Friday - September 07, 2007

Friday, September 7, 2007

Day +59.  From the surgeon’s and anesthesiologists’ standpoint, the surgical procedure is long and harrowing. Ultimately, Jessie ends up in ICU as planned, but it is a tough haul for today’s medical team to get her safely there. Tonight she remains stable, but in serious condition for the next few days, and won’t be released to 6West until surgical service is satisfied with her stability. (Although honestly, given the day’s events, she once more amazes people with her recuperative abilities once in the ICU.)

IMPOSSIBLE WITHOUT FRIENDS: As usual, kudos to our friends, who step into the breech. Our friends Martha and Betsy have come in and out of Boston today: Betsy gives platelets, Martha is making pickups and dropoffs of supplies. Maureen, of course, helps pack up room 614 and keeps mommy company until daddy can leave his office and come down for the majority of the day. The Hardie-Mohrlangs willingly offer Sarah their companionship. 

LUNG SURGERY SUCCESSFUL: After a morning of getting ready (being NPO after midnight, getting red blood and platelet transfusions starting at 3am, and flushing her ACE at 6am), she goes into the operating room at 7:30am. Nurse Caitlin comes into the hospital on her day off to keep Jessie company, and goes into the OR with us, to help Jessie go calmly to sleep. 

After preparations, the procedure starts around 9:30am or so. Basically, the lung surgery goes beautifully. Dr. Lillehei is able to perform a thoroscopy, which means using a scope to view her lungs and chest wall, and make smaller (less painful) incisions between her ribs to insert instruments and remove the affected portion of her lung. He removes the intact mass, which they continue to think may be an aspergilloma (ball of fungus). Only the biopsy will confirm this identification, and that may take a while. But the mass is gone, and her lungs are in good shape.

SUDDEN CHANGE, FROM STABLE TO BLEEDING INTERNALLY: They call us periodically from the operating room to provide updates. At 11am, they report that the lung procedure is finished, and they’re just closing up. An hour later, the surgeon and two transplant doctors come out to the waiting area. They’re all clad in blue surgical gear, and they’re clearly stressed. They call us into a consult room.

Her condition has changed drastically! She’s bleeding internally (her hematocrit drops from 30 to 10 quite quickly). Other indicators are concerning. Her belly is swollen and tight, and different diagnostics, including scans and sampling the belly fluid, shows that blood is collecting there. They decide that the likeliest culprit is her spleen. And the conclusion is that Dr. Lillehei has to go back in, confirm that the spleen is the source of the bleeding, clean up the internal bleeding, and correct the source of the bleeding if he can. They’re replacing blood and fluids as she loses them, but coagulation factors and clotting ability and other parameters are totally out of whack, so the anesthesia team struggles to keep her stable as Dr. Lillehei works.

They have brought the transplant team into the decision-making process, and the attending Dr. Sid Rao comes in and out of the operating room to assess Jessie’s situation and confer with the surgeon.

A few hours later, Dr. Lillehei reports that he has located the source of the bleeding, and is working to resolve it. We wait.

SPLEEN AT RISK: Her primary surgeon, Dr. Rusty Jennings comes out with a brief update. (He’s “surgeon of the week” which means he’s handling emergency cases and supporting staff with sudden problems such as this one.) The cause of bleeding is definitely the spleen, and they are trying to save the spleen. Both Sid Rao and Craig Lillehei feel strongly that it should be saved if possible.

Finally, Dr. Lillehei comes out to talk to us. By now it’s later in the afternoon. Jessie is stable enough to be transported to ICU, while Dr. Lillehei is speaking with us. He has repaired a laceration in the spleen (where lesions from candida were already present on the damaged spleen, making it exceptionally vulnerable). He has resolved the bleeding, and the anesthesiologists have stabilized Jessie. 

Jessie is at high risk for further bleeding into her belly. If this happens, they will have to perform a second surgery, and probably remove the spleen. If this situation occurs, it will do so in the first 1-2 days. So for now they’ll keep her in ICU under close monitoring and management, and hope that she remains stabilized. 

We work through shift changes and different rounds of doctors and nurses, expediting communication between the handoff from surgeons and anesthesia to the intensivists, with input from the transplant team. She has lots of visitors from 6West and the surgical unit, checking on her well being. The refrain? Wow, she looks GOOD! Apparently we all have a very odd sense of what looks good these days, because we agree. 

WHAT’S THE TALLY? She has additional incisions, such as a vertical one down the middle of her belly. Stitches inside and tape outside, plus dressings. She’s intubated. She has the arterial line, two peripheral IV’s, an NG tube, a foley catheter, a chest tube, and of course the PICC line in her arm and the central line in her chest. Plus the original 3 incisions from the lung surgery today. Staples in her lung. A repaired spleen. A resected lung. Monitors. Blood pressure cuff and O2 sat lead. 6 pumps. Plus lots of ancillary machinery measuring outputs and doing mechanical work on her behalf, such as breathing.

TALKING INSTEAD of SLEEPING: In ICU, they aim to keep her heavily sedated for the night, so she remains still and allows the repaired spleen to heal a little from the trauma. She fights the sedation, breaking through over and over to wake up and try to talk past the breathing tube. 

Daddy draws out the alphabet in a grid on a piece of paper, and she points at letters and spells out her questions. “How long will the tube be in? When can they take it out? How do they take it out? Can I have some water?” 

The staff is delighted to see how alert she is, considering the day’s events, but they want her to sleep. And she just doesn’t. And of course, she habitually tugs at tubes, so we have to gently restrain her hands by tying them. 

The team transitions to using an anesthesia for deeper sleep: propofol. This means that the ventilator does all the breathing work for her, while she rests and heals. 

If she remains stable through the night, without signs of bleeding, they may remove the tube on Saturday morning. Go, Jessie, go! Afterward, it’s a matter of being sure she’s not bleeding, and then she can be released back to 6West for further recovery.

Wow. 

CHANGE of ADDRESS: We are packed (thanks to Maureen Gedney), some bags in storage, a lot more going home again, and officially without a room assignment on 6West by noon. They’re shuffling rooms, and they’ll re-assign us to a different room over the weekend. Until then, we’re living in ICU anyway, out of a few brown paper bags.

Phones don’t work in here. Use email to contact us, please. 

THE REST of the WORLD KEEPS on TICKING: Meanwhile, Sarah has a day at school, then an afternoon shopping for soccer cleats, and a sleepover at friend Sidney’s house. We are glad that one member of our family is busily engaged in better pursuits than waiting-room waits and ICU advocacy.

CHANGEABLE: The situation changes quickly around here, as you can imagine. Pray for Jessie. Dream for her. Believe in her. She makes everyone work hard to achieve stability, but she responds and triumphs, over and over. Like today. 

It’s been a long day and a long night. We’ll post more tomorrow. For now, we’ll catch a little bit of sleep. We have a lot of work ahead! Zzzzzzzz?!