febrile neutropenia

art journal illustration of person in anguish

I’ve had many unpleasant physical experiences during my breast cancer journey, including excruciating pain following my double mastectomy, severe nausea after my first chemotherapy treatment with the drugs FEC, and the worst migraines of my life after my third chemotherapy treatment. But possibly the scariest experience has been this past week, after my fourth chemotherapy treatment – and my first time with the drug DOCEtaxel – because it was potentially life-threatening.

Chemotherapy works to kill cancer cells, but it also kills other fast-dividing cells like bone marrow, where our red and white blood cells are made. White blood cells are part of the body’s immune response to infection, and when white blood cell production is slowed because of chemotherapy, and our white blood cell counts go down, the body is vulnerable to a condition called febrile neutropenia – a fever caused by low white blood cells called neutrophil granulocytes or neutrophils.

Before I started chemotherapy, my oncology team warned me about watching for fever, and to immediately seek medical attention whenever my body temperature got above 38 degrees Celsius (100.4 degrees Fahrenheit). They even gave me a “fever card” that’s supposed to get you faster past the triage nurse at the hospital emergency department, and prioritizes your case to be assessed immediately.

fever card for chemotherapy patients

While undergoing chemotherapy you’re also supposed to avoid possible infection, which is part of the reason that I’m on sick leave at the moment. I don’t go out much, I stay away from crowds when my immunity is at its lowest (from days 7-10 after each chemo), I wash my hands religiously, and have lots of other OCD-like procedures to avoid germs. From everything I’ve read, DOCEtaxel is also one of the breast cancer chemotherapy drugs that’s hardest on the immune system, so I was prepared to ramp up all my compulsive cleaning rituals after my last chemo.

I can’t say I really wanted to try out the effectiveness of the fever card though, as much as I may have wished for it in the past whenever I visited the local emergency departments. I think you can guess where this story is heading. I got to play the fever card this week.

The adventure started last Saturday, three days after my fourth chemo. I felt kind of feverish during the day, and sure enough my temperature hovered around 99.5 F all afternoon and into the evening. I was nervous that it might slip above 100.3 when I was sleeping, so I set my alarm and woke myself up every couple of hours to keep taking my temperature. It never got above 99.8, but I can tell you that that’s enough of a fever to feel really crappy. Saturday night was not a good night.

Sunday was more of the same, and so was Monday. I had maybe a bit of a runny nose, but didn’t really have any other symptoms of illness (like sore throat (cold or flu), shortness of breath (pneumonia), or pain on urination (urinary tract / bladder infection)), so I just kept monitoring my temperature. I went in to my family doctor’s for a separate issue on Monday afternoon, but didn’t even bother mentioning my temperature.

I went to bed early on Monday night with a chill, and then woke up around 10:00 p.m. burning hot. When I checked my temperature I couldn’t even tell what the temperature reading was at first, because I kept looking in the 99 degree area, but couldn’t see the end of the mercury. Turns out that’s because my temperature was 102. I was kind of freaked out once I finally realized what my true temperature was.

chart of body temperatures

If I’d developed the temperature during business hours I could have called the cancer clinic, but that late at night I had to go immediately to the emergency department at the nearest hospital. I’d planned ahead a little bit, and had already figured out the few things I wanted to take with me in a tote bag:

  • My Ontario health card (medicare card) and fever card
  • $40 in cash for cab fare or other small expenses if necessary
  • My iPhone and its charging cables, plus a battery backup charger
  • A small container of hand cream (my hands are really dry with this chemo)
  • Some Kleenex tissues
  • My home keys on a chain that can go around the neck

I fed my cats a bonus can of food, in case I was admitted and no-one else could get to them first thing in the morning to feed them their breakfast. (This is the unhappy part about being single and undergoing cancer treatment – there’s no-one to look after you or the cats 24/7).

I walked over to Emergency, and called my mom as I walked, to let her know what was happening. Thankfully it was a mild night. It was a nice walk.

I was all upbeat and friendly with the triage staff. Playing the fever card was kind of fun. One of the staff was chit-chatting with me about the kind of cancer that I had, and gave me the name of a cream to use to soothe burnt skin if I have radiation.

