Laughing, Weeping, Living

Life happens. You laugh about it or cry about it, sometimes both.

All the Doctors and Nurses

And Nurse Practitioners and Social Workers and assorted Therapists.

Sydney knitted a beautiful prayer shawl, which we kept in Agnes' bed.

Sydney knitted a beautiful prayer shawl, which we kept in Agnes’ bed.

Agnes had a huge impact on many departments at Akron Children’s Hospital. I think there were only a couple units that had no dealings with her. On Friday as we were reflecting on Agnes’ life and preparing for her end of life, I began a list of all the people who have cared for Agnes throughout her life. I only wish I could remember everyone; there are many faces I can see in my memory, but I don’t know the names anymore. My family was so blessed by the sensitivity and concern of the PICU staff during Agnes’ final days. We are especially thankful for the nurses who spent shift after shift caring for Agnes during her final admission, particularly Eric and Kathy.

100_2019All 173 names I can remember before memory fails:

Katie, Maria, Nicole, Colleen, Lori, Kristen, Missy, Molly, Sarah, Susan, Linda, Allison, Kristi, Denise, Helena, Marlene, Denise, Hannah, Heather, Katy, Eric, John, Betsy, Matthew, Earline, Jackie, Betty, Susan, Reyhanna, Chris, Mary, Ashley, Jessica, Anna, Josh, Carrie, Laura, Kathy, Melissa, Karen, Tracey, Megan, Kristen, Vicki, Joanna, Megan, Dawn, Chelsea, Leanne, Amy, Lisa, Taryn, Elizabeth, Kari, Christian, Tara, Laurie, Ashley, Kayla, Julie, Kaylee, Chris, Nate, Rebecca, Julia, Christian, Wade, Brenda, Angela, Melissa, Zach, Jennifer, Angie, Ralph, Leah, Jennifer, Penny, Darla, Linda, Alyssa, Karli, Bridget, Amber, Lois, Christine, Amber, Cathy, Hannah, Carrieann, Amy, Karah, Melissa, Tammy, Kelly, Melissa, Joe, Beth, Melissa, Ann-Marie, Julie, Lisa, Sofya, Cathy, Tatiana, Kelly, Heather, Samantha, Joanne, Karen, Kevin, Tracey, Holly, Jenna, Caroline, Nancy, Leslie, Usha, Michael, Cathy, Dave, Mona, Mike, Emily, Jennifer, Marc, John, Tsulee, Kim, Cortney, Ryan, Chris, Urmila, Maria, Jim, Heather, Roger, Debbie, Vivek, Cassandra, Mark, Alison, Rajeev, Starla, John, Robert, Tim, Todd, John, Christine, Ted, Melissa, Gregory, Todd, Haynes, Scott, Becky, C.R., Vivek, John, Samantha, Wassim, Jaime, Elizabeth, Cooper, Jessica, Danielle, Stephen, Ibrahim, Andrew, Leslie, Patrick, Diana, Lauren…

Agnes' final footie sleeper. So perfect.

Agnes gets dressed to meet Jesus in a perfect footie sleeper.

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Terminal Again

This time it’s real. This time we have been instructed to choose a time and a place before Agnes chooses it for us. This time the treatments they try don’t work. This time her condition declines and never fully recovers, so she loses something each time.

The doctor told us she talked with all the other ICU attendings over the last 48 hours, and they all agree there is nothing more they can do. The doctor told us we are talking in terms of hours or days Agnes has left. The doctor told us the several episodes of Agnes declining are her body telling us she is done.

Agnes is done.

Done.

Now it’s up to us to let her go. We can try to plan for it by preparing a specific time with the pain-killer medicines needed, all the people who we want to be around, for us to be ready and present and not in the bathroom or down in the cafeteria when Agnes leaves this earth. The longer we wait, the likelier it is Agnes will choose her time, and we might not be there, or our priest might not be able to make it in time, or Agnes might suffer more because the medicine she needs to be comfortable won’t be at her bedside.

So.

