Thursday, April 30, 2009

I want my Ava back

This is the third entry that I have written for this evening. Each time I have struggled with what to write, what to share, and what to keep private. My internal debate struggles between trying to be supportive, trying to give hope, trying to be the historian of this tragedy, and just trying to tell things how I see them. I will likely fail at some point if I try to do the first three. It seems to me that the beauty of something like this is the rawness of it. It is up to you to do with it what you will. It is up to you to see the goodness or ugliness of it. It is up to you to decide its value and impact on your own life. It is up to you how your life will be different because of it, if at all. I can only tell things how I see them. So this is how I see them…

Ava is still in bad shape, despite the gains of the past week. I think that it is important for you to understand Ava’s condition so that you can have a framework from which to work. Ava opened her eyes for the first time just a few days ago, and this was an amazing achievement, especially given that the discussion in the ER Thursday night was, “Prognosis is very poor. She likely won’t survive.” Ava has suffered a tremendous head injury and has an infarcted (dead) area of brain as a result. (We discussed this two days ago… the occipital lobe infarct). While Ava has opened her eyes, it is not the same as when you wake up your two-year old and they are a little disoriented. They look around the room a few times, thinking “where am I?” Looking inquisitively at you, thinking “who are you?” You know that they are registering their environment and will make the connection very soon and be the same loving child that you knew before they went to bed the night before. This is not so with Ava right now. She can open her eyes but stares blankly ahead. Her eyes do not track and it is unclear what she is registering. She has some spasticity of her arms and legs. Her fists are clenched tightly. Her arms are tense. Her legs are firmly extended and her toes pointed, as if she were trying to stand on her tippy-toes. These things are the result of a bad head injury. I am not trying to bring you down, but it is important that you know the reality of what is ahead of this family. Ava will survive, this is clear… and for this we must thank God, but the road that is before them now will likely be long, and all of us will be needed.

Ava has already had special shoes ordered to help flex her feet into a normal position and help minimize the contractures (shortened muscles) that will likely result from her immobilization and spasticity. The necessary physical therapy will be demanding. I helped flex her legs and arms yesterday. This is not like moving the limp arms and legs of your kids when they are asleep. This is the equivalent of you trying to move their arms and legs when they don’t want you to. Please do not be lulled into thinking that the sequence of events will be… 1. “72 hour window.” Check. 2. Extubation. Check. 3. Go home and life is grand again. This child has a lot of recovering left to do, and there will be many difficult days ahead for Traci and Manny both. We cannot forget this. They will need us even more in the coming months.

I went to the hospital to see Traci, Manny and Ava this evening. Jennifer had told me earlier in the day that Ava had several seizures through the night and that as a result, she would not be extubated today. I was disappointed and reminded of a conversation that I had with Traci last Friday evening. “Fred, do you think that she will be alright?” “Yes, but it isn’t going to be easy all of the time and it won’t happen right away. Recovery is often two steps forward and one step back.” This is how the past two days have been. Yesterday we were all so hopeful that she would be extubated today, only to find that not only was she not extubated, but now she is having seizures! One step back.

Ava was started on an antiepileptic medication today because of the seizures. As a result her ability to breathe on her own was affected early in the day, and she was not able to be weaned from the ventilator. She just couldn’t wake up enough to do it on her own. Her doctors offered to try again later in the afternoon, but Manny declined out of concern for her tiring-out and then needing to intervene in the middle of the night, when there is only partial staffing to address the problem. It is almost always better to address these issues early in the day, when there is full staffing, their minds are fresh, you can be better rested and have your wits about you in the event that you need them.

When I arrived in the PICU, I saw Traci sitting in a chair facing Ava’s bed, holding Ava. Ava was reclined across Traci’s lap and facing the doorway. The green and yellow lights of the multichannel IV pump was a backdrop, silhouetting her head. Traci had clearly just been crying. Her eyes were still wet and her face was somewhat reddened. Traci had her left arm supporting Ava’s head and neck and her right arm wrapped gently over her, caressing Ava’s arm and face. The endotracheal tube remained in place, with the piston-like sound of the ventilator in the background. Manny’s mom and Traci’s aunt Diane were standing off to the side of the room. Everything was so quiet. No one was speaking. Manny’s mom was standing to the side wiping a tear from her eye, watching Traci. Aunt Diane was also watching her, silently. The nurse was at the head of the bed adjusting the tubing from the ventilator. Traci was staring at Ava through teary eyes. I felt like I had just walked in after some terrible news, and that I was the only person in the room who didn’t know. I waited there quietly for several minutes before anything was said by anyone. I couldn’t help myself any longer, “How is everything?”
As it turns out the tears were joyful, as Ava had just been put in Traci’s arms again for only the second time since being hit by the car last Thursday. We sat and talked for a little while. Her emotions ranged widely. Anger and guilt, sadness and joy, hope and sorrow. So much pain still encircles them. So much uncertainty still lies before them. It is my belief that we need to continue to encourage Traci and Manny to talk openly about these things and not try to fix them. They are entitled to their sorrow and need to get it out if they are ever going to be able to get past it. But what do I know?

I just know that I sat there with Traci tonight as she cried, “I want my Ava back,” and realized that I couldn’t make that happen. All I could do was listen, and that that was okay. Please continue to pray for them and hope that tomorrow we take two steps forward.


