But wait, there's more . . .

A long day, starting with the usual blood draw, followed by a session of inhaling pentamidine (an antibiotic that should give me 30 days of protection against pneumocystis pneumonia), exit interviews with transplant nurse/coordinator and hematologist, and finally the removal of the Hickman catheter (aka the central line).

It turns out I'm not too good at this inhaling business. They positioned me in front of a hood (above which was a TV with some Discovery Channel show about surviving in Alaska) and handed me a plastic mouthpiece with small clouds of vapor pouring out, I was to stick this in my mouth and "breath normally." As soon as someone tells me to breathe normally, I have no idea how to breathe. Nose? Mouth? OK definitely not mouth. Nose is ok. Don't hyperventilate. Deep breaths. No, regular breaths. By this time and for the next 15 minutes I am totally lightheaded and never did feel right for the rest of the day. Meanwhile, the Alaskans had to kill their old milk cow in order to get enough meat to survive the winter.

The exit interviews started smoothly enough, with the nurse/coordinator giving us instructions that apply to most of the transplant patients. After a while, I remembered that the schedule was going to be different in the case of tandem transplants, although we hadn't decided yet whether to go that route. So that confused things.

Tandem transplants (in other words, two planned transplants within a short period of time) are kind of a weird idea.

Consider the basic transplant: first, you harvest a bunch of stem cells and freeze them. Next, you kill off the remaining stem cells in the marrow with melphalan. Next, you put the stem cells back in, and wait for them to grow. They grow, and you go home.

But a tandem transplant means that you give those cells a few weeks to multiply happily, and them you kill them. And do it over again exactly the way, except using a bag of stem cells that's been frozen for a couple of months.

So how could that be better? It turns out that the melphalan doesn't kill all the stem cells. Labeling studies seem to show that recurrent disease doesn't come from the transplanted cells, but from cells that survived the chemo. So the second transplant cleans up after the first, and the first batch of stem cells is sacrificed for the purpose. That's the theory. Personally, I'm trying not to feel too much loyalty to that first bag of cells.

The next piece of complexity is that the clinical trials that established that tandem transplants work better than single ones for people with disease like mine are getting a little old, many of the drugs have changed, and a lot of new drugs have come on the scene lately that seem very promising. So it's difficult to decide what to do next.

Working on it. Stay tuned.