How do I announce the death of my child before it happens? Doesn’t that seem weird to anyone else? All I can say is, she will probably go before the weekend is over. We tried to explain to Stephen that the angels were coming to take Agnes to live with Mary and Jesus in heaven, but I’m not sure how much he absorbed. We’ll try again. It was good for us to think about the angels, too. Agnes has one foot out the door, and we’ll stay with her and watch until she leaves with the angels.

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Up in the Air

There is not too much to report on Agnes since a few days ago, other than her overall condition appears to be stable and slowly improving. Yesterday she did very well maintaining a body temperature without the hot air blanket or the medicine that assists with perfusion. She is also in process of weaning down the hard-hitting narcotic pain killers. She is also clear of the intestinal infection that caused some swelling and “free air” in her belly. Her lungs sound back to baseline for her, which is to say they are stiff and slightly diminished on the left side, but at least she’s back to “normal.” She is happy on her home ventilator.

But today they decided to try stimulating her guts by starting tube feeds at a very slow rate, and she didn’t like it. She spiked a temperature and some formula seeped back out to her stomach where it appeared in the suction tubing. I guess that’s the nice thing about Agnes’ G/J tube: you can feed her guts while leaving the stomach open to suction, which helps prevent throwing up. So Agnes demonstrated an intolerance to food, so they stopped feeding her. I’m not sure what the plan is for restarting.

Plus it is not clear whether her shunt is actually working or not. I do believe that it was functional at the time of the CT scan a few days ago. But in the meantime, the neurosurgeon tapped off some fluid and that procedure demonstrated a very high level of pressure in Agnes’ ventricles. Plus today she was very sleepy. So…I guess we’ll see on Monday what the next CT scan shows.

All in all, we are still in a grey area. Agnes did improve her condition since last week; she is like a new baby! We are grateful for that and happy that she didn’t die. But as we go on, it is not clear whether this recovery is lasting, or if she is on her way to a relapse. We are very conflicted about how to proceed here. We were sad she was dying, but also a bit relieved that she wouldn’t have to suffer anymore. Now that she got better, it feels as if we are traveling the same road again, the road of suffering. The fact that Agnes did recover is a miracle and the mid-week news that her shunt was working felt like another miracle. Those events happened and many people derived spiritual benefit and faith, and trust in God because of those events. Now we know that thousands of people are praying to saints and to God on behalf of Agnes and our family, which is amazing. Even if Agnes takes another turn for the worst this weekend, that extra week she was here brought boundless grace to thousands of people. Who knows what she will do from this point forward, but every day she is here is a gift and an opportunity to draw close to the Lord and experience grace.

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9 Lives?

So…Agnes is not dying anymore? Maybe? At least not soon? Maybe?

Agnes is very slowly crawling back from the edge of death. The doctors have been able to turn off a couple of the medicines, and reduce some of the ventilator support, and take off a lot of the fluid that had built up in Agnes’ body.

It seems as if Agnes is enjoying another of her many lives. Make no mistake: Agnes is still very very sick and it is entirely possible if not probable that she will not make it home this time. But, there is a hope that she will recover. There is a small chance now that she will become well enough to live at home again.

Since she seems to be on the mend, Jeremy and I have to start making decisions about her care again. We can’t ignore the shunt anymore. We already know it isn’t functioning, so we have decided to try again with the plan we developed before Agnes decided to have a near-death experience. The neurosurgeon will get a CT scan tomorrow morning and depending on what that shows, and depending on Agnes, she may go to surgery for a shunt revision Thursday or Friday. The neurosurgeon will lengthen the catheter in Agnes’ heart so hopefully it won’t pop out again. If it does, we will know without a doubt that a VA shunt is no good, and we will have to make some serious decisions. But, at least we will know for sure, having given the VA shunt every opportunity to work.

It is strange territory, where we are. On the one hand, we know Agnes has an underlying condition that is terminal. On the other hand, she does not appear to be more ill than she has at times in the past. What should we choose to do? Should we aggressively treat her, knowing that anything we do is merely a band aid? Should we leave her alone and keep her comfortable while her body fails at an unknown pace? This is really hard.

