Month: April 2017

Vaccination Day

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Post op day 11

Today I went to get my shingles shot. With the impending start of my chemotherapy, I needed to make a very important decision- vaccinations. Cancer increases risk for infections especially for pneumonia, influenza, respiratory difficulties and Hepatitis B. Increased risk may be due in part to the cancer itself stressing our immune system and from chemotherapy or radiation therapy. Even though I know the risk of shingles is very small, that is my fear. I spoke to my oncologist and she reported she has not had any patient get shingles while getting chemo. However, I know too many non immunocompromised people to not be concerned. This is a point that feelings vs. statistics collide. I looked into the risk of getting the shingles vaccination prior to getting chemotherapy. Shingles is not recommended get while undergoing any immunosuppressive treatment. Shingles is a live attenuated virus vaccination- meaning the vaccination is made up of active virus that has been weakened to prevent an active infection but allow for the immune system to mount a defense. With a decreased ability to mount a defense for immunosuppressed a live attenuated vaccine can potentially cause the illness. For any live attenuated vaccination you need at least 4 weeks prior to the start of the immunosuppressive therapy and 2 months after the end of the immunosuppressive therapy. I was just within 4 weeks prior to the start of my chemo. Therefore I could safely get the vaccination now. The efficacy of the shingles vaccination is at 51%. This means that it will work to prevent shingles in about 51% of the time. While this isn’t as robust as I would like, it does help to decrease the possibility of me getting shingles and it will help to lessen the severity of shingles if I do in fact get shingles (it is 67% effect at preventing severe pain known as post herpetic neurologia). While the vaccination potentially may not help prevent shingles, the risk of an adverse affect vs. the stress and fear I feel from worry about shingles made me choose to get the vaccination. I will also get the Pnuemovax to prevent pneumococcal infection (one cause of pneumonia). Strange how I am not as concerned about pneumonia as I am for shingles, even though the pneumonia is more common for people undergoing immunosuppressant treatment than shingles, I went first for my shingles vaccination and am lackadaisical about the Pneumovax. A more detailed description of vaccines can be found here.

The shot was not more painful than any other vaccination. However, I have a 1-2 cm hard bump that developed and is really painful and difficult to move my arm. This can occur in just over 1% of people receiving the vaccine. It is not to the point that I regret getting it but it is an annoyance since I was finally able to have full range of motion post surgery. I hope that I do not get shingles but at least for now, one less stressor is welcome.

Turning the corner: the bucket list

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Post op day 10

Today, I woke up and noticed a change- my body felt like my body. For the past 10 days I have been having pain, decreased range of motion, inability to pick up objects 1 pound or more, and a feeling of heaviness. The feeling of heaviness has bothered me the most. I have arthritis and all the other things come when my arthritis is acting up. However, the feeling of heaviness has disturbed me the most. It comes from my port. I can feel the weight of it. It presses against me and was noticeable with every breath I took. Today, it wasn’t that ever present foreign invader but a part of me. I didn’t have to think about each movement I made, whether it was turning my head or raising my arm or simply just breathing.

The course of cancer is filled with bumps, hills, and mountains. It is nice to have a moment where the path is smoother. I don’t know how many smoother days I will have, but I want to make sure I have a way to make the most of it. I decided to make a list of things that I really want to get done when I feel good- a cancer bucket list if you will. For me, I believe that it will help me feel energized. The buckle list could include anything from projects to work on, cleaning and organizing, seeing family and friends, or just taking a moment to enjoy the day. One of my things on my bucket list and in fact the first thing I decided I wanted to do, was to eat my favorite foods before chemo started. I wanted to make sure that I could enjoy the meal to the fullest in case chemo changed my ability to taste food. Today I am going for chilaquiles and for Chinese barbecue – not at the same time of course- but my day will be filled with good food and plenty of outside time. The other thing I will do today is fill out the rest of my bucket list. Just the thought of that has reinvigorated me. It is amazing something so simple can be so empowering. Empowerment is all too fleeting and I am going to take it when I can since I don’t know what is around the next corner.