Care Calendar

First off, we can’t thank you all enough for the generous outpouring of love and support you have shown the Lopez family. It is overwhelming. We have all been forever changed by Ava’s story. As parents, we want to shelter our children from harm and make them all better when they’re hurt. Ava has an incredible team of doctors/nurses who are doing everything in their power to heal her. So many of you have called on our Heavenly Father to protect Ava and provide strength and healing. In just seven days, God has performed miracles and we know this is just a small glimpse of what is to come.
During these times of crisis, it’s wonderful to see humanity at its best. Many of us feel completely helpless and are yearning to do something. Manny and Traci have an incredible support system of family and friends around them, but it is our duty to ensure that we keep them healthy when their physical and emotional health is compromised.
If you or a few families would like to provide dinner to the Lopez family, please log on to with the following credentials:
Calendar ID: 15804
Security Code: 9927

Once you have scrolled to the May calendar, you will notice that the word dinner appears every other day, beginning tomorrow, May 1st. Once you have found a date that works for you, make sure the word dinner is in red. If the dinner appears in green, then it is already covered. After you click on the red dinner, a screen will appear prompting you to enter helper information (ie. Name, Main Dish, Phone and E-mail). Please be sure to enter the Main Dish you are preparing to avoid overlap.

Our goal would be to have a 5-6 person dinner delivered to the Lopez home around 7:00pm every other night. In the event that a family member is not able to be at the home, a close friend will be there to intercept the meal.

This is one less thing the family would have to worry about as they focus all of their attention on getting Ava better.

If you have any questions at all, feel free to contact me (Kerri Thompson at 210-764-1252 or Until we have a P.O. Box set up, you may send mail to:

The Lopez family
c/o Kerri Thompson
18414 Rogers Place
San Antonio, TX 78258

I will ensure everything is taken to the Lopez’ home.

As new needs pop up, we will continue to use the calendar for these requests. Thanks again for all of your love and support.

Wednesday, April 29, 2009

Awaiting Extubation

Tina Fraser has made a very important contact for us that you all need to know about. Melissa Montgomery is an activist and speaker for MADD (Mothers Against Drunk Drivers). MADD is a group with much political clout and can help us make sure that this tragedy is not merely given lip service and forgotten. Far too many families have been affected by drunken driving and every effort should be made to put an end to it. If even only one life is saved by MADD’s efforts and our own, then it is worth it. Please e-mail telling her that you are concerned about Ava Lopez and the Lopez family and that you want the District Attorney to pursue this case, in an effort to prevent and deter future such tragedies. Please include your name, phone number and/or e-mail address. This is the equivalent of an electronic petition. Please do this for Ava. Much appreciation to Tina for getting this information.

Tonight we should talk a little medicine. For those of you who want the short and sweet… small gains continue to be made. They were not able to take Ava off of the ventilator today, but will try again tomorrow and are very optimistic that they will be able to do so. She is slightly more alert than yesterday, but is still not tracking people or things with her eyes. Her chest x-ray was a little better, but she continues to need suctioning pretty often to get some of the secretions out of her lungs. Manny and Traci’s spirits are very high. They look GREAT! (I feel like Tony the Tiger… “They’re GREAT!!”). They are so happy now that they know they will have a future with Ava, regardless of the obstacles they face getting there.

For those of you how are interested in a little doctor/nurse speak… read on.

I have mentioned previously about the endotracheal tube, the ventilator pushing air into Ava’s lungs, the need for the ventilator to push air into her lungs because she would not be able to pull air into her lungs on her own; given her injuries to her rib cage and lung. We should discuss extubation (removing the endotracheal tube and ventilator support)and weaning her from the ventilator.

Getting her through the “72 hour” window was objective number one. Check.
Objective number two is getting her off of the ventilator and getting her breathing without assistance.

Why is it so important? The longer the tube stays in, the greater risk of further infection and the greater chance of causing the trachea to scar and narrow. The longer she stays on the ventilator the greater the likelihood of damaging the lungs. And, of course, she must be able to breathe on her own in order to go home.

We rarely ever actively think about breathing. It just happens. Take a few slow, deep breaths with me and pay attention to the following…The diaphragm contracts and pulls the lungs down. The intercostal muscles (muscles that connect between the ribs) contract and pull the ribs up. These two things together do one thing… they increase the volume in your chest. The diaphragm goes down. The ribs go out. Physics again. If the volume in your chest increases, then one of two things must happen… either the air pressure in your chest goes into the negative (like trying to take a breath with your hand over your mouth and nose), or air gets pulled in (breathing). Fortunately for all of us, it is almost always the latter of these two.

Why even mention this? It is to help you understand why getting her off the ventilator can be difficult. If you have ever been sick and stayed in bed for a day or two, you know that when you try to finally get out of bed, your muscle tire very easily. You haven’t used them. Your body has quit wasting resources on what you are not using, hence your muscles weaken. Breathing is not much different. As the ventilator has assumed the job of getting air into her lungs, her diaphragm and intercostal muscles have not needed to work, hence they weaken.

So how do we know whether or not she can breathe on her own? Well, as you can imagine the only thing worse than being intubated once, is being intubated twice. The doctors/nurses would really like to assure themselves that she will be able to breathe on her own, and continue breathing on her own, before removing the endotracheal tube. This is not so simple as just shutting off the ventilator and seeing whether or not someone turns blue. The endotracheal tube is still in place. Have you ever tried to breathe through a straw. It takes a lot of work. It is impossible to sustain. There is a lot of extra resistance in pulling air through the narrow tube and for the extra distance that the straw adds. Doctors get around this by putting her on CPAP (pronounced “see-pap”). It stands for continuous positive airway pressure. The CPAP pushes just a little bit of air into the straw continuously, but only enough to overcome the resistance that the straw creates. This way it is much like breathing normally, without the straw.

Today, the doctors put Ava on CPAP and watched her oxygen saturation and how hard she looked like she was breathing to get the oxygen that her body needed. Things that they look for, other than oxygen saturation, are her rate of breathing and how hard she has to work to get the air that she needs. When a person, especially a child, is trying really hard to catch their breath, the spaces between the ribs indent, or get pulled inward. These are called “retractions.” This is what Ava was doing early in the day. The doctors know that if they were to take her off of the ventilator and remove the endotracheal tube that she would not be able to breathe like that for very long and eventually her muscles would tire and her oxygen levels would start to drop, then… she would need to be re-intubated. This is a form of respiratory failure. Not fun.
As it turns out the doctors tried again in the afternoon, and she was breathing more comfortably, but with a slightly increased rate of breathing. They decided to put her back on the ventilator and try again tomorrow.

