Evening Update II

I just got off the phone with Chip who had just finished speaking with the doctors. This is what he had to say:

The overall prognosis is good, TJ is alert -- even smiling and "chuckling!" Although, for obvious reasons he isn't in a great mood.

This morning's chest X-Ray show improvement over yesterday. The doctors think that may have come from the pressure of intubation. However, they also had him on 100% oxygen yesterday, which is now turned down to 60%. As a side note, they are really staying on top of things. Normally you wouldn't start someone on 100% O2 right off the bat, but staying ahead of the curve is great and could significantly speed up the recovery process (in the hospital and out).

His white blood cell count is down from yesterday (I don't know by how much) which is another good thing. His kidneys are also functioing better than yesterday although Chip says they were never bad (amazing, given that they have been an issue even in the last few months).

I'll probably head off to bed again soon, so expect this to be the last update for the evening. Feel free to leave questions if you have any as always.

Prayer Points:

• Pain: TJ was feeling pretty crappy before he "left," and is feeling worse now. It's great that he is not sedated past what is necessary but everything else aside, being intubated is not a fun thing. In my mom's words, "it's like having a garden hose shoved down your throat." Ouch. So pray that he is as comfortable as can be.
  
• Wisdom/Safety: The doctors may increase the pressure on the ventilator to try to continue to "push" the pneumonia out. With ARDS this does carry a risk of rupturing the lungs, no good. Pray that the doctors make the best deciscion, and that if the pressure is increased there are no negative side effects.
• Complete Healing: We continue to ask God to completely heal TJ, and to bring him back to his level of health he had before MRSA (which he never fully regained).
• Praise: I can't say this now with confidence, but we may already be at the turning point (although last time around we had a few of those, or thought we did). I can't say it with confidence because if we are there we are in the middle of it and can't see it yet. Still, we thank the Lord for all He has done so far.
• Patience for the family: All of us had the same reaction as the news came in: you've got to be kidding me! Again??? Patience is not coming quickly. We thought we were "over this." There is a sense of bewildermant. How does this happen twice? So please pray that we are patient through this process and that we wait upon the Lord while praying boldy at the same time.

A Couple of Notes on the Evening Update (Update 8:10 CST)

There are a couple of things I feel like I should have fleshed out a little bit more.

First, as pneumonia, ARDS and Sepsis are both collections of symptoms there is going to be some overlap between the three. My guess is that the doctors could have said TJ has ARDS yesterday. The fact that they are only calling it that now isn't as big of a deal as it may seem. Of course, I'll be able to speak with at least a little more confidence on the matter when I hear from Bangkok.

Second, even if the recess of fluid in TJ's lungs was slight it is a very good sign. It suggests that the antibiotics are kicking and working, even if all they have done is stall the pneumonia that is great. This post from yesterday explains why even small steps can be big wins. We don't need the antibiotics to "heal" TJ so much as help his immune system step up to the plate and swing harder.

Third, MA and I were discussing whether TJ was actually in septic shock or not. Without having all the facts, being there, etc., one can't say for sure, but our conclusion was that TJ probably had sepsis which got translated into, "the first stage of septic shock." It is the precursor to septic shock, but again, there is a world of difference between the two.

Sepsis is bad, don't get me wrong, but it means that while TJ's body is under incredible stress it is dealing with it still. Septic shock, as I said yesterday, is when the dominos start falling. Thus I mostly see encouraging signs at this point.

Finally, if you do Skype you can find me at madjon84. A screen name that I was starting to let drop until I realized how handy anonymity can be (my last name is not on my profile). Calls are accepted by default and will go to a Skype voice mailbox if I am not around. I may end up getting an online number through Skype so anyone without it can call and leave a message. (The advantage is basically giving myself an emergency number [the one currently posted] and a non-emergency number.)

This just came in from one of TJ's guardians who took the night shift (I think he meant "AM" below):

I left [TJ] last night around 4pm Bangkok time. He had just been bathed and the nurses had given him some sleeping pills, so they said they would wake Chip in the apartment (there are apartments for family only right on the same floor as the ICU) if they needed to. However, the BP has been in the ‘low normal’ range (105/65) and the sats are in the mid 90s, but again he is intubated. I took a taxi back to the hotel where the conference was and just woke up (8:20am here in Bangkok).

[TJ] is aware of the events surrounding him. I talked, he nodded or shook his head to communicate. A couple of times he wanted a pad to write on.

Evenening Update (Updated 7:36pm CST)

I got to Chip once since I've been up, I think I caught up right as he was getting up. The good and the bad:

TJ is stable and alert. "He knows what's happening." Another member said that he could communicate with winks and nods, write a note from time to time. This is drastically different than last year.

The same person said that his blood pressure was stable and pretty good overnight, and that TJ's O2 sats were in the mid 90's throughout the night as well. Granted, TJ is vented, but last time round we had a hard time keeping them in the upper 80's. For at a least a couple of days the vent was set at "full blast."

The pneumonia has made a small recession since the last chest X-Ray (done yesterday afternoon Thai time, early yesterday morning U.S. time).

He has been diagnosed with ARDS -- Acute Repository Distress Syndrome. We've been down this road as well (December 15th, 2007):

He has also developed acute respiratory distress syndrome (ARDS) from the MRSA. The most important part about this is that it can lead to increase pulmonary edema, , e.g., more fluid [and/or inflamation] in the lungs... ARDS can lead to complete respiratory failure, so it is very dangerous...