Good Enough

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Post op day 9

The realization of the change in my ability will be an on going struggle. I have written before about this struggle. Today it is rearing its head again. I slept most of last week. I have finally woken up and looked around and saw all the things that needed to be done. How do I tackle everything that needs to be done? Where do I start? What will I be able to do when my chemo starts? All of these questions plague me. I am sure this overwhelming feeling will occur time and time again in the future. It is time to take a deep breath and reevaluate my goals. This struggle reminds me of the words from a theorist, Winnicott. Dr. Donald Winnicott was a pediatrician and psychoanalyst who studied children’s relationship with their mother. He saw that imperfections with the mother benefited their children more than when mothers were perfect. He writes:

“A mother is neither good nor bad nor the product of illusion, but is a separate independent entity; the Good-enough mother… starts off with an almost complete adaptation to her infant’s needs, and as time proceeds she adapts less and less completely, gradually, according to the infant’s growing ability to deal with her failure. Her failure to adapt to every need of the child helps them adapt to external realities.”

The concept of good enough is a powerful concept that speaks to the drive for perfection and it is not necessarily the healthiest drive. Our imperfections and failures can do more for us to grow and become stronger than restricting ourselves to be perfect. Sometimes in the midst of challenges or tragedy we must take a step back and allow ourselves to strive to be good enough. This is not to say that we shouldn’t try to be the best we can, but our perspective of who we are may be better accessed by the strive to be good enough and accept our failings as a moment of learning. It is through my failings now that I have been able to allow for the support and care from my family and friends. It is through my inability to be who I was before that I have grown closer to my loved ones. It is through my mistakes that I have learned to appreciate other aspects of my self. I have started writing, a skill that I felt was rudimentary at best. Everyday I write medical evaluations, progress notes, and letters. I have always thought that my words were clunky and my grammar unsophisticated. However, now that I write about my experience, I feel a different part of me is developing. I find I like this new me that is emerging. I started writing this blog because I couldn’t do much. I am fatigued and achy. I cannot pick things up, dress my self, cook or do most things as I used to do. But I can sit and read and write. I would never have started this website if I hadn’t failed at being who I used to be.

In this time, that change is inevitable, and failure is part of the picture, finding that good enough self may go a long way towards finding your new self- a self that you might really like.

The appointment

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Post op day 8

I met today with my oncologist. She is a very sweet doctor with a calming demeanor. I guess it is necessary to have such a calming demeanor when part of your job is to give bad news. She went over the pathology. Her voice was like a babbling creek running over the stones of my illness. My tumor was over three times the size that was estimated. While this is not uncommon for estimates to be off, it was my tumor and how common the underestimation didn’t matter. But yet it was hard to be upset as my oncologist lulled me with her voice. My lymph nodes were still clean but pathology identified the tumor invading into the wall of a lymph canal or blood vessel. The technical term is lymphovascular invasion (LVI). LVI prognosis is difficult to judge. It depends on if the cancer went through the entire wall of the vessel or not and if cancer cells broke off into the blood stream or the lymph. Lymphovascular invasion is a scary term. But it is treatable.

My oncologist discussed the new chemotherapy regimen with me and my husband. It needs to be a more aggressive treatment due to the possible breaking off of cancer cells into the blood stream or lymph. You can be lymphnode negative and LVI positive. The prognosis is slightly worse than LVI negative alone but it is important to know that chemotherapy medications are for precisely that possibility- the possibility that there are other cancer cells in your body that haven’t been picked up yet. Even though, as a doctor, my head tells me this, my emotions are in a free fall. So I go back to the ever soothing voice of my oncologist as she tells me about the new medications that will be used and the change in schedule for my chemo. There will be two additional medications added and the infusion will take a longer time both in hours for the infusion and weeks I will be getting this regimen of chemo.