If she breaths comfortably, then they leave it like that for a while, then give her a break, then try again later. Once they feel comfortable that she will be able to sustain her breathing on her own, then the endotracheal tube comes out. This is what we are hoping for tomorrow.


Tuesday, April 28, 2009

Hugs and heartbreak

The things that I want to convey to you today regarding Ava’s recovery have the potential to make this a long entry. This is an upfront apology. Well, let’s just see where this goes… Hugs and heartbreak.

I had not thought too much of either of these things in Ava’s recovery prior to two separate conversations this evening. Let us start with the heartbreak.

I was speaking to Jennifer about her most wonderful visit with Traci, Manny, and Ava today at the hospital and our conversation took my emotions down a path that I was not expecting. Follow along with me. Like all of you, I have been (and continue to be) elated to hear of today’s earlier news. Ava is doing great, given the horrific abuse that her body has endured. She is opening her eyes, moving her arms and legs, then Jennifer told me that she just wanted to cry thinking about how confused she must be right now and not being able to explain it to her or relieve her of it. I had not thought of that much. I tried to imagine myself in the PICU room, watching her, seeing her look around the room through a cloud of injury, pharmacology, and youth. Her last recollections were of a happy time with her sister and mother… now this? It would be difficult enough to understand as an adult, and she is a mere baby. The irritation of the tape and tubing against her skin. The sounds, the commotion. The strange faces. The strange environment. The inability to escape any of it. We all understand the necessity of it and how elated we are to even be at this point given the direness of the situation less than one week ago, but how can she be expected to understand all of these complicated issues? My heart goes out to her and reminds me of another thing for which to pray… peace and solace be upon her.

Hugs. I spoke with Traci on my way home from work this evening. It was an extremely uplifting discussion that made me want to weep for them… with them. Today, Traci held Ava for the first time since this senseless tragedy began. At this very moment any mother who is reading this just crossed their hands over their chest and pressed firmly, their heart melting, for they know exactly of what I speak. Has your heart ever longed for someone so badly, actually yearned is a better word, that you felt empty inside and wanted to do nothing other than to hold them against you and never let them go? Having children I have on a few occasions witnessed their heartbreak and wanted nothing more than to hold them close in some vain attempt to absorb their pain unto myself and relieve them of their suffering, and I am not a mother. Having been an Obstetrician and Gynecologist for many years, I firmly believe that this is a relationship that few men can truly understand. Sorry guys, but I include myself in the “not truly understanding” group. While I don’t truly understand, I do understand that this relationship between a mother and child is special… very special. The comfort that is offered to both mother and child from a consoling hug is immeasurable. I have seen it first hand with Manny and his mom when they met that first night. I was not present with Traci and her mom, but know that the heartbreak and yearning were there from the accounts of others. And these are adult children… and then I think of Traci and Ava. Seeing her little broken, lifeless body on that ICU bed for days on end, without being able to hold her, I can think of no better word than “yearning.” How her heart yearned to hold Ava and remove this pain from her. How her heart yearned to hold her and receive comfort from it. How she yearned to see Ava awake and know that it would all be better soon. Ugh! It pains me to even think of it all… and I don’t even truly understand. I am sure that you have traveled with me and know the elation that my heart felt for both of them when Traci said, “I got to hold Ava today.”


MRI results...

The latest word, as of 3 minutes ago...

"She is doing great! They stopped the Versed last night (Versed is the medication that keeps her sedated while on the ventilator), and... pause... pause... Fred, she just opened her eyes!!! She is moving her arms and legs and is looking around!

"Traci was in the room with him at the time. I can barely type, I am so excited for them... for all of us!!!

As for some residual medical issues...Her MRI of the brain from yesterday showed some "Right occipital lobe ischemia." The occiput (pronounced ox-a-put) is the the area of you head that contacts the pillow when you lay on your back. The occipital lobe of the brain is mostly responsible for vision and some speech functions. It is unclear at this time whether or not these areas are seriously affected. It may be unclear for a longer period of time given her young age and that she has not met many of these developmental milestones as of yet. Again, time will tell.

The MRI also showed some ligamentous injury to C1/C2. The cervical spine is numbered from the top/base of the skull to the bottom. The cervical spine has 7 vertebra and is number C1...C7, then thoracic, then lumbar, then then sacrum. C1 and C2 are unique vertebra. They are not like the others. Their function is critical to allowing you to look around, turn your head, look up/down, etc. Disruption or injury to this area can allow the cervical vertebra at that level to sublux or shift on one another. If that were to happen, then the spinal cord would be pinched and possibly severed. Any disruption of the spinal cord higher than C3, you are not able to breath without a ventilator and you would not have use of your extremities. To treat this concern for ligamentous injury/laxity she will wear a cervical spine collar for a few weeks or so. This is very similar to the cervical spine collar that Traci was required to wear after her injury just days ago. Again, Ava's young age benefits her and gives her a good chance of complete recovery from this.

As for her lungs, she continues on the antibiotics for her pneumonia and continues to be assisted by the ventilator. The ventilator assistance now is mostly being continued because of pulmonary edema (swelling of the lungs). The pulmonary edema would make it hard for her to breath on her own. The ventilator is able to generate more pressure and overcome the resistance of the pulmonary edema; therefore, push more air into her lungs. Her body should start getting rid of this on her own and will be excreted through her urine. The medical team will watch urine output closely. When she starts making more urine than fluid she is getting, then this is an indicator that the body is getting rid of the extra fluid, hence the pulmonary edema improves. They watch other things as well, but this is one of them. Hopefully tomorrow she may be extubated, but again... time will tell.

