John vs. Cancer #5: PICC (a tube), I Choose You!

***Previously on John vs. Cancer: after a week or two of hanging around in hospital waiting for something to happen, our heavily cannulated hero cracked on with a) his first and possibly only round of chemo and b) becoming a sort of social media mascot for lymphoma. All a bit odd. We rejoin him more or less as the last tube is disconnected.***
 
Towards the end of Chemo Round One, I began to run into problems. The classic side-effects – nausea and vomiting, ulcerated mouth, suddenly wanting to experience a list of incredibly trite activities – had entirely passed me by, but after a few days of concentrated intravenous poison my veins were in pretty poor shape. My chemo regime (much, much more on which in my last blog) required that I be fitted with two cannulae, one for drugs and one for saline, and although a clear cannula should be good for at least three days’ use (pre-chemo, mine were lasting nearly a week), by day three I was having at least one of them changed every day. I was also being bled every day, in whatever drug-free window the phlembotomist could find. Two or three needles per day may not sound like much, but when you’ve already got three burst veins and scarcely a platelet to call your own, it’s more than enough.

For a little while, it looked as if my arms might be spared the prospect of death by a thousand cuts. In the days preceding my first toothsome bag of Etoposide, several nurses had referred (without elaboration) to me “getting a pick”. Working from context, I assumed that a pick was some sort of heavy-duty cannula – the phlebotomists use ‘butterfly’ needles, so the nickname didn’t seem that odd. I was eventually told that a PICC, or Peripherally Inserted Central Catheter, was one of the preferred delivery methods for chemo. A thin line that enters a vein in the upper arm and heads straight to the top of the heart, it neatly eliminates the need for both cannulae and bleeding – the drugs (and the saline) go in via two dangling plug affairs, and blood can be syringed out for tests without ever needing to break the skin.

A PICC sounded like just the thing. But as Round One, Day One crept closer, I hadn’t heard anything about when mine was going to be fitted (a five-minute procedure, I’d been assured). Finally, the day before my chemo started, I was told that I’d been booked in for the day after it finished. My cannulae were holding up well, the clinic was very busy and, reading between the lines, there were other poor sods whose veins were more in need of a break. This didn’t seem like a problem – there’s something reassuring about being well enough to take the scenic route whilst some other poor sod is rushed to theatre – and I felt obscurely proud of my plucky little blood vessels. They didn’t need some bloody plastic interloper. At least, not yet.

Because here’s the thing: catheters are bad news, aren’t they? Obviously, pretty much everything that’s designed for hospital use – bone saws, Betadine, bedpans, and loads more stuff that doesn’t begin with B – is bad news for someone, but generally medical gear is either pleasantly humdrum or excitingly outré. Gosh, a bone saw! I’ve seen them on House. Ah, a bedpan – just like at Nan’s house. D’you see? Hospital stuff is either dangerous and interesting, or suffused with essence of beige. Catheters – boring but absolutely necessary, keeping you alive in the most cobbled-together, we-designed-this-in-a-shed way possible – aren’t thrillingly rarefied OR reassuringly everyday. A catheter is perhaps the only thing on earth that manages to be both traumatising and dull.

Deriving from the doubly appropriate Greek verb meaning ‘to let down’, the word ‘catheter’ now refers to any tube that’s put into the body when the tubes God put there aren’t doing their job properly. I think this is why they feel so thoroughly depressing – they’re not generally a treatment per se, they’re just a workaround for something that oughtn’t to matter. Catheters are a sheaf of folded beer mats under the leg of the wobbly pub table that is your (or in this case my) living body, and that’s ghastly. They’re not weird or life-threatening enough to be very interesting, but not everyday enough to be normalised. You won’t have come across one unless you or someone you know has the sort of dull chronic condition that means their veins are wearing out, or they can’t piss properly, or their arteries have narrowed and need forcing open with a weird balloon. Maybe it’s to deliver insulin, maybe to drain an abscess. Something fucking rubbish, anyway.

For most people, I expect, ‘catheter’ is permanently allied to ‘urinary’, the Dolorous Adjective. Nothing good ever starts with ‘urinary’, does it? Urologists probably spend all day trying to find ways to talk about their jobs without using it. People who do urinary things for fun definitely don’t use it. Urinary means tract infections, incontinence and, of course, catheterisation. Happily, the closest I’ve come to needing the D.A. scrawled on my chart is when I was tempted, SORELY tempted, to create a urinary disturbance by flinging bottles of piss (mine, anybody’s) at the imam, my last and worst roommate. My catheter was to be strictly venous – a long, blue, damning reminder that when push came to shove, my veins weren’t up to scratch.

Before I started treatment, I was quite excited about having my PICC put in. Once it became apparent that I wasn’t going to get one, I stopped thinking about it (in fact, I was quite relieved to hear that I was well enough not to need one immediately). By the end of the first round of chemo, which dragged on for seven days and left my arms looking like a painting of a warzone rendered entirely in blackberries, I didn’t want to see another needle ever again – and I certainly couldn’t imagine where the nurse, charm she never so wisely, was proposing to introduce a half-centimetre tube into my battered veins.

If you were on Twitter on the morning of August 10th (yep, I’m now blogging nearly a month after the fact, because cancer doesn’t somehow cure you of being a lazy writer), I imagine you’re already cognisant of how nervous I was about having my catheter fitted. I believe the word ‘PICC’ trended worldwide for about half an hour, fuelled exclusively by the eight hundred million whiny tweets I sent immediately prior to visiting the day unit and its array of tubes, blades and people intent on putting both into my precious arm-meat. Of all the times I’ve fled to Twitter in a panic over the last couple of months, this was the occasion when I genuinely don’t know how I’d have coped without a phoneful of cheerful strangers.