We still have a lot to decide, and the goal line is definitely shifting every day. That is really hard, too. For the present, we will address the urgent issues like her shunt and her respiratory status, and see what she does.

I know I’ve said it before, and I’ll say it again right now: MIRACLE. Agnes was more or less dead and now she is not. We have been given an opportunity that we don’t want to waste. It is clear that Agnes has more work to do on this earth. I can’t even believe the number of people who are praying for her and for our family. It must be thousands with friends and family, and friends of friends of friends… and all over the world, too. It is amazing that such a tiny, sick baby can inspire so many to seek God through prayer. Agnes is truly helping to save souls. Her suffering is bringing graces to thousands of people. That is a miracle, too. There are so many hearts united in her cause. How can we not believe in the power of prayer, with what we have seen in Agnes’ life?

Slowly recovering from near-death.

Slowly recovering from near-death.

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Terminal

Yesterday Agnes took a turn for the worse. Her overall condition has been described to us as “critical stable.” And, “fragile.” And, “terminal.”

We have heard the words, “there is nothing more we can do except help her to be comfortable.”

Agnes is comfortable right now, and she is stable within her very fragile balance, but it is also clear that her body is failing.

After all this runaround about her shunt, it turned out not to be the deciding factor. Her ongoing trouble with pulmonary hypertension is what now her “terminal” condition.

In a nutshell what is happening is the pressure in the blood vessels going to her lungs is so high, that the right side of the heart has to work extra hard to move blood. The right side is enlarged, to the point where the left side is being compressed. Agnes’ heart isn’t able to keep up and so blood is backing up in her veins, unable to get to the heart to be re-oxygenated and sent through the arteries to her her body. Blood is backing up and with nowhere to go, fluid from her vascular system is seeping out into her tissues. The slowdown in circulation is affecting her organ functions. There is not enough blood flow to her liver, kidneys, and intestines. She is not absorbing nutrition from food, or her medicines. Her lungs are very stiff because of the inadequate blood flow so her ventilation needs a lot of support.

They could try to fix her shunt, but with organs in the process of failing what good would an operational shunt do for long term? The shunt is small potatoes. The biggest issue now is that the problems are affecting nearly every system in Agnes’ body.

She is dying.

There is always time for a miracle, and we haven’t given up hope for one. We are also talking with palliative care about Agnes’ end of life options and what we feel like we could or should do. We are always striving to make the best choices for Agnes. Right now she is behaving so we have some time to think and pray. There really is no telling how much longer Agnes will hang on. She is the boss lady. In any case it does not appear at this time that Agnes’ death is imminent–at least not in the next day or two. So that’s a relief.

Fr. Sal did allow her to receive Eucharist last night, in her own way. She got to lick the Body of Christ and I consumed the rest of it. I know she doesn’t need that sacrament because she is a baby and pure and sinless, but I wanted her to have it.

I do plan to write a beautiful post about what I’ve learned from Agnes, about the meaning of suffering and the power of prayer and all that stuff. When I feel like I can get through it! Hopefully I will be able to manage that soon.

Thank you all for your continued prayers.

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Stupid Shunt

Agnes was home for one week then on Monday morning early she was up to her old tricks. The overnight nurse did something like change a diaper or reposition Agnes, and she got mad. Her O2 saturations dropped and they wouldn’t come back up. We tried a bunch of stuff. She puked. We called in and they told us to go to the Emergency Department. We arrived and prompted a flurry of exciting, critically urgent care. They rescued Agnes with aggressive treatment. Agnes was admitted to the PICU. X-Ray and CT films were taken, cultures sent away to check for infections, heavy-duty hospital ventilator was fired up and Agnes got snuggled in for a inpatient stay.

We were hoping all her outpatient follow ups we had scheduled for this week would have satisfied her longing for hospital life, but she missed her favorite PICU staff. She must have heard that her favorite intensive care doctor was attending on Monday morning or something.

Anyway, to make a long story short it ended up being a shunt malfunction at the root of her distress this time. Plus a bit of an upper respiratory infection (read: a “cold”) thrown in for fun because why go halvsies when you can go all the way?