As for Ava's family. Their spirits are high and want me to convey to you how deeply indebted they feel to each of you for your persistent pray, compassion, thoughtfulness and understanding. They recognize that you have been their foundation of hope and love. Please know that you are also in their thoughts and that they feel blessed to have you as friends. Manny reiterated this point to me many times. "Please let everyone know how much we appreciate everything!!" "Yeah... I got it Manny. You're sorry you can't talk to everyone. Hugs and kisses all around... Yeah... I got it!... Yes, I am sure... I got it.... Manny sorry, buddy, but I gotta go... okay... I'll tell them..."

You get the picture.Please continue your prayers. fw.

Monday, April 27, 2009

Awaiting MRI results

I spoke with Manny again this evening. His spirits sound high and he expressed optimism regarding Ava's condition.

As stated earlier the intracranial pressure monitor and EEG were discontinued earlier today. She had an MRI performed this afternoon, but the results will likely not be available until tomorrow.

As we spoke this evening I could hear the joy returning to his voice. He almost laughingly spoke as he described Ava holding on to his finger. This is indeed great news!!

She continues to be sedated secondary to needing to continue on the ventilator. These issues tend to be addressed day by day. The team comes to round in the morning. They discuss the events from the prior evening, most recent labs, vitals signs, current ventilator settings, etc and what the plan will be for the day. Sometimes the prior evening, etc gives them the green light to press forward on weaning certain medications and support, sometimes it results in a pause in therapy. Tomorrow will tell. Again, the most reassuring thing is that the "72 hour" window has come... and gone... Thank God!!

Prayers for Ava's continued healing and full recovery are needed.

Appreciation for being there for the Lopez and Southerington families can not be expressed enough. They feel blessed beyond measure by the kindness and thoughtfulness that has been expressed and displayed by all. I don't think that my keyboard would bear the typing that would be required to describe it all. Suffice it to say that they have been moved to tears by the sadness and joy that has come from such a senseless tragedy.

Continue to pray for Ava and her family. Your friendship will never be forgotten.fw.

72 hours has come and gone

I just got off the phone with Manny. Firstly, the "72 Hour" mark has come and gone and Ava is weathering the storm. Her intracranial pressures are good, her EEG is good, her vital statistics are good, the doctors are optimistic regarding her recovery. A light appears.The plan will be to remove the intracranial pressure monitor tomorrow, followed by an MRI and start weaning her from the ventilator. She may even have the endotracheal tube removed tomorrow. This is amazing. I had chills when speaking to Manny and knowing how dire things appeared 72 hours ago.Manny commented that if anyone said to him 72 hours ago,"I can put Ava in X condition (where she is right now) or you can take your chances," then he would have said, "DEAL!!" He is very relieved to see her in the condition that she is in at this time, now that the 72 hours has come and gone. The 72 hour mark is typically the time frame that no further swelling should be expected and resolution should begin. This is why it is so uplifting to have her medical situation where it is right now. Please continue to pray for them.Secondly, he wanted me to convey to everyone how greatful their family is to have you all as friends. They have been overcome with the outpouring of prayers, love, and support from all of you. They are sorry that they have not been able to speak to each of you personally, and hope that you understand that their emotional bank has only so much in reserve and that it must be saved for her and them. I told him to shut-up. Not a one of us is offended, and if you are then I am going to beat you myself, and I am bringing with me a few thousand other people, so be prepared (this is where you can have a slight tension-relieving laugh).In sincerity, the Lopez/Southerington family is breathing a sigh of relief and knows that your thoughts and prayers played a role. Please know that you are loved by them and they could not endure such hardship without such a loving foundation of friends.Please continue to pray for a full recovery. All their love, The Lopez Family.fw.

Ava opens her eyes

Ava continued to do well through the night. The Neurosurgeons removed the intracranial pressure monitor this afternoon, and discontinued the EEG (electroencephalogram) monitoring. They are very pleased with her progress.She will have an MRI done this evening to look at her brain tissue. The plans to wean her from the ventilator may be slightly delayed as she has a small pneumonia now.The greatest news of the day... Manny told me that she tried to open her eyes this morning!! Amazing! Given that she is becoming more arousable, she will need to be sedated to keep her from fighting against the ventilator.Keep your prayers coming, they have been working.fw.

Sunday, April 26, 2009

Glimpse of Optimism

Ava's intracranial pressure has stayed below 20. Thank you for your prayers. Currently it is around 16. The plan is to remove the intracranial pressure monitor at around 8pm (72 hours after the injury) if her pressures remain less than 20. They will likely do an MRI tomorrow and extubate her after that. Traci asked the doctor whether or not he was optimistic and he replied, "very!" Ava would still have a lot of recovering to do, but her injuries, including the brain issues, should fix themselves in time. Traci stated that this is the most at ease she has felt since this began nearly 72 hours ago. Your prayers are still needed. Please continue to pray for them and respect their need to focus on Ava and not be distracted by our good intentions (i.e. No calls, no visitors).Thank you for your loving concern and prayers for her full recovery.fw.

Uncle Tony's Gift

Ava's Uncle Tony (Manny's brother) coined the phrase "All for Ava" and is the mastermind behind the beautiful sketch that was used on the t-shirts. Tony, thank you for pouring your heart and soul into this inspirational artwork.

Tough night

Manny just called a few minutes ago. Last night was difficult. Ava's intracranial pressures went up to 26, but didn't stay there. Her intracranial pressure is now around 14. She was having difficulty with being ventilated, but that is also somewhat better, and she is anemic again. They want to get another CT scan but feel that she is too unstable. She now has continuous EEG monitor to look for any worrisome changes in her brain activity.All of us (you) are so appreciated by the Lopez family but they request that you pray for Ava and let them focus on their family today. Please resist the temptation to call or visit. Go to church, pray, let others know to pray, but allow them to focus their energies where they need to be during this critical time.Pray, pray, pray for them. Do not call or visit.Thank you for your love and concern.fw.