My initial plan was to go to work in the morning on Fridays and go for chemo in the afternoon. My Fridays are pretty easy. I run a clinic until noon and have meetings and administrative work in the afternoon. My meetings could be changed to phone meetings and I could log into the hospital computer system since I will still be at the hospital. Easy to fit in chemo into my work. See patients in the morning and run over and get hooked up for chemo in the afternoon. Now this will change. My Friday clinics are a specialty clinic. I am the only doctor of my specialty that does these evaluations in my state. There are  doctors of other specialties that will see patients, but if the question is more appropriate for my specialty, there is only me. As you might imagine, any decrease in my ability to see patients in this clinic is significant. I am not sure which I was more upset by- the worsening of my treatment and prognosis or the decline in my ability to see my patients. We all have responsibilities and the ability to adequately take care of our responsibilities is a part of what makes us tick. One of my responsibilities is this clinic. My cutting down on the amount of patients I can see is not only detrimental to the patients waiting to see me, but also to my finding ways to function as normal as possible with my looming illness. Looking for bright spots in an otherwise ominous cavern is essential for helping with coping. This change is difficult to swallow. I try now to replay the melodic sounds of my oncologist as I remember her words. Today, reality is creeping in too much. I am ill. I have cancer. My life will be different. This cancer is constantly changing my definition of me. I need to find a way to be happy with my new definition and a way to feel good. I should have recorded my oncologist and just play her voice on an endless loop. But for now, I write and hope to find solace in the expression of my thoughts. Tomorrow is a new day.

The Call

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Post op day 7

Today I received a call from my oncologist. Her sweet voice started off asking how I was but then the unexpected came from her. My tumor was larger than originally thought. Her lyrical voice made it sound alright. She wanted to meet to go over the chemo protocol and we moved my appointment up to tomorrow. I hung up the phone and once I was no longer under her spell, I realized that the tumor was not just larger, but it was over three times larger. The 1.1 cm tumor was 3.5 cm. This will put me in a different stage. I will no longer be “Infiltrating Ductal Carcinoma, stage 1 grade 2, triple positive” . I will now be ” Infiltrating Ductal Carcinoma, stage 2, grade 2, triple positive” . Will my name change again after meeting with her tomorrow? What else will change?

There is so much unknown about cancer that I have found  grabbing onto anything that is constant helps keep me sane. However, small changes or even not so small changes can really throw me off. Often people will run to the internet and search the sea of information. It is difficult to navigate. There is so much out there. It is mind boggling. Even in my saner moments when I am reading for information for this website, I feel overwhelmed by the amount of information out there. It is crazy making trying to shift through the facts and the interesting but not proven, the completely untrue, and the dangerous.
I know for myself it is important that in this moment of trying to stabilize myself again, the internet is no place for me to be. It is a trap that is recommended by doctors to try to avoid. I give my patients and their families safe, well established websites for them to look at if they need additional information. But I ask them to try to stay away from searching the net – at least until they feel more settled. I also recommend that my patients be with friends that can give them some perspective about what they are looking at and to come to me with what they found so that I may help make sense of it for them. It is important that your doctor is willing to talk to you about what is out there for any diagnosis. It is important to have that relationship. The search for the cure or for help is natural and should be supported by your doctor. I am glad I have doctors on my team that I can ask questions and not feel judged. While as a doctor, I have a lot of knowledge about my cancer, as a patient I lose all of my medical knowledge. My doctors understand that and allow for my temporary loss of information. The urge to search is strong. The need to be able to cope is imperative.

Here are things that help me in my search for information

1. Try to find a doctor that you feel comfortable with talking to about your questions. You should feel comfortable approaching your doctor about any question and feel that your doctor listens and is not judgemental. Your doctor should be able to discuss your concerns and questions or know of someone who can help you, or search for the information to discuss with you later. This does not need to necessarily be your surgeon, oncologist or radiation oncologist. It could be your primary doctor. Sound medical advice is important.

2. Realize that the statistics about prognosis  include a large number of women that may have different treatment or differences in their illness. The numbers are going to include women who have a poorer outcome due to extenuating circumstances and not necessarily are reflective of what your prognosis will be. Do not get overly focused on statistics that show higher rates of reoccurrence. Talk to your doctor about your situation. The numbers are a guidance more for treatment decisions rather than a statement about your actual prognosis.