In essence, his lungs are being pounded once again and developing an inflammation which in turn impairs the breathing process and again in turn impairs the rest of the body as oxygen levels drop. Fortunately, last I heard his O2 Sats were still good.

This time we don't know from the ARDS -- or the pneumonia or anything -- is from yet. Chip heard that blood cultures were coming back today, however they normally take 72 hours. Thus my ever so thorough medical knowledge (look it up as we go along) makes me think that what is coming back today must be a pretty narrow sample, that is, only testing for some specific things. I imagine there are more culturals being done that will take 72 hours.

I'll probably have one more update this evening, but it may be a couple of hours. Thank you all for reading. As I know longer have an Rn of 20+ years besides me anymore, anyone with medical expertise is more than welcome to contact me if anything I post is innaccurate or needs to be clarified.

P.S. My travel plans are to probably stick it out another day here.

P.P.S.: UT sent in this link on ARDS. It is more readable than anything else I've come across so far.

Brief Update (Updated at 12:45 CST -- See P.S.)

I don't have much in terms of real news but thought I'd update a couple of small changes.

Earlier this morning TJ's blood pressure was back into a normal range. As I assume many of you remember this was a major problem last time around and the only good news to emerge out of the last 24 hours.

TJ is also not in a coma; apparently they completely sedated him for the intubation but is only partially sedated at the moment.

Chip managed to convince the doctors that TJ could have MRSA again (not likely, but possible, especially given that the type he had before appeared to be a new strand of MRSA.) All in all, the Thai doctors have been listening closely to whatever MA or Chip have said, which is good.

Chip also managed to get some rest, or at least so I hear. Hopefully he is sleeping now.

MA is at the airport and the flight is schedule to leave at 1:oopm CST. She is completely exhausted. While she tried to get some rest last night all she managed was to lay down for a couple of hours.

Finally, I am going to get some sleep myself. Feel free to email me or leave a message over IM (GoogleTalk, madjon@gmail.com) or, as always, leave a comment. I am reading them all.

I believe that is it. Thank you all for your prayers, I speak on behalf of the entire family: we firmly believe in the power of prayer, we saw it a year ago like few people ever do. And we ask that you continue to pray for complete, miraculous healing once again. We know in a very personal, tangible way that God can and does bring people back from the dead. And we really want to see it again.

-jon

P.S. One year ago today, around 6:00pm CST, TJ was discharged from the United ICU (not the hospital, that would come ten days later). There is an irony here -- I think. In another way, it is like December of 2007 picked up just in time, as if it is not over. I am too tired to grasp whether that is profound, stupid, just a random thought, or a combination of all of the above, but it does come to mind. At the very least the story is not yet over.

P.P.S. My plans for travel are still up in the air. I'll decide whether I fly out 24 hours from now or not later this evening, depending on changes, if there are any.

Intubating and Going Under

To clarify, after a question, this does mean TJ is going into another induced coma.

Intubating

They are currently intubating TJ.

Please continue to pray for Chip (Steven) who has been handling just about everything over. He has been the go-between for the doctors and my mom, and all the information that we have. He also get to sign all the consent forms. While he is a tough young man, I don't know anyone who would want to be signing consent forms for their parent.

Probably Intubated

TJ is probably going to be intubated. Probably meaning, "the odds are greater than not." Another specialist is apparently being consulted first.

Getting Worse

I just got a text from Chip, TJ appears to have pneumonia in both his lungs now, the left one bad.

The pneumonia is spreading now -- very bad. His lungs looked better this morning than they do now. As always, there will be updates as soon as I have them.

Please pray that the antibiotics kick in and the pneumonia starts retreating. If it does not, than we have hit 2007's level of seriousness.

Update 5 minutes later: TJ is also being switched from his C-PAP to a BiPAP. This post from our last major health battle explains the difference.

Message from the Field

Message from the field so to speak. I was just talking with the doctor and as of right now things are looking up. TJ's stats are good, and his BP is closer to normal and he is coherent. The doctor is optimistic, which as many of you may know is a pleasant break from the norm. (And yes find it a little odd that we have 'norms' for this kinda thing) thanks, keep praying. (specifically that...)

• The antibiotics would take hold and eliminate the infection
  

• His lungs would clear quickly so they do not have to ventilate him
  

• Protection in the spiritual side of things, bangkok can be a pretty dark place

-Chip

Another Answer/Important Update

TJ was just put on another drug, Rifampin, a strong anti-biotic. MA says, "Basically he is on the same drugs that worked last year. But that could change when they get cultures back [in order to determine what the infection is] which can take up to 72 hours." Depending on what the cultures show that drugs he is on may change.

In good news, his SATS are at 97 (remember that a glossary was setup last time round) with his C-PAP (a machine for sleep apnea that keeps a continuous pressure on the lungs, as opposed to actually being put on a ventilator which forces the lungs to stay at a certain pressure).

Someone I was chatting with asked:

Are we in the same stage we were last year but this is attacking more rapidly?

I am just going to give you the transcript of the chat for the answer:

(1:24:29 AM) jon-lappy: No
(1:24:34 AM) jon-lappy: There are a couple of differences
(1:24:51 AM) jon-lappy: Odds are he doesn't have one of the worst viruses in the world at this point [aka MRSA, pretty much a once