Saturday, April 25, 2009

Please pray for Ava

Manny and Traci are entering a very trying time. Ava's injury occurred just over 48 hours ago and the "72 hour" window still looms over them. This evening Traci called to let us know that Ava's intracranial pressure has increased to 19. The concern for irreversible brain injury is high when the pressure rises above 20. Everyone is obviously very concerned about them, but please allow the Lopez family some time to focus on their family. They are so very moved by the love and affection that people are extending, but feel more stress when they don't feel that they are properly acknowledging your concerns. We are all keeping our distance for the next day or so, but keeping our prayers close to them. Their only need and request at this point is for all of us to pray for Ava. Either Kerri or I or someone will update this as soon as we know something more. This will most likely not come until they call us, because we are keeping our distance too. Please pray for them all, for their lives are one. Manny, Traci, Ava, Jack, Isa please know that you are loved.

The first 48 hours

My name is Fred. Manny and I have been friends for nearly 15 years, since attending medical school together. I am sorry but I can only recount what I know. Many people have done many wonderful things these past few days, and I can’t even begin to know the half of it. I know that it is long, but I am trying to recount to those who are not able to be here the things that I know about, so that you can know. One thing to be certain your prayers are needed and wanted. Your love is appreciated.

For those of you that have children, a pet, or anything in your life that you care about, the following account will hopefully make your cherish what you have more, hug them longer, and realize the fragility of life.

The house that Manny, Traci, Jack, Isa, and Ava Lopez live in is the corner house on the entrance to a small cul de sac. The front of the house faces the street of the cul de sac, but the side of the house is on one of the busiest roads in our subdivision as it is just before one of two entrance/exit gates to the community. As you come in the gate you travel uphill and the side/back of their house on your right. As you leave the community, the hill slopes down and you approach the front/side of their house, across the street on your left. There is a stop sign at the intersection next to their house, but people often disregard it. As the road slopes slightly downhill, toward the gate; consequently cars are often traveling somewhat faster as they are heading to the exit.

On Thursday evening, the 23rd of April, at about 8pm Traci, Isa, and Ava had been in front of their house playing with the Larkin family, who live across the street from the Lopez’s. Manny and Jack had been at baseball practice and were returning home. The Larkins went in for dinner. Traci and the girls wanted to pick up some grass clippings on the side of the house before going in for the evening. Ava in particular wanted to be helpful and put grass in the garbage can herself, but was not tall enough to reach the top of it and wanted Traci to lift her. Traci recounts it as a fun and loving moment, one that makes you smile inside about the perfection of your life, as it is. It was the simple joy of being together and a loving moment of harmony. Traci set Ava down so that she could pick up the last few clippings and noticed a Convertible Mercedes from the periphery of her vision. The car was heading toward the exit and coming down the slope at a high rate of speed. She noticed from her periphery that the car should have been on the other side of the road, but rather was approaching close to her house. She looked up to see the car hit the curb and leap up onto the sidewalk and part of her side yard. The car hit all three of them and a large garbage can, throwing them into the air and against the outside of their wooden privacy fence. Jennifer Wiedenhoefer was approaching their house from the gate at the same moment and saw their three bodies thrown effortlessly before the abrupt halt of the fence line. A scene she describes as, “one of the most horrible things that I have ever seen. It was awful.” The driver of the Mercedes straightened the vehicle, steered around Jennifer, and left the subdivision, despite pleas for help. She had two blown out tires, a broken front headlight and a broken windshield and was only slowed by the bodies she hit.
Traci’s moment of harmony had become one of horror as she saw Isa, conscious but against the base of the fence and looked for 18 month-old Ava. Ava had come to rest several feet away and was lying lifeless, facedown in the grass. Despite her own injuries she went to her and rolled her over to see her non-responsive and with little respiratory effort. She gave Ava a few breaths and then was aided by a physician neighbor, Scott Thomas, who had just moments before avoided the woman in the Mercedes who was driving in the wrong lane, when he heard a loud crash behind him. He helped stabilize Ava initially and tended to the others with Jennifer.
The Larkin family was now aware and came out to help while waiting for the ambulance. Jeff Larkin called Manny, to tell him to get home right away. Manny called him back, “Jeff, what is going on? You’re scaring me.” “Manny, Ava was hit by a car, get home.” Manny arrived minutes after the ambulance and began assisting with Ava’s care in the back of an ambulance. I arrived a few minutes later on the tail of an emergency vehicle.

As I came up, a fire truck, three ambulances, and police cars were all around. Traci was sitting on the curb with Isa and was being tended to by a paramedic. Blood and dirt was smeared across her legs and arm. Her right arm held stiff and straight because of the pain. The tragedy of the situation was apparent on the faces of the neighbors that had gathered. Anxious for news of Ava, I was sent to find out how she was. I looked through the back window of the ambulance to see Manny giving mouth to mouth resuscitation to a lifeless Ava. The pain of that moment was heart wrenching. There was so much despair in the few minutes looking through that window that I can barely describe. A father with the medical knowledge enough to fix most anything, but a lifetime of schooling can’t prepare you for that. How do you cope with wanting to breathe the very life that you have into your child and not being able to do so? You could see the thoughts of desperation, despite the surety of his actions… “Dear God, not her. Not her. Take my own breath from me, but not her.” The recollection of the event makes my tears flow freely.
She was intubated in the ambulance a few minutes later with Manny’s assistance and supported with a breathing bag that you squeeze by hand to push air into her lungs. I saw the tremble in his hand as he continued squeezing air into her lungs, tears flowed.

