the nurse patient's body did not accept her donor cells and because we killed her bone marrow permanently with HUGE doses of chemotherapy, she is incredibly vulnerable. very sick. and has high, high risks for mortality. her only chance at survival is a second transplant. and this is COMPLICATED.

this week, we had several lengthy meetings about the nurse patient's options - some with the patient, some without. what it boiled down to is a race against the clock. the longer the patient is without an immune system, the more likely she is to die of something (and it would be something stupid - like the common cold she has acquired - or a fungal infection). there is only one potential donor in the whole world and he is in germany. for some unknown reason, he is unable to donate until april 17th (which means the nurse patient would likely develop an immune system 2-3 weeks after the transplant date of april 17th). unrelated donors have high rates of graft versus host disease, but it is not a risky transplant - typically, people who get unrelated transplants at least engraft (except for in the case of nurse patient's unlucky first transplant). her only other option is to get a double cord blood transplant; these stem cells come from cord blood donated by delivering mothers. this type of transplant has a higher risk of graft failure, but the cells are ready NOW. nurse patient could get her cells within one to two weeks - which is great. BUT engraftment (developing an immune system) takes longer with cord blood transplant - anywhere from three to four weeks. so, what is the right decision?

nurse patient was presented with these options. there were very blunt discussions about her risk of dying before cells are made available to her. and she was told of all of the risks associated with each type of transplant and the race against time (remember, she is a pediatric transplant nurse - she KNOWS the risks). but the doctors could not sway her in any one direction. amongst the team of physicians, there was a 50:50 split. there is no conscensus. hence, the nurse patient had to make a decision all on her own. her husband, being a lay person, had very little advice or opinion on the matter. so, the weight of the world was on nurse patient's shoulders. she asked me what i would do and all i could do was be honest. i would cry. i guess i wasn't super honest. i think what i would do is pack up and go home to die. but as a mother of two teenage daughters, i guess nurse patient HAS to live. she has to chose one of the two scary options. and once she does, i told her she has to believe it is THE VERY BEST OPTION.