3. Many of the personal stories on the internet or on social media are stories when things go wrong.  Many people are looking for help or just wish to talk about when things go wrong.  These stories are obviously sad  and some are horrifying.  However,  this does not mean that the same problems will occur with you nor do these stories represent the majority of people’s outcome.  Your treatment and outcome may be very different.

4.  There is a great deal of non scientifically proven information out there. Even things that have some research may not have solid research and is only a possibility rather than a strong recommendation. Much of the information is only anecdotal, meaning some people report it. This does not mean that most people will find the same effect. There are a multitude of reasons why something may work for one person and not work for someone else. It is important to note that solid research will find things that are more likely to be effective than anecdotal reports. Also, I have often found that lay press does not accurately report the findings of research studies.  I will read the actual research and not rely on the lay press interpretation of the research.

Having some basic ideas of how to evaluate research is a good start when screening information on the internet or other sources. Here are some basic concepts for evaluating research.
1. Animal studies: many studies are done in mice or rats or other animals. While there are some similarities with animals the correlation is not 100%. Animal studies only give researchers a possibility of effect and will need human studies. It is not recommended to try something or eliminate something solely based on animal studies. Further studies with humans are needed.
2. In vitro studies: these are studies where animal or human cells are exposed to an illness or treatment and look at how the cell responds. These studies are mainly used as a starting point for further research and are not seen as definitive. How cells and treatment respond in the body (in vivo) may be different.
3. Human studies: There are a variety of types of human studies. A good description of the types of studies can be found here.

In general double blind studies or epidemiological studies such as a cohort study are more powerful studies. A double blind study is a method of studying the effect of a drug, supplement, or procedure where both the participants in the study and the researchers do not know whether the participant is getting the studied item or placebo. Studies with a minimum of 25 participants are better. Of course,  the more participants the stronger the study. Studies with less than 25 participants are too small to be statically significant. These small studies are good for giving clues for future research but you should not base a change in lifestyle or trial of a procedure, medication, or supplement only based on a small study’s results.

A cohort study is a study in which a group of people who are currently receiving a specific treatment, eating a specific diet or have a specific illness are followed over a course of time and compared to a group who are not receiving the treatment or have the condition. Cohorts studies are very powerful studies since they can be very large and can be participants can be followed for years.

Additional things that add power to a study include  accounting for factors that could be potentially affect the results of the study  and  how are outcomes evaluated, for example which scales or instruments are used or the manner in which information collected.

Anectdotal accounts (the most commonly found reports on the internet)  do not need to be discounted but it is important to remember that there may be a variety of factors of why someone may have benefit or seemingly have benefit from a treatment that will not correlate with it being effective for anyone else.  Sometimes these treatments may have dangerous side effects or be detrimental to your cancer treatment.  Research studies are needed to find the risk and benefits of any treatment. For example, antioxidants such as vitamin E can change the effectiveness of radiation therapy because it can act as a protectant for normal cells as well as cancer cells. It is extremely important that you let your doctors know about any supplements, vitamins or change of diet.

I have found that looking at the Cleveland Clinic  health library or Mayo Clinic , American Cancer Society, and  Komen  have solid information.  There are other sites such as Breast Cancer.org  that have very useful information but some of the information is not completely accurate and needs to be scrutinized.  To find research you can try Google scholar, Gigablast,  or NIH Medline. Your doctor will have access to research that is not available on the internet and may be able to obtain information for you.

The mirror

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Post op day 6

Today is the day. The day has come that I will actually look in the mirror. While I have showered, I have not yet looked at my breast in the mirror- full on to see the wound. I have looked at my port site in the mirror (mainly because it hurt and was red and I needed to make sure it wasn’t infected). But for some reason I have resisted looking at my wound on my breast. I was a lucky one that was able to get reconstruction at the time of surgery. My surgeon specialized in oncoplastic surgery (cancer reconstruction). She inserted in me a filler called Biozorb. Biozorb is a very cool implantable biomarker that will give a three dimensional marking of where my cancer was. It is made of “bioabsorbable” material that will fill the space from the lumpectomy, give structure for new tissue to grow and will provide a close approximation of the curve of the breast post surgery. It has titanium markers that enable the radiation oncologist to locate where the tumor was and provide a more targeted approach to radiation therapy. Targeted radiation means a better outcome and less risks. The bioabsorbable material will dissolve away over the year just leaving breast tissue and titanium markers. Pretty cool. Except, I have searched for what exactly is that bioabsorbable material and have come up empty.