The sound of a helicopter approached. Manny exited the ambulance and it departed to meet with the helicopter so that she could be flown to the nearest trauma center, University Hospital. Some discussion ensued between the ambulance drivers/EMTs as they tended to Traci and Isa, as to which hospital to take them to. Manny insisted, “She is going to University with Ava!!” “You will take her to University.” It seemed like a good deal of time assessing Traci, who was now on a stretcher and a C-collar before being able to leave. Several people offered to take Manny to the hospital to be with Ava, the response, “I am not leaving Traci.” More waiting… “What is taking so long? We have to get to the hospital!!” Not long after, they were on their way to University Hospital.

Eilene Larkin was the first to arrive at the hospital and spent much of her time with Isa, who was evaluated and miraculously released later with only a few minor scrapes to her arm. This allowed Manny to split time between Traci and Ava. Manny came and sat with me, while Eilene was with Isa, and tearfully said, “we’re gonna lose her.” The neurosurgeon had given Manny a very grim prognosis… her pupils are fixed and dilated, she is non-responsive, the gray-white matter differentiation is lost (I’ll explain later). These are all the bad buzz words in head trauma for a potentially unrecoverable head injury. Her list of injuries: skull fracture, subarachnoid hemorrhage, multiple rib fractures, pulmonary contusion, adrenal hemorrhage.

We spent the next several minutes together as Manny talked of Ava’s personality and smile. He spoke of how just the day before everything was so perfect. One day earlier, they had watched American Idol together as a family. After it was over, they all walked hand-in-hand upstairs to go to bed. For those of you with several children, you know how rare that event can be… your children, willfully, lovingly holding hands. The disbelief of the situation is firmly entrenched. “How can this be?” “I can’t go without seeing her smile again.” Several more minutes were then spent with Isa sitting ever so quietly, as is her nature, in Manny’s lap. His face pressed into her hair, gently kissing her head, and offering gratitude in the form of “I love you,” to her over and over.

Eilene then took Isa, and Manny went back to Traci. I went out to the lobby to update several people who had gathered in the ER waiting room, anxiously awaiting news. As they waited the ER televisions played the lead story for the local news: a woman and her two young daughters that were victims of a hit and run. The other people in the waiting room watched in disbelief of such a senseless trajedy, little did they realize that the Lopez family was just down the hall from where they sat.

Jennifer and I went back to the treatment area to see Traci and Manny. Shackled men in orange jumpers with police escorts seemed to be quite normal for this ER. Ava was being admitted to the Pediatric Intensive Care Unit. Traci remained on a stretcher, in a C-collar, with cuts and bruises along her right side. The extent of her injuries was not yet known. More imaging and evaluation needed to be performed, but she was stable. The neurosurgeon returned to talk to Manny and Traci and talked of some of the things that will be happening soon. “We need to find out what the pressure is inside her head. That is very important for us to know whether or not our interventions are working. We do this with an ICP Monitor (Intracranial Pressure Monitor).” This is also called an intracranial bolt. It is a screw that gets tapped through the skull and reads the pressure inside the head like a tire pressure gauge. Traci and Manny almost replied in unison, “Do anything that you have to do to help her.” “We are getting her up to the PICU now. You will need to sign some consent forms.”

“We need to get her music box. She listens to it every night. It plays ‘You Are My Sunshine.’ She loves that . We also need to get her polka-dotted blanket.”

Traci pleaded with Manny to go be with Ava. Minutes later the nurse led us through a back hallway to an elevator that put us at a back entrance of the PICU. Her room is a typical ICU-type room. Large sliding glass doors with easy visibility into all of the rooms from the nurses station. The privacy curtain was partly closed. We stepped around it to see Ava intubated and lifeless on a large hospital bed that was nearly big enough for an adult. She was dwarfed by the size of it. The head of the bed partly elevated so that you could see her face so clearly. A ventilator was at the head of the bed. Oxygen, suction, and monitors were to the right of the head of the bed. A multichannel IV pump was to the left, with colored tape and hand-written labels taped to the different channels, “3% NaCl” “Epi” “NorEpi” etc. The monitors were reading the electrical activity of her heart, pulse, oxygen saturation of her blood, respirations, blood pressure, central venous pressure, urine output, and soon the intracranial pressure. As we walked into the room a pediatric fellow was on Ava’s right side, trying to place an arterial line into her right wrist. Her body was partly covered by sterile green towels as the doctor worked, trying to place the catheter. Manny crossed to the other side of the bed to hover over Ava’s head and whisper inaudible words to his youngest, kissing her intermittently. Work paused as the doctor painfully watched Manny interact with her. After a moment being face to face with Ava he noticed small puffs of air coming out of her mouth and nose as the ventilator blew air into her lungs. “Does she have an air leak(around the endotracheal tube)?” “In babies, we mostly use straight, uncuffed endotracheal tubes. Some air usually leaks around them because there is nothing there to keep some of it from blowing back.” An uncuffed tube is like a drinking straw. It is just a straight tube. If the trachea is just a little bigger than the tube then the air will go to the place of least resistance. Most of the air goes into the lungs, but some of it will leak out as the ventilator pushes in more air and generates more pressure. A cuffed tube has a small balloon on the end of it that gets filled with air to make a seal with the trachea and prevent air from leaking out and allows much greater pressure, and consequently more air to be pushed into the lungs when needed. In babies, uncuffed endotracheal tubes are often used because their endotracheal tissues can be fragile and are small. When the balloon is blown up it can create a sort of pressure ulcer against the inside of the trachea which can ultimately lead to scarring and narrowing of the trachea.

