Monday, May 4, 2009

Ava's distended belly...needs some relief

What a difference a day makes. Seeing Ava this evening was great! She looked great!
Today didn’t start great, but it ended well. Manny told me that her belly was looking distended this morning, and she looked uncomfortable. Her pulse and blood pressure were also elevated, and her belly was tympanic. Tympany is the hollow reverberation that a drum has when you hit it, but duller, kind of like thumping a watermelon. When the abdomen (stomach/intestines) fill with air to the point that the abdominal wall is tense, then tympany results. You tap on the belly and it makes a kind of hollow sound. This can be worrisome because it usually means that the patient has a bowel obstruction or an ileus.

What is the difference? A bowel obstruction is usually mechanical, meaning that something is blocking it. It may be twisted (volvulus), stuffed inside of itself (intussusception), pushed through an area that it isn’t supposed to go through (hernia), or be pinched from the outside (scar tissue or adhesions). There are some other causes also, but less likely. As it is, she doesn’t have any good reason for having a mechanical obstruction. An ileus; however, is just where the intestines aren’t working very well for a little while. It is like they are asleep and are having a hard time waking up. The intestines need to be awake for anything to get through; otherwise, it just keeps building up until it comes back up the direction that it came in. That is what happened early this morning when Ava threw-up on Manny. It looked like used “coffee-grounds.”

When medical people hear “coffee-ground emesis (vomiting)” it means one thing… blood is in the stomach and the stomach acid is making it look like coffee grounds. This is most likely because of her ICU hospitalization. It is common for patients to get a gastritis (gastro – stomach; itis – inflammation) or inflammation of the stomach with resultant bleeding. She was started on medicines today to minimize this problem, and they generally work well.

Despite her vomiting, her abdomen was still distended and her pulse and blood pressure remained high. A tube was put down her throat and into her stomach to suction things out. They removed a lot of air and fluid and immediately her distention went down and her vital signs improved… Oh… and Manny felt a lot better, too! This happened one other time in the day, with the same treatment and same result… and Manny felt a lot better.

The extra air is likely related to the oxygen that she is still getting by nasal canula. Invariably some of that air will be swallow and build up in her stomach, especially with an ileus.

Now all of this does have an unwanted side-effect. Her discharge from the hospital may be delayed. Because of the ileus, she can’t take full tube feeds and intravenous fluids needed to be restarted. She won’t be discharged from the hospital if she still needs IV fluids and won’t be discharged from the hospital if she can’t be fed properly (via the nasogastric tube).

Her breathing is better. She still drops her oxygen saturations some, but not as deep and not as long. She still needs oxygen but not as much. These are all good things.

One other problem arose today… her white blood cell count (which is an indicator of infection) was pretty high today, over 26,000. That is pretty high. It is usually between about 4,000 and 10,000. They removed the big IV in her groin/leg today because that could be a source of infection causing her high white count. She doesn’t look infected otherwise, and doesn’t have a fever, so hopefully this will help get her white count back down. Unfortunately, they still needed an IV to give her medicine and fluids and had a difficult time getting IV access. They eventually ended up putting on in her foot. It is working and that is what matters.

As for her neurologic status, she is looking much better. The spasticity that I have described in prior entries is improving. Her arms and legs are much more relaxed. Tonight she looked like a sleeping child, complete with an occasional yawn! It was great seeing her look so good.
Manny and Traci are also looking good. You can see their tensions start to fade. It is a wonderful thing!

I was again instructed to pass along how indebted they feel to all of you for your support, compassion, and love. They truly believe that Ava would not be doing so well if it was not for your prayers and love. They have been reading your guestbook entries which have continued to rejuvenate their spirit and determination. They feeled blessed to be able to call you “friend.” Much appreciation and affection.

Please continue your prayers and efforts. Ava is not running down the sidewalk yet.


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