With the BioZorb in place and a very small incision around my nipple, my breast should look very good. Except I resist. Even though I know I have cancer and have told may family, friends, and coworker, I seem to still wish to be at some level in a state of denial. The looking at my breast seems a way to not deny it any longer. I wonder if it is helpful to continue on with my small area of denial or if I should face it head on. I wonder how I will feel. Does this last remnant of denial allow me to have some corner in my mind of solace from the daily grind of dealing with cancer? It is a good thing or bad thing? There is no turning back once I look. Today is the day to look at my breast. Or maybe it will be tomorrow.

Independence

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Post op day 5

After sleeping for 4 days straight, I can no longer sleep. I am up before the rest of the family is up. I decided to make myself a cup of coffee and eat some yogurt- things that I had already set up to be able to do without anyone’s help. It really gives me a spark of hope when I can do things on my own. I tend to be a very independent person. Like many women I take care of a multitude of things at the same time- my household, my child, my husband, my work, etc. I had worked years without a medical assistant and when my hospital told me I had to have one I didn’t know what to do with her. She is great and found a way to make my work day better and really has added to helping support my patients. It took her a while to crack my independent, I don’t need help shell but she did and I am grateful for that. One of the things that I was most concerned about when I got my diagnosis was that I would have to rely on others. I would lose some of my self. It is a very daunting task for me to give up a part of me I am so comfortable with- a part that I am so proud of. My desire for independence needed to balance with my change in life and the need to let others do for me. One of my friends so aptly pointed out that I should allow others to do for me what I do for them that in this way I would in fact be helping them. Odd but true.

So what can I do? What can anyone do? Part of my own search for balance has to do with my understanding why I strive so much to be independent. What does that mean for me? Growing up, I was not very independent. I was very spacey and needed much help. I would get lost going to the bathroom. My parents tried desperately to teach me to be independent. I knew how to cook, clean, sew, knit, crochet, change my oil, change a tire, rewire a lamp, patch walls, repair a multitude of things in the home, but I still relied on others. My freshman year of college was an eye opening experience for me. I realized one day that I knew how to do many things but really couldn’t do them without someone telling me what to do. For all of my knowledge, I felt helpless and powerless. Independence to me meant not only growing up but it also meant empowerment. I strove to find my independence and by the time I graduated medical school, I decided I needed to really spread my wings more and I moved to California for my residency. Living in California was great. It helped to really form who I am today. But now I need to find a way to still feel empowered but be able to get help. That for me is a tall order. It has been over thirty years since that fateful day in college. Thirty years of being a strong independent go getting woman. Thirty years is a long time.

These are some of the things that I feel I must do to find my balance.
1. Find simple things I can still do for myself. Such as the feeding of myself with my yogurt that I have made or set up stations that are accessible for me like my coffee station or a place that fruit and nuts are that I can just pick up. I have clothing that is easy for me to put on and take off without much arm movement (still can’t raise my arms well).
2. Find new outlets to still feel good about what I do. This blog and website is a good example. Much of my identity is wrapped up in helping others and teaching others. Even though I cannot go to work right now, I can write and feel by sharing my story, I could be helping others as well as packing my site with information.
3. Understand that the support people wish to give me is due to love and not my own weakness. My friend is right. I have done much for others and rarely let others do for me. My letting them do is really good for them. I am still struggling with this concept but she is right.
4. Identify things that I feel I can give up to do for myself. Delegating is a skill I needed to learn at work, I can learn it in my personal life too. Starting small and working my way up to bigger things. This is clearly a work in progress.
5. Most of all I need to let go and not worry about theses changes in my life. I need to let my life evolve and learn from it along the way.

