PE

Late Saturday night, with literally everyone still awake for some reason, I saw that Rory was on the phone. Strange, since it was after 11pm. I had one of those feelings when she got my attention and asked, "So, do you want to take me to the ER?"

"No," was my response as I started putting on my shoes and coat. Who WANTS to take someone to the ER in the middle of the night?

For a few days prior, Rory had mentioned that feeling of "someone sitting on {her}" and it being difficult to breathe. Finally heeding Dr. Esplin's comment that she doesn't complain enough, and more likely listening to promptings from the Holy Ghost, she put in a call to the on-call oncologist who recommended a visit to the ER since she'd had those symptoms for a couple of days. When we got to the ER it seemed like we were the only ones there; apparently that wasn't the case just a few hours earlier when the place was extra busy. But, Rory got right in and they started their investigation. Concerned that she couldn't breathe well earlier in the night, she had borrowed dad's oximeter to check her oxygen saturation, and the numbers generally came in at 95%. Looking back, she usually does hit 100% so maybe we should have been more concerned early on. Her heart rate was also elevated slightly at about 115 bpm. That was still the case while we were in the ER.

Almost before her in-processing was complete a tech was there to do an EKG. Last time she reported similar symptoms they suspected heart issues, so that wasn't a surprise to me.

The ER nurse made a good attempt at starting an IV, but pretty quickly put in a call for someone trained on the ultrasound machine to come and help. "Sorry, I probably should have warned you up front that you'd need the ultrasound tech." I guess my own brain was too tired to make that connection and help her out; Rory's nurses pretty much ALWAYS need the additional technology assist to start those lines. The nurse returned with a student along to observe and assist. "See that right there ... it's an artery. Look underneath that right here; I think that's the line we want." Rory almost enjoys being one to help train up-and-coming medical professionals. Even with the ultrasound assisting, it took some work but eventually the line was in, and blood was drawn.

What seemed like only minutes later (although, I might have dozed off in the chair) a mobile xray machine was wheeled in and they took film of Rory's chest. I say "film" because that's still what they call it, even though on the machine's monitor the image was immediately available and was obviously digital. Ah, technology.

Just as I was about to nod off again, a certified gurney driver came in and took Rory down for her contrast CT. I didn't realize until talking with a doctor on Sunday how amazing those scans really are. It's more than just a "picture" of the internal organs. More on that later in this post.

After that early flurry of activity, things slowed down a bit. It took awhile before the doctor was able to give us the official diagnosis: pulmonary embolism (PE). In between her nurse checks I did what I imagine the hospital staff dread: I went searching for information online.

https://www.medicinenet.com/pulmonary_embolism/article.htm#pulmonary_embolism_blood_clot_in_the_lung_overview

Seems that there are pretty scary outcomes of PE, especially when not treated right away. So even though we were both worn out, and only one of us (not me) was in a bed and got a little bit of sleep, it was obviously very good that we were there in the hospital. The treatment strategy is to put the patient on a blood thinner to prevent the gooey clot mass from increasing in size. The thinner also reduces the chance that other clots to also move up into the lungs. They typically start at the ends of the extremities, such as lower arms or legs, where blood flow is relatively low anyway, and then "break off" and then move up to and typically through the heart before getting stuck in the lungs. So while attempting to prevent another clot, the body is given time to heal by re-absorbing the clot material. We already have to be careful because Rory's new chemo medication causes increased bleeding and bruising issues, which will be even MORE pronounced while she's on blood thinners. While it may take 4-6 weeks for a clot to be completely healed, that medication typically is given for 3-6 months or sometimes even for the rest of the patient's life to reduce future clotting risks.

One of the visitors while in the ER was a pharmacist. I was able to help with Rory's rather impressive (to us) list of medications, making sure her chart was updated with all the latest dosages. (Yay! I actually did something to help!) His other contribution was to share two of his young son's recent jokes:

"What is orange and sounds like a parrot? A carrot."

This next one he apologized for before sharing, justifying it because he has five sons at home who still think "potty humor" is funny. This one sort of is, actually:

"What do you call someone who doesn't fart? A private tooter."

Eventually the team, including Rory's non-IMC oncology group, agreed that she could be admitted right there at Alta View. There was some discussion about transporting her to the main IMC hospital in Murray again because she's in active cancer treatment, and other thoughts of transporting her all the way down to Utah Valley Hospital to be closer to her oncology team. But, thankfully, they all agreed that Alta View was well-enough equipped to deal with the embolism and would stay in contact with everyone else. So, we headed upstairs.