Then I made my way to a grumpy nurse who was trying to process a few different people (including me) at once. I had to wait a little bit (maybe 10 minutes) before being shown into the emergency pod, and given a bed. I gave them a urine sample, and then they took a bunch of blood samples. The latter part was not fun – I’m getting seriously unhappy about being stuck in the arm with a needle.

I’ve never had a problem with needles or giving blood before – I’ve always been pretty nonchalant about being pricked and poked. But since they’ve been having so many problems finding good veins for my chemo treatments, I’ve been starting to feel a little ill at the thought of anyone trying to find veins in my arms. And the emergency nurse was not gentle. She said that my veins have probably become so callused, and the nerve endings so sensitive, that I feel the pain more than I used to; all I know is, it hurt like hell for her to get the IV line in, and I was suddenly not at all upbeat and friendly anymore. I may have even cried a little after the nurse left. I hurt, plus I was feverish.

They took some x-rays of my chest to check for pneumonia, then wheeled me back to my little cubicle. They had to wait for the blood test results to determine how serious my condition was. If my neutrophils were too low, they would admit me and give me IV antibiotics. If not, they would send me home after giving me some IV hydration. Thankfully my neutrophils were above the danger point. I lay there for an hour while the IV dripped into me, and then was allowed to go home. (They also gave me some Tylenol to bring the fever down.)

I was bored out of my mind while I waited. I’d brought my phone, but it wouldn’t connect to the Internet inside the emergency ward, and I couldn’t focus enough to read any of the books on my Kindle app. In the end I just lay back and watched the staff go back and forth outside the open curtain at the foot of my bed.

Admitted around the same time as me was a teenage girl who was complaining of vomiting. When the triage nurse asked her how many times she’d vomited, she said she didn’t know.

“Two times? Three times?” the nurse asked.

“I don’t know.”

“Five times? Ten times?” the nurse prodded, impatient.

“Like, twenty or thirty times,” the girl replied morosely. I couldn’t help myself – I laughed silently at the vast difference between the nurse’s guess and the girl’s reality.

In another bed was what sounded like an elderly man who was having some kind of problem with his catheter and his blood pressure. The nurse who took his blood (a different nurse from the one who’d taken mine) responded to a question from him that I didn’t hear by saying she was Ukrainian, but spoke both Russian and Ukrainian fluently. He then said something to her in Russian, and she said he spoke Russian very well. Turns out he was German, and had learned Russian as a schoolboy. I wondered what I would be like to be fluent in three languages like the nurse, or two like the old man.

Near the end of my emergency visit they wheeled another man near me. He had an English accent, and sounded like he was maybe in his 50s, and had maybe had a stroke. He was very coherent and easy to understand, but later I heard two residents talking about his facial droop.

When they took out my painful IV line, I didn’t keep pressure on it long enough for the blood to clot, but instead started putting my clothes back on (I was undressed above the waist and wearing a hospital johnny). When I went to put on my jacket I saw a huge, bright red bloodstain on the gauze in the crook of my arm. Sh!t. I was hemorrhaging.

I went looking for someone to give me a clean gauze pad, and they cleaned me up. I kept the pressure on for a while after that. Maybe too long. One of the nurses came by and seemed surprised that I was still there. Then I walked home, talking to Mom again on the phone again as I walked.

The next day I called the cancer clinic’s triage nurse to find out if there was anything else that I needed to do, or to watch for. They told me to check my temperature at noon that day, and call back if it was over 100.3.

At noon my temperature was exactly 100.3. I figured that was close enough. I called them back.

They told me to come in to the cancer clinic. My medical oncologist wasn’t in that day, but someone else would see me. They took more blood tests. (Virtually pain-free, this time. I swear, I adore the technicians in the cancer clinic. They’re so good and so gentle when they take blood.) I had to wait about an hour-and-a-half to finally see a doctor, but at least they got me into an examining room about half-way through my wait, and I could lie down. I didn’t get Tylenol for the fever until the end of my visit that day.

Turns out my neutrophils had gone up since the night before, which was really good news. I wasn’t at risk of sepsis. They were still thinking that I must have some kind of virus, since the only symptom I had besides fever was some nasal congestion. (I never did develop any other symptoms.)

Crisis averted, but I still spent about six days (Saturday to Thursday) feeling awful. To get a viral infection on top of chemotherapy seems pretty cruel and unusual punishment.

Photo 1: untitled art journal page, collage and wax crayon on paper, September 2009