The neurosurgeon repaired Agnes’ shunt yesterday by replacing the valve and flushing out the two sides of the shunt tubing, but today it appears the problem is not solved. The brand new valve works great! The shunt is still not draining out her brain juices, though. So the neurosurgeons have three more things to try:

1. flush the distal side of the shunt tubing (the end that goes to Agnes’ heart) with an anti-blood clotting solution to break up any clots, if there are any. It is possible there is a small clot in the catheter that is preventing flow. They will try this tomorrow (Thursday) morning.

2. go to surgery to reposition the distal side of the shunt tubing deeper in Agnes’ heart so that the high pressures in her heart can not push the tubing out of place. They will try this Friday.

3. if those two solutions fail to produce a working shunt, the last thing to try is placing the shunt to Agnes’ gall bladder. This is very uncommon and has an iffy rate of success in even the more favorable patients. The neurosurgeon said he hasn’t done one of these in years. Also the risk of infection is much higher because…gall bladder. They will try this if/when the VA shunt proves a failure.

And that’s the end of the line. If Agnes burns through that short list of options we are done. There is nothing left to try on the cure-focused path and we switch by necessity to the path where we keep her comfy and manage her symptoms until she dies. We did start the conversation about hospice options today, just to start gathering information.

Jeremy and I are both very sad. Given Agnes’ history with her shunts, there is only a slim chance any of the final three options will work. There is still opportunity for a miracle, but I’m not counting on it.

Of course we remain grateful for your prayers. We are counting on them at this point. We don’t necessarily want prayers for healing; that is not realistic. Prayers for strength and discernment of God’s will would be lovely. Prayers for the doctors and medical staff who will be talking with us in the coming days and weeks. Prayers that we will always choose the course of action that will be best for Agnes. Prayers that we will feel peace about the decisions we make. Prayers that we will know it if the time comes when we must let go of Agnes’ earthly life.

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Christmas Surprise

On Christmas Day, we were in the midst of Agnes’ shunt saga and coming home was not even on our radar. We went to church and had a nice family dinner, we visited Agnes in the hospital and wondered how her shunt surgery would go on the day after Christmas. We snapped a few photos:

Merry Christmas from Agnes in her cute booties.

Merry Christmas from Agnes in her cute booties.

After Divine Liturgy on Christmas morning.

After Divine Liturgy on Christmas morning.

Agnes did do well with her shunt surgery. So well, in fact, that she was transferred out of the PICU on Saturday, while the rest of us were in Perrysburg, OH for a holiday gathering of extended family. I got a picture with my grandma:

Four generations: my grandma, my dad, me, Stephen.

Four generations: my grandma, my dad, me, Stephen.

When we came back to Akron and visited Agnes on Sunday, several people asked us if we were still planning to take her home that day, as in Sunday. Um…no that’s not really possible. We thought maybe by Tuesday all the home care stuff would be organized; that’s what we were expecting.

On Monday morning, I went with Stephen to visit Agnes while Jeremy took care of some car business at the BMV. As soon as I arrived at the hospital, before I saw anyone or spoke to Agnes’ nurse, I got a call from home with the message that the home care agency would be out at our house to reopen Agnes’ case since she was scheduled to come home that day, as in Monday. Well, that was news to me. So I called Jeremy and told him to bring all of Agnes’ travel gear when he was done at the BMV.

It was a whirlwind, but we still managed to keep the tradition of discharge-day photos:

snapped a selfie

snapped a selfie

daddy wanted to do a selfie, too

daddy wanted to do a selfie, too

We brought Agnes home in her Christmas present minivan, and she did a great job. No crying, perfect O2 sats, no puking. She has been very stable since coming home. She has been able to sat 100% almost all the time on a mere 1 liter of oxygen, which is something she was never able to do. Not since the week or two immediately after coming home with a trach only.

I can’t even believe she came home after only two weeks in the hospital. I am still amazed by what seems to be a miraculous recovery. It is hard to believe that only two weeks ago, she was so sick we were talking about what to do if it was The End, and the social workers were whispering “hospice care” to each other. And now, she seems to be healthier than ever, at least from a respiratory standpoint. She still has a bit of mysterious distention in her belly, which can’t possibly be shunt-related anymore since the shunt is now in her heart. If it’s not brain fluid, then what is it?