After a few minutes, the Neurosurgeon arrived to put in the intracranial bolt. Here are the consent forms, here are the risks,” blah, blah, blah,” were the words that I am sure that Manny heard. I watched him be respectful, while I could see the agitation… “just where do I sign?” appeared to be the thought in his head. We went to an adjacent, empty ICU bay while they finished placing the arterial line and the intracranial bolt. Desperation still loomed. “Manny, she is gonna be alright. The neurosurgeons mostly deal with adults. She isn’t an adult. Kids her age are like superballs, they bounce back from anything. They recover from the unrecoverable. The same injuries in you or me would like be the end of us, but not her. I know it in the depth of my soul. She is gonna be alright.” This is a true statement. It is amazing how plastic pediatric patients are. It will be an amazing world one day when medicine is finally able to tap in the regenerative and healing abilities that we had in our youth. Manny nervously joked about telling this story on her wedding day, then cried at the thought of it.

Manny called his mother, who was already aware and had left to come here. He called his sister, Tika. They we heading to the airport and would be here in a matter of hours. More tears. While we waited, much of the time in silence, Jennifer called. “You have to get down here and get Traci moved along. She needs to get up to see Ava. Around the same time Jennifer Smith and Kerri Thompson returned from Traci’s house with the things that she wanted for Ava, and other things. I went to the ER for both while Manny stayed with Ava.

When I arrived downstairs more trauma cases were coming in to the ER. Bloodied, shirtless, young men with lots of tattoos get wheeled in on gurneys just feet from where Traci lay confined. They were now consuming the attention of the nurses and doctors. Traci is emotionally beside herself regarding Ava, but is unable to be with her. She is desperate to see her. Tears continue to flow. A few wails of painful desperation echo through the ER, but go unnoticed amid the chaos that surrounds us. It makes me want to cry for her, for them. So helpless they all are right now… Manny waiting for the doctors stabilize his daughter; Traci lying imprisoned on ER gurney with her heart torn from her; Jack and Isa confused; and Ava seemingly lifeless being manipulated and proded. I am prompted by Jennifer to do something to “get Traci out of here,” but feel somewhat helpless myself as I see the battle-hardened veterans deal with the ugliness of life. I approach Traci’s nurse, who is with a group of people attending to a bloodied man who is hand-cuffed to his gurney, wrists and ankles. She looks at me with an expression of someone who has been taken advantage of too many times and will not ever allow it to happen again. She has hardened herself to the heartbreak that is seen in this place routinely. She seemed wholely unmoved by the tragedy of the Lopez’s situation and seemed unwilling to make concessions for them or even offer a sincere expression of sympathy. At nearly the same moment a Trauma surgery resident came up and started disconnecting Traci’s monitor preparing to take her to Radiology himself so as to move her through the ER so that she could be with Ava. The nurse initially protested weakly about moving her. Another male nurse arrived and took Traci’s cause upon himself and assured us that he would push her through the system and get her up to see Ava, and he did, but after her x-rays were completed.

I returned to the PICU with Ava’s things. At about the same time the neurosurgeons had finished placing the bolt. We went in to see her again. Two wide pieces of white tape covered the top of her head, securing the very thin pressure catheter from being inadvertently pulled-out. Manny was told prior to the bolt being placed that they want the pressure to stay below 20. Injury to the brain is unlike a sprained ankle. When you sprain your ankle the tissue can swell and expand outward, swelling can rise into the leg or down into the foot. But even in the leg, if there is too much swelling then the pressure within the tissue gets higher than the pressure within the small arteries. When this happens it becomes simple physics. The blood pressure can’t overcome the tissue pressure, then tissue starts to die. In the head this is so much more fragile. When the brain gets injured, it tries to swell also, but as it swells it has no where to expand to because of the skull. As a result the pressure builds up faster. Worse yet, the brain is very sensitive to not getting oxygen. Brain tissue starts to die after only a few minutes without oxygen. If the intracranial pressure rises above 20, then we should be very worried.

The 72 hours following the injury are critical. Just like if you were to break a bone, immediately after it happens the tissue around it is still normal. It has not had time to recruit the cells from the blood stream and tissue that cause the swelling that comes later. The brain is no different, the swelling will likely peak by about 72 hours, then should start to decrease. These three days will be critical, how things are now, is not necessarily how they will stay. We know that the reassuring gains can be lost in a moment. Let us pray that they are not lost.

The initial intracranial pressure measurements were 12, then 5, then even as low as 1 at times that first night. Manny resumed his position at her bedside. I brought him the music box which he continued to wind and play for the remainder of the night.

Then the most reassuring thing happened… she moved. Not just a deliriously looking for any sign of hope movement that was really the result of the nurses moving some tubing or something… She really moved. She tried to raise her arm and moved her feet. This was huge. In order for her to have such a movement, her brain is still getting oxygen and is still working. Hope!!

Traci, Jennifer, and the male nurse that promised to get her to Ava arrived. She was in a wheelchair that was big enough for someone four times Traci’s size. Her fears were confirmed as she saw her daughter for the first time since the moments after the intoxicated driver irrevocably changed their lives. Tears. Traci demanded to stand and kiss Ava. It was emotionally painful to watch her navigate her own pain while wearing a C-collar, keeping her neck straight, and trying to be careful not to move Ava in any way.

The male nurse and Jennifer then went to Traci’s hospital room on the 7th floor, for the first time. Ava appeared to be stable and we sat in her room, as Manny recalled some of the loving times with Ava. Continuing to wind and play the music box.

Traci returned with Jennifer and was in tears. “I am not going back to that hospital room. The woman sharing the room with me told me that I needed to ‘move on and focus on the other children.’”Ugh! Sometimes people can say the most senseless things.