This was our first time in the main refurbished hospital. Everything and everyone was very nice. Rory had made a rather long list of things for me to pick up from home, expecting (based on that bootleg internet research) to have to remain for several days at a minimum. The overnight doctor came in and had further discussion with us, and said her plan was simply to wait until the full ultrasound department was staffed early on Sunday, and get a real-time look at how her heart was dealing with the blockage. Somehow I never realized that the various chambers of the human heart don't pump nearly the same pressure, with the right side pumping at a MUCH lower pressure than the left. That's because the left side pumps oxygenated blood to the rest of the body, but the right side only pumps blood into the fragile lungs. You know those blood pressure numbers typically measured, such as 120 / 80? Those are millimeters of mercury, and represent typical "left-side" blood pressures. The right side can be as low as 2! So if the right side has to work hard AT ALL, such as from a blockage in the lungs, that can pretty easily stress that part of the heard muscle. Although the CT "snapshot" looked good, getting that ultrasound in the morning would give much better information about her heart.

https://www.heart.org/en/health-topics/high-blood-pressure/the-facts-about-high-blood-pressure/pulmonary-hypertension-high-blood-pressure-in-the-heart-to-lung-system

Somewhere about 6:30 I headed home to pick up just a few things on the list. I had texted my parents and Colton and Kaeli through the night, but most had not been awake and didn't see those messages. So I waited until my parents and kids were awake so I could fill them in a little bit on what had happened while they were asleep. The kids seemed to take it OK, and I got them dropped off to church on my way back to the hospital.

By the time I was back to the room, they had already come and completed the ultrasound. Rory said it was another "very cool" mobile unit that they used right there in her room. She was up and poking around at her breakfast, and was quite alert and talkative for most of the morning. I thought the plan was for me to drop off her pillows and medications and a few other items, then return home for a few hours to sleep while the rest of the family was at church. But, the nurses and doctors kept saying that everything looked good so they were going to get us out of the hospital as soon as possible. (I should have gone home for that nap.)

The doctors were very good to check in and explain what was happening, and what the plan will be going forward. Rory's PE was deemed to be a "Saddle Pulmonary Embolism" which is of course not great. "Saddle" means the clot straddles BOTH sides of pulmonary arteries.

https://www.ausmed.com/cpd/articles/what-is-a-saddle-pulmonary-embolism-pe

The magic ultrasound and CT scans were able to show more than just a simple visual; the doctors were able to "see" that even though the pressures in the right side of Rory's heart were elevated, and even though her heart rate was elevated in the body's attempt to compensate for having those lung arteries blocked, there was no permanent damage or issues with the heart muscle. They were also able to tell from density detection that the clot really is blood, and not fatty material or cancer cells or anything else. The doctor also said that although Rory was being sent home with the injection-based Lovenox that the practice has always used for patients experiencing active cancer treatment, there are other recent studies that suggest some of the traditional oral blood thinners may be just as effective. So we'll have to see what Dr Esplin suggests and prescribes this week. (The hospital pharmacy only had enough of the Lovenox for 5 days, so we'll be getting another prescription soon.)

One of the check-ins was from someone on the PT staff. The more she asked questions about setup at home, the way Rory gets around, accommodations, etc, the more it sounded like the stuff Kaeli has been studying in her OTA classes. Jen held up her hands with fingers interlocked, stating that there in the hospital, Occupational Therapy (OT) and Physical Therapy (PT) overlap quite a bit. They just don't have OT's on staff all the time, so she covers for those concerns quite a bit. She got Rory a walker, and in true drill sergeant style made her walk around the hallways for awhile. It's always good when they can get their patients up and moving around. In addition to just being up, she made several suggestions for exercises and movements Rory can do from a chair or even in bed, in hopes of reducing the chances for additional future clots.

Seems like we got home about 1:30pm, in plenty of time for the planned dinner with Rory's Miller cousins. From the moment we got to the ER, she was expressing a desire to be home for that dinner, and the team came through for us. I finally got to bed about 2:00pm, and didn't wake up until Rory's medication alarm rang at 8:30pm! Oops, I slept through dinner. I went back to sleep until my alarm rang at 4:00am. So, I'm writing this a day after everything was happening; hopefully Rory will fill in any "gaps" in my journal.