On the one hand, I am thrilled to have Agnes home and I want to relax and settle in to a routine at home, and feel like a “normal” family, as much as we can. But on the other hand, I keep expecting Agnes to pull a fast one in two or three days, “I told you so!” and end up back in the hospital.

Only she knows the truth.

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Agnes’ Tricky Shunt Surgery: UPDATE

Agnes’ shunt surgery yesterday afternoon was successful. The surgeons were able to place a V-A shunt on Agnes’ left side without a problem. This morning they sent Agnes to do a head CT scan just to check up and everything looks like it is working.

Of course, the big unknown factor is Agnes’ pulmonary hypertension and whether the pressure in her heart will prevent the shunt from draining properly. This may take a while to develop fully, but things appear to be working at this time. My feeling was that if the shunt didn’t fail right away, we have a pretty good chance that it will continue to work. Agnes has been more awake today and she got mad a few times, and the shunt still appears to work, so I  am encouraged.

In other good news, Agnes got back on her home ventilator today, her tube feeding is back to her normal rate and schedule, all her home medications are going without any problems, she is tolerating routine care like baths, diaper changes, and trach care. Her incision sites still look gross of course, but they are healing according to expectations. Her belly is soft again, though still a bit more distended than what her normal should be. No one is concerned because that distention she had was more than likely shunt-related, and now that issue is resolved. It will take a little time for her fluids to balance out again with all the recent changes in shunts and other drains.

To top off the surprising news, we were told today that Agnes will move out of the PICU and up to the regular floor for trach and vent dependent children. This is mostly because the PICU is full to capacity and they need Agnes’ room for an incoming, critically ill child, but it is all because Agnes continues to improve and the PICU isn’t doing anything for her that she can’t get on the regular floor.

And finally, word on the street is that Agnes will come home next week. Like, early next week. Like, if she continues to do well and the shunt appears functional, and all the home care gets organized, she could be home for the New Year. Whoa.

We were expecting Agnes to have a Nissen wrap surgery this admission, as well as an I.V. port installation, but those two things now seem to be optional at this point. The intensive care doctor is convinced that Agnes’ recent gastro- problems were a result of the extra fluid in her abdomen, and now she is tolerating food well, and everything seems to be normal in that area. So, a Nissen is not indicated. As for the I.V. port, that may be something for Agnes in the future, but it is not emergent and can definitely be scheduled if and when the need arises. Plus, the neurosurgeon wants Agnes to have a chance to totally recover and heal from the shunt surgery, so we’re looking at weeks at least if we decide she needs the other stuff sooner rather than later.

So.

Big news.

We are shocked still, and we can’t even feel excited or happy because this is so unexpected. I am convinced there was some miracle here. The story changed way too quickly to be entirely medical. Someone out there must be a really fervent pray-er. Or some saint intercessor is very powerful. I guess we’ll never know the agency of this miracle. God is good.

Thank you all for your prayers. Obviously they are working!

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Agnes’ Tricky Shunt Surgery

So on Tuesday, the neurosurgeon and the general surgeon went into Agnes’ surgery together to place a V-A shunt through her right side jugular vein. When then assessed the location with ultrasound, they were not pleased with what they found. The jugular vein is more or less destroyed on that side because of the heavy-duty I.V. Agnes had while inpatient at the NICU, so the surgeons were not able to thread the shunt through on Tuesday. There was another possibility on the right side of Agnes’ body, another large vein that would be a less direct path for the shunt, but still acceptable. So they assessed that location, and they were unable to thread the shunt in that vein as well, for whatever reason. Agnes has always been a difficult gal to stick I.V.’s or draw blood, and I’m sure this was the same kind of problem. With one thing and the other, it took them 2 hours to get to this point in a surgery that should have taken just over one hour.