It seemed like just minutes after she returned to the ICU, one of Ava’s alarms started sounding. It was her pulse oximeter. It monitors what percentage of her hemoglobin/red blood cells are carrying oxygen. It is a measure of how well her lungs are working. They put the suction tubing down her endotracheal tube and suctioned out some blood from her lungs. A minor improvement. Then it dropped again… 80’s… 70’s. They would take her off of the ventilator and use a bag ventilator that they squeeze by hand, forcing air into her lungs. Every time they stopped and put her back on the ventilator, her oxygen saturation would drop again, despite 100% oxygen. It seems that the multiple rib fractures and pulmonary contusion (bleeding into the lung tissue or big lung bruise) have begun to cause problems of their own. The damaged lung tissue has begun to swell and fill with some blood. This increases the lung’s resistance and requires more and more pressure to push enough air into it to get the oxygen into her blood. Too much air pressure and it will start to leak out of the lungs, causing a pneumothorax. If this complication were to occur, then this would require another intervention… a chest tube.
The pediatric fellow was on her i-phone talking to her attending, keeping him/her abreast of the situation, and feeling somewhat nervous as Ava’s physician-father watched her anxiously. “Switch her to a cuffed tube,” were the instructions. This is not such a simple feat, like changing a band-aid. The ABC’s of emergency care begins with “A-irway, then B-reathing.” If you lose an airway, then you are in a world of hurt. Everything depends on having a reliable airway… everything!!!

Anesthesia arrived to change out the endotracheal tube. We left the room and went to the adjacent vacant ICU bay. We talked of prayer and hope. We talked of the good indicators, like her low intracranial pressures and her movement. We talked of her young age and that this will help her. In the background we continued to hear the alarms sound. When will it end?

Finally the ET (endotracheal) tube was replaced. She was placed back on the ventilator and her oxygen saturations were 100%. A sense of relief returned. Everything seemed to calm itself. No more alarms or scares, other than the reality of being in the PICU with Ava. The next few hours passed with small conversation and tears. The music box continued to play.

Jeff Larkin called and was on his way from the airport to the hospital with Manny’s mother, sister, and brother, Tony. It was about 420am. They arrived shortly before 5am. We went to the security doors outside the PICU to meet them. Manny and his mother had a long embrace the moment the door opened. A mother tries to comfort her child. Tears. I could see the helpless and loving expressions on the faces of Manny’s sister, Teka, and brother, Tony, and friend, Jeff Larkin.

Jeff, Jennifer, and I left shortly after the family arrived. I learned the following morning that Ava’s head CT was maybe somewhat improved and that she had a normal EEG (Electroencephalogram). This is like and ECG (electrocardiogram) of the brain. Doctors can put monitors on the head and record the electrical activity of the brain. Just like an ECG can show signs of a heart attack or other heart problem, an EEG can show brain abnormalities. A normal EEG in this circumstance is very reassuring… more hope. The neurosurgeon expressed cautious optimism… more hope. Still the “72 hours” continues to loom.

Traci’s mom arrived in the mid morning on Friday. A group of the neighborhood women took her to the hospital. Traci is staying in a two patient room. I was told that as she entered the room she glanced at a young woman who was in a cervical spine collar and thought to herself, that poor girl. A moment later her legs weakened, and she stumbled to one side, being braced by the women accompanying her, as she realized that the “poor young woman” was her daughter, Traci. Yet another mother is heartbroken by the injury of their child.

Friday, during the day, a good friend of Manny’s and fellow Iraq War Veteran, Colonel Joe Brennan brought Manny home to shower and change clothes and spend some time with Isa and Jack. The hope was that he would also sleep, but Manny refused and insisted on returning to the hospital to be with Ava. Much of the day was status quo. Ava had still not regained consciousness, but her vital signs remained stable and the intracranial pressure remained low. She was started on hydrocortisone for steroid support given concern regarding her adrenal gland injury. The adrenal glands are a pair of glands, one positioned just above each kidney, in the back, next to the spine. They make steroids for your body for a variety of important functions.
Yesterday, Traci was to be discharged from the hospital, but was kept as an in-patient to speed up an MRI evaluation of her neck to exclude a cervical spine injury and hopefully get her out of the C-collar. The MRI was not done until the late evening and the results would not be available until today. She was in a fair amount of pain as the soreness from the trauma the day before took hold. After the MRI was completed, she was finally discharged, between 11pm and midnight.

Manny and Traci spoke at Ava’s bedside after being told that she will be discharged, and she agreed to go back to their house to sleep and spend some time with Jack and Isa. A decision that was very difficult for her. She continued to insist that she be called if there was any change and stated that if anything were to happen, and she were not at the hospital to be with Ava, then should would never be able to forgive herself.

Eilene Larkin and I packed up her things and drove her home. She was very upset about leaving but needed to get some rest. As we were driving back to the house Traci fell asleep. After she had been asleep for a several minutes she suddenly threw both of her arms forward and kicked her legs forward as if she was trying to block something. Nothing was said, and she quickly settled back down, but I had to wonder whether or not this event was replaying through her dreams.

She refused to drive in the back entrance, by her house, and expressed anxiety about even going back in her house. She didn’t want to stay there. She closed her eyes as we approached the area where they were hit and didn’t open them until it was out of view.

Teka and Tony helped get her settled in her bed. She was is a lot of pain. We gave her some pain medications and Benadryl, to help her sleep. Teka told me that she slept for about 5 hours or so, then got up and went back to the hospital. As for Manny he stayed at her side, with the expectation that he would come home today to get some sleep.

During the night Ava’s intracranial pressures had gotten as high as 16, and reminds us that “72 hours” has not passed. The intracranial pressures are now lower, at around 12, and will intermittently fluctuate, but I can only imagine the anxiety that they were experiencing as the number gradually increased from its prior low. Seeing it drop again brings hope.

Despite these small glimmers of hope, Ava remains unconscious. Manny and Traci, and their families have maintained a constant vigil at Ava’s side. One or both of them have been with her constantly.

The vigil continues, and the music box continues to play.

Pink ribbons for Ava

Let's all support the Lopez family by tying pink ribbons to our trees. They feel our love and now they'll be able to see our love. Thanks for all of your support!!!