I am sure this will be a struggle that I will constantly be in throughout my treatment and beyond. It is a natural part of growing old. I always found it ironic how we do everything for our children as they grow up and one day they must take care of us. I see it time and time again with my elderly family members, friends, and patients. It is hard to give up independence.  But by giving up some of my independence, I am allowing others to show me their love.  Love is a very good thing.

GI distress post surgery

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Post op day 4

I have been progressively improving. Today I am not as fatigued as yesterday and I hope that continues. Pain is completely manageable without pain medication. I have been off the narcotic analgesic since post op day 1. I was on Norco (codeine plus Tylenol). However, my GI tract is very unhappy. I have continued rumbling and a mix between diarrhea and constipation. It really sucks to have both. GI distress is a common side effect post surgery. The more significant the surgery and the longer you needed to be under anesthesia the worse it can be. It is recommended that immediately after surgery you start out with light meals such as clear liquids and broth. You might be able to then move to a soft bland meal and progress from there. Often it is recommend to follow the BRAT ( banana, rice, apple, toast) diet the first day. If you can tolerate that well then you can expand your diet.

However, even with careful adjustment of your diet you can experience GI distress. This can happen due to a few reasons. Anesthesia can cause decreased motility (movement of your GI tract) which will can cause constipation. In addition the opioid medications used for pain control can cause constipation. It may help to try to decrease use of the opioid pain medications as soon as possible and switch to non opioid pain medication such as plain acetaminophen (generic Tylenol) or Ibuprofen (generic Advil or Motrin). You should still avoid aspirin.

Things you can do:
1. Try to get up and move. Movement helps increase GI motility.
2. Drink plenty of fluids: water helps with softening the stools
3. Limit medications that can cause constipation (opioid pain medications, scopolamine for example)
4. Limit caffeine intake or other stimulants
5. Don’t smoke

There are also some herbal remedies that may be helpful. I must qualify that I am not formally trained in herbalism or botanical medicine. I have over the years needed to learn about herbs and food to help many of my patients. I have many patients that have food sensitivities, limited food intake, or do poorly with medication and need other options. Refer to reference section for the list of books and resources I have used in the past.

Here is a brief description of some supplements/herbs you might try. It is important to clear any use of supplements with your doctor. Some of them can interact with medications you might be taking or are anticoagulants. Some of them are not recommended to take while pregnant. Also, some with interact with your chemotherapy. For a more complete description of each refer to the Supplements/herb page. There you will also find some recipes as well as how to use the supplement.

Fatigue

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Post op day 3

Today I am fatigued. I am completely and utterly fatigued. So much so that I have basically slept the day away. It is disheartening since yesterday I started off really well. I had my momentary small crisis but felt really energized after that in the morning and then progressively became more tired. Today, I can barely do more than eat. I have been up for about 3 hours total- about 1 hour for each meal I have eaten. It is 9 pm and I am finally writing because I slept most of the day. I had plans- many plans, but I had to readjust my thinking and realize my body needs to heal. I should allow it to heal.

Fatigue is a common symptoms post surgery. About 30% of people will be fatigued from just the anesthesia for a few days up to a few weeks. Unfortunately, the older we are the longer it might take for the anesthesia to fully get out of our system. Fatigue should be looked at in progressive chunks and not from a day to day progression. If you are less fatigued one day does not mean you will necessarily be even less fatigued the following day and you might be even more fatigued the following day. It is over the course of the week to evaluate whether you are overall less fatigued. If your fatigue is worsening over the weeks then talk to your doctor. There are a few things that can make your fatigue worse such as anemia or infection.

To help your fatigue, make sure you are eating well and drinking plenty of fluids. Some doctors recommend vitamins, but talk to your doctor first. Also make sure you get plenty of rest. If you need to go back to work but remain overly fatigued, then talk to your doctor about other treatments to help increase your energy and awareness. Some doctors will prescribe a stimulant medication but it depends on your circumstances and your doctor.

Setbacks

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Post op day 2.