So the surgeons decided to give up and leave Agnes’ shunt externalized. They did look at the veins on the left side of her body while she was sedated in the OR, just to preview other possibilities, and they thought there were a couple promising sites, but they didn’t want to go for in on Tuesday. Agnes was in surgery for an excessive length of time, with a whole parade of surgeons and other assorted characters in and out of her operating room. Her neurosurgeon didn’t want to take the risk and install a brand-new left side shunt only to have it become infected due to the semi-chaotic circumstances of her surgery. They are so careful to do everything sterile, but mistakes can happen, especially when there is so much going on around you. So, they will put the new left side shunt in tomorrow (Thursday) at 12:00pm noon.

Obviously we wish the Tuesday surgery had been successful, but at least they did not give up on the V-A shunt idea. And at least they didn’t put the shunt in a less than favorable location only to have it fail right away. That’s looking on the bright side. Tomorrow they will start fresh, with their goal in sight, and hopefully the surgery will be quick and they can do what they need to do without any more funny business.

12:00 noon Thursday. Agnes’ shunt surgery. Praypraypray that it works out!

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Back For More

Today we had a big Family Meeting that included Jeremy and me, many people from the Palliative Care team, the attending PICU doctor and a PICU Nurse Practitioner, and the neurosurgeon and his Physicians Assistant. It was a full conference room.

We talked about a few major items.

Smiling in her sleep.

Smiling in her sleep.

1. Agnes’ shunt. This is the determining factor for her, going forward. It will be what limits her progress and dictates what further steps need to be taken. Tomorrow (Tuesday) at 12:00 noon, the neurosurgeon will replace Agnes’ current shunt with a V-A shunt, which will drain Cerebral Spinal Fluid directly into the right atrium of her heart. This type of shunt is already not a super good choice, and in Agnes’ case it could fail right from the get-go, because Agnes has increased pressure in the right side of her heart due to pulmonary hypertension. The pressure difference may not be great enough to allow the shunt to drain properly. If this turns out to be the case, we could know within a few hours to a day that the shunt will not work. If the pressures are kind of borderline, it might take a longer period to know whether the shunt will work or not. Or the shunt may work indefinitely. The neurosurgeon could not make a prediction. My personal feeling is, if the shunt does not immediately prove to fail, I think it has a pretty good chance of working out long term. That is not based on any medical facts, just my own gut feeling.

2. What happens if the V-A shunt does fail. There are two more obvious solutions for shunt placement. When I say “obvious,” I mean for a neurosurgeon. No one else has heard of them and there are a list of reasons why. The first alternate option is to drain the shunt to the gallbladder. The final option is to put the shunt in a major vein in the head. The gallbladder option may work for Agnes if needed, but it has some of the same concerns as the V-A shunt, infection risk and inability to place extra catheter. The brain vein option is not really available because as Agnes’ neurosurgeon put it, if the shunt doesn’t work in a major vein in her chest, what makes us think it will work in a major vein in her head? If those shunt options are exhausted, there is really no where else to go and we would be at the end of the line.

Her smiles are so sweet!

Her smiles are so sweet!

3. How close are we to the end of the line. As I said before, it really is dependent on the shunt. Agnes does not have any terminal condition at this point. Her respiratory failure and pulmonary hypertension are being managed with significant yet not extreme measures. There is no reason to think at this point that her conditions–apart from the shunt–cannot continue to be managed. There are a few other interventions that are possibly in Agnes’ future, such as a Fundoplication (Nissen) wrap to prevent reflux and a permanent I.V. port to facilitate access for medicine and blood draws. Those options will be open for discussion once Agnes has a chance to recover from the V-A shunt surgery. In the meantime, Jeremy and I have made it clear to all the doctors that all available methods are to be used in preserving Agnes’ life. We can revisit the question later if we start to feel like things are being done to Agnes rather than for her.

The meeting was good to have, even if no new information was uncovered, just to get all the teams on the same page. And now they all know they are supposed to do anything if Agnes has a crisis. I feel good leaving things at that point for now.

For a prayer request, could you please pray that the V-A shunt works? That seems to be the cutoff between not-extreme and extreme care. Mary, Mother of God, pray for us. Saint Agnes, pray for us. Saint Maria Goretti, pray for us.

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