JOURNAL ENTRY #1

An uncomfortable clinic situation

January 2015
A female patient in her 80s was a two-site patient. We were
treating her spine and right hip; she had bony mets from her breast.
The bone is a common spread pattern for breast cancer. These
treatments were strictly palliative. After being treated for a week or so
the patient came in for her treatment. We started off treating her spine
then we would have the patient scoot to the end of the table so we
could switch to her hip set up. This particular day was the same as all
of the previous except for one thing. When we went to switch her set
up and treat her hip she complained about being a little nauseous.
Knowing this information we lied her down extremely slow and moved
the table slowly to decrease the chance of motion sickness.
Once her second treatment finished we moved the table down
and waited until it was in a stopped position to help her sit up. Another
therapist and myself attempted to help the patient slowly sit up. Once
she was seated she quickly had to be lied back down due to dizziness
and nausea. After waiting a few moments we tried again, with no
prevail.
After waiting a couple of minutes and trying once again to get
the patient off the table we got the doctor. She tried to lift the patient
with us and the patient insisted on continuing to lie down because of
her dizziness. After the doctor and us tried multiple times we finally
transferred the patient onto a gurney and called an ambulance. Luckily
there is a hospital next to the clinic and the wait was only moments.
This situation helped me better understand patient care and how to
handle a stressful situation.

JOURNAL ENTRY #2
November 2015/March 2015
Between every patient one of the other therapists or I wipe down
the treatment table and all of the immobilization devices used. On this
specific day we were running roughly 20 minutes behind and our next
patient was a female who was being treated for lung cancer. Pathology
was small cell. This patient from the beginning had been extremely
emotionally unstable and we always had to watch what we would say
to her for that reason. She came into the treatment room right after we
finished wiping off the table and there were a few watermarks that still
remained. She made a comment about the table being wet and asked
if it was from another patient, which we replied with no.
At this time its understood that one of the other therapists had
rolled her eyes when this comment was made. This particular day also
happened to be doctor day, where all of the patients would see the
doctor after their treatments. When we finished her treatment she
walked out of the room without saying a word, which no one really
thought much of because she was usually in a bad mood. None of us
knew anything was wrong until after she had visited the doctor. The
doctor had approached us about the situation immediately after and it
was deemed the other therapist should no longer be in the treatment
room while setting her up.
The rest of her treatments finished without incident. In March this
patient had returned for prophylactic whole brain radiation. The
therapist who had rolled her eyes also was unable to participate in this
patients treatment. This incident showed me that even if someone
does something and doesnt realize it, people are always watching and
will interpret things however they please. Its important in therapy to
always be respectful and kind to even the most difficult patients.

JOURNAL ENTRY #3
January 2015
Claustrophobia is a crippling fear of being in an enclosed or
confined space for a period of time. This patient had a particularly
extreme case. She was an older woman who had a head and neck
cancer. An aquaplast mask is a commonly used immobilization device
used today in treatment planning to keep the head, shoulders and
neck in the same position throughout the duration of treatment.
This patient from the beginning struggled heavily with the idea of
the mask. She came in for her simulation and wasnt able to calm
herself down enough to go through with it, which ultimately lead to the
simulation being rescheduled for a later time. The doctor at this point
had prescribed the patient Valium so she would be able to go through
with the simulation.
When the patient came back the second time, she was able to
make it through the simulation. We explained to her that the simulation
would be the longest she would have to keep the mask on and she
seemed relieved. We also cut out a portion of the mask for the eyes. A
couple of days later the patient came back for treatment and despite
taking a Valium prior, was unable to go through with it. We continued
to try with this patient on several occasions but she was still unable to
go through with it. The doctor ultimately decided if she couldnt do the
treatment with the mask on, there would be no treatment. So in
conclusion, we were unable to treat this patient.

JOURNAL ENTRY #4
October 2014
A few of the patients Ive experienced during my clinical
training have come in for palliative treatment and would be going to
hospice after treatment had finished. This one patient was a female in
her sixties who presented with stage IV rectal cancer. Her mass was
over five cm large and she had metastatic disease. We were treating
her pelvis to help relieve pain from the malignant process.
This patient came in everyday from the beginning in a
wheel chair, completely zoned out with absolutely no expression on her
face. She was on a lot of pain medication so the other therapists and I
assumed thats why. She never really spoke much and was barely able
to stand to get onto the treatment table. She was literally skin and
bones. After about a week of treatments she had eventually stopped
coming and was ultimately moved straight to hospice. This patient
sticks out in my mind because it was the first patient I had experienced
in clinic that looked and smelled like death. It really had an impact on
me.

JOURNAL ENTRY #5
December 2014
During my time in clinic Ive seen a lot of very large lung
tumors, this patients in particular had stuck out to me. Another
therapist and I had done his simulation together and on the CT both
noticed his mass took up literally his entire right lung. This was one of
the worst Id seen on CT and we were both shocked he came in without
oxygen, because we had seen patients with much smaller tumors
come in with oxygen tanks.
He started treatment a couple of days after the simulation and
we did daily CBCT on him. After about two weeks of treatment the
mass had reduced by at least half in size. After a couple more
treatments had passed more of a response showed. His chest/lung
capacity had changed so dramatically we had to do another CT and
treatment plan for him. This patient stuck out so much in my mind
because it was the first and only time (this far) that I had seen such a
dramatic response in such a short amount of time. It was a really good
feeling being able to see literally what you were doing to the tumor on
a daily basis. When the patient first started treatment he was short of
breath and was never really in the mood for conversation or anything.
As treatment moved forward and the tumor shrank in size his
breathing got much better and he was able to get off the table without
help from any of us, which he had previously needed. We could all
really tell what a positive effect the treatment had on him physically
and mentally.