This morning I woke up in pain. After minimal pain post op day1, I immediately went there- I am worse! I needed to collect my thoughts and I went and examined my wound site where the pain was. The pain was coming from my port. It has been red and I was monitoring it. I rushed to see the area and saw with much relief that it is less red but had a large bruise surrounding it. This is a normal part of healing. Nothing wrong. I let my breath out and sighed. I began to wonder though about set backs that women will go through. I thought about what would I say to my patient that had a set back with treatment. Setbacks can be both emotional and physical (medical). They are normal and it would be unusual if you never had a setback. It is important to recognize that and find ways to help yourself during a setback.

Here are some steps that might be helpful:

1. Understand the course of healing. Remember, sometimes perceived setbacks are part of normal healing. In my case, my increased pain came from my bruising and some amount of swelling. I had not been feeling as much pain and had stopped using pain meds and stopped the cold compress on post op day 1. Along with bruising is swelling of the site. Bruising and swelling should peak around 3-4 days. I was day 2, so increased swelling meant increased pain. My site is not more red nor is it hot. I am ok. I took some Tylenol and got some coffee.

2. Know when to call your doctor
Your doctor should give you an information sheet about what to look for and when to call. In general the guidelines post op are
a. Call your doctor for temperatures 101  degrees F or more. There is sometimes a slight low grade fever post surgery.
b. If you have increased redness that is spreading and hot
c. If you have new redness around the incision or there is pus coming from the wound or drain
d. Bleeding at the wound site
e. Swelling in your arm or hand that is worsening. Small amount of swelling is normal for up to one month post surgery and can be relieved with elevation of arm.
f. Increased pain not controlled by pain medications
g. Increased drainage from surgical drain (greater than 240 cc or 8 oz in 24 hours)
h. Misc problems such as shortness of breath, cough, dizziness

3. Eat healthy: it is important to continue to eat well. Make sure you are getting a well balanced meal. With decreased appetite multiple smaller healthy snacks may be easier than eating larger meals. You can check out my up coming wellness section for ideas.

4. Drink plenty of fluids. Being well hydrated can help with body functions. If you have had GI problems or any nausea or vomiting ,  replenishing fluids is the utmost importance. The new standard recommendations are to drink to your thirst meaning that you drink if you are thirsty. However, the exceptions are if you are immunocompromised, elderly, living in the desert area or undergoing chemotherapy you should drink 8 glasses of water a day.

5. Have a plan: Make sure you know who you can call if you have a medical or emotional setback. What are the emergency numbers? What are your doctor’s hours and who do you contact on off hours? Who can you call just to talk? Or do you feel better writing or going to a forum? Should you have wellness checks? Schedule someone to check in on you while you are going through treatment.

6. Make small goals. Often times when we don’t feel well, we cannot accomplish things we would like to do. This can negatively impact how we feel. Have some things preset up that can be goals you are happy with. For instance, I had premade individual yogurt servings (recipe in wellness section) and was able to feed myself. I didn’t have to depend on my husband and daughter for everything the first few days post surgery. That was a good goal for me and helped my mood. Find goals that are doable and set them up a head of time to make them possible

7. Use relaxation techniques such as muscle relaxation techniques or imagery.

8. Consider counseling, therapy, or support groups. You do not have to have clinical depression to go to therapy of any kind. Sometimes therapy can help prevent us from become clinically depressed. If you feel you are clinically depressed then please seek help. There are multiple support groups as well as places to get individual therapy. Resources such as the American Cancer Society can connect you with a local group. You can call your church and ask them about counseling services. You can also find local mental health services by calling a hospital near you that has mental health department. The intake for the hospital programs can also give you referrals to other community mental health centers. Therapy can be either supportive therapy (you talk to people for support and listening), Cognitive Behavioral Therapy or Insight oriented therapy. Cognitive behavioral therapy helps to look at our automatic negative thoughts (thoughts that come up automatically when something goes wrong) and helps to change them to be more positive instead. Insight oriented therapy looks at reasons of why your response is causing your mood symptoms and finds ways to change your patterns.