In the hour or so before the procedure, I heard from nurses who put PICCs in for a living, patients saying their PICC was the best thing that had ever happened to their treatment, and one chap who’d just let his heal over when it was no longer needed because it wasn’t worth the trouble of removing it. The spectrum of available experience was, as it always is on Twitter when you ask the right questions, completely incredible. Having been so frightened that I was seriously on the verge of withdrawing my permission for the operation, I found myself heading up to the seventh floor (on my own! No wheelchair, no porter!) with a song in my heart, just keeping things warm for the tube that would shortly be joining it.

Obviously, since I’d convinced myself it would be painless and over in a few minutes, the PICC insertion was completely horrible. This was in no way the fault of Stephanie, the absolutely lovely nurse who took care of the actual bloody bit – it was 100% a John-made cockup, meticulously planned and executed by my subconscious without me needing to be involved at all.

The theory behind a PICC insertion is very simple. Using an ultrasound machine, you find a vein in the upper arm that’s at least twice as wide as your intended catheter (otherwise you’re asking for a clot). Having numbed the area, you cut into the vein and insert the catheter, which contains a metal guide wire. Veins all go straight to the heart, so simply feeding the tube into the vessel should see it safely home – but just in case, a metal detector thing on the patient’s chest tracks the wire’s progress. Once it’s made it into the top of the heart, the wire is withdrawn from the catheter and the entry wound dressed. A cursory X-ray checks that everything’s where it should be. And that’s it.

Alas, there’s one main sticking point with the above – if you’re stressed, scared, in pain or simply hyperaware of what’s happening to your right arm, your veins are quite likely to go into spasm, shutting down completely and making it very hard for even the most dexterous nurse to ram a tube up them. Stephanie had no problem finding a nice fat vein, but as soon as she went near it the bastard clamped down like a Tory government determined to solve the problem of welfare by killing all the poor (oh shit, looks like some TOPICAL SATIRE in the middle of this catheter blog! You’d better believe it). And oh god, it hurt. We’re not talking bone marrow biopsy bad, not quite, but it’s worth bearing in mind that this vein was about 3cm into my arm. That’s an inch and a bit of flesh that has to be bisected before the catheter can be poked down and into the pulsing vein beneath.

Stephanie gave me another two shots of local anaesthetic and tried again. I managed not to burst into tears, but only by swearing foully at every inanimate object in my field of vision; I was looking very determinedly away from my right arm, which saved Stephanie from being included in the barrage of abuse. I fucking told that ultrasound monitor where to get off, though. None of it did any good – my vein spasmed shut, the catheter had nowhere to go and the whole thing had to be hauled out again.

On the third attempt, I did burst into tears. I think by now my arm had been anaesthetised six times, and I was still feeling every tug and poke. I’d given up on swearing, and completely lost track of my conversation with Stephanie despite her heroic attempts to keep me chatting. I just lay and whimpered, my whole right side throbbing with every tweak of the tube. Surely she’d give up soon – this was clearly, indisputably not going to work. The way is shut, Stephanie. It was made by those who are dead, and the dead keep it. Bin the tubes, give me a fresh cannula and take an early lunch.

And then, almost without me noticing, it was done. “I felt you give up,” Stephanie told me later. “Your whole body relaxed; you’d obviously just resigned yourself to it being a failure.” Never let it be said that resigning yourself to failure is in any way a bad move – that’s what I’m taking away from this. There wasn’t even much pain, although I was warned that the three failed insertions would mean some (more) fairly spectacular bruising. The whole thing had taken something less than an hour, of which at least twenty minutes had been spent covering every possible surface with those paper blanket affairs. All that remained was the routine X-ray, and then-

“The thing about the X-ray is that, although I used an extra-long catheter, your chest is so broad that the end might not have actually reached your heart. Hopefully it’ll be fine, but if not we’ll need to take it straight out.”

Heavens. I’m not a medical man, but I’m certain something could have been done in advance of that incredibly painful and POTENTIALLY USELESS procedure to find out whether the catheter was long enough. Measuring it? Measuring me? Draping it artistically across my chest to see whether it ended up in broadly the right area? Anyway, it all turned out to be fine – better than fine, in fact, because whilst I was in Imaging another patient recognised me from the Times. It would probably have been worth having to have the PICC straight back out for that, if I’m honest.

Nearly a month after being fitted, my PICC is the best friend I’ve ever had. My blood tests are now painless and nearly instant, any amount of chemo can be delivered without the pain or inconvenience of cannulae, and one particularly adept nurse has successfully changed my IVs without even waking me up. I am thrilled to have it and wholeheartedly encourage you to acquire one if you end up in a cancery situation and there’s chemo on your horizon. You do have to wrap your arm in clingfilm when you shower, which will never not be odd, but otherwise it’s a perfect solution to what had been an extremely wearing problem. Catheters, it turns out, are not so bad after all. (Except the piss ones. Piss catheters are still really grim.)

 
***NEXT TIME ON JOHN VS CANCER: Countdown to Neutropenia – John has escaped hospital, but for how long? Place your bets now!***
 
SERIOUS ASIDE
I’m going to keep writing these blogs until I die or get better, probably, and although I don’t really want to sell them (there’s a time and a place for editors), I do want to include a regular plug for Anthony Nolan, the charity that will hopefully save my life with a stem cell transplant some time in the future. I’ve written a thing about them over on JustGiving, and put in a button below to make it as unavoidable as possible. You can give them your spit and maybe save a life sometime down the line, or give them some cash and support the work they’re doing right now. Either way, if you don’t at least have a cursory read then I’ll know, and I’ll lie in my hospital bed wishing you were a better person.