JOURNAL ENTRY #6
November 2014
One of the more sad cases I had experienced during
clinical training was the treatment of a young woman who was only
thirty-one years old. She presented with primary liver cancer. We were
treating her abdomen and abdominal nodes to help with pain from the
malignant process. This patient began chemotherapy right before
starting radiation treatments. At the beginning of her treatment she
seemed relatively healthy for what she was going through, but that
would soon change.
A week into her treatments of both chemo and radiation she had
steadily begun to go downhill. We used CBCT on this patient daily and
recorded SSDs every five treatments. After the first week of treatment
we had noticed we were making extreme shifts from the CBCT and the
body contour was no longer matching up.
This patient had lost over 2 cm from her abdomen in a week of
treatment. This was the first and only time as of now I had seen
someone that needed to be rescanned because of extreme weight loss.
Once the new plan was made she continued to lose more weight, but it
was under 2cm and the physicist had approved the CBCT. This patient
was the first time I had seen such extreme weight loss in such a small
amount of time.

JOURNAL ENTRY #7
January 2015
This patient is also a first of mine. He was a 24 yr old male who
has had a history of cancer throughout most of his life, beginning with
Leukemia. He started off as a one-site patient, his wrist. There was one
major problem though, he was a massive man weighing over 350
pounds and only standing a mere 53. There was no way he would fit
through the CT bore lying supine or prone. After some critical thinking
and help from the physics team it was decided we would try to fit him
through the scanner lying on a vaclok on his side.
His arm would be outstretched on the vaclok so it was possible
for his wrist and a small amount of his upper body to make it through
the scanner. Treating this patient was also complicated. Between every
angle we had to go into the room and manually move the table so it
wouldnt collide with his body. There were also multiple times after
making shifts from the weekly port films where the table would move
and we all braced ourselves as his body shifted and couldve tipped
over the side of the table.
After a few weeks of treating this patients wrist we also began
treating his adrenal glands. This was also challenging because of his
weight. It was extremely difficult to get him on his tattoos and move
him on the table. Eventually this patient started coming less and less
to his treatments and then completely stopped and didnt answer his
phone after that.

JOURNAL ENTRY #8
February 2015
This patient presented with bony mets throughout his body. We
were treating a mass on his right rib; it was the lesion giving him the
most discomfort at the time. This patient was going to hospice after
radiation treatment so it was strictly palliative. Unfortunately the
disease progressed faster than the treatment could help.
During his treatments we had to stop multiple times because he
would move. There were more times than not he put his arms down
during treatment, we beamed off, and he refused to continue for the
day because of such extreme discomfort. Knowing his extreme distress
and him unwilling to complete any daily treatments, his family would
not quit. It was explained to the patient and his family multiple times
little to nothing is being done when he only would get through 1/3rd of
his daily treatments.
At this point it was decided to rescan this patient in a more
comfortable position he would be able to hold for longer periods of
time. This helped a small amount; he was able to make it through a
few of his treatments. He ended up completing his radiation therapy
treatment fractions.

JOURNAL ENTRY #9
March 2015
I decided to do my case study on a head and neck patient. He
had undergone radical neck dissection and chemotherapy and still had
recurrent cancer in his neck. I went in on his consult and I immediately
could tell what type of person he was. He seemed stubborn and
unwilling right off the bat. He didnt seem enthusiastic to begin his
treatment or to even be in the consult talking about it in general.
He came in for his simulation as scheduled, we told him we
would be contacting him once the plan was made and insurance was
approved. A couple of days later we contacted him and got no
response on his cell phone. The next day we tried again, and then tried
his home phone and his wife answered. She explained he was in denial
about needing treatment and was going back and forth with the idea.
In the consult he had been informed a lot of head and neck patients
need a feeding tube placed because of the major side effects from
treatment.
Eventually the patient began coming in for treatment. He
surprised us all and came every single day, never missed a treatment
and was on time if not early almost every single day. After treatment
began he did everything that was asked of him, he listened to every
request/ suggestion the doctor made. This patients dedication to his
treatment was quite astounding.

JOURNAL ENTRY #10

March 2015
This patient presented with rectal cancer that was confined to his
lower rectum. His treatment field required us taping his scrotum out of
the field, which was already a first for me. As a part of this patients
treatment he was going through chemotherapy as well as radiation
therapy. He ended up starting chemotherapy before radiation.
One day, around his second week of radiation treatments, this
patient came into the treatment room looking confused. He explained
that he had been watching his chemo pack and thought something was
wrong. He thought the drug was coming out too quickly; the pack he
was supposed to have on for a week had been nearly empty after only
24 hours.
After his radiation treatment with us that day he was scheduled
to go to chemo. The chemo office ended up calling us about an hour
later and explained the patient was correct, there was a major error
that had taken place. The patient was being transferred to the hospital
to have his organ function and counts monitored from the amount of
chemo drugs he had received in such a short period of time. This also
meant the patient was put on a break from radiation for a week as well
until the situation was figured out. No one wanted to risk the chance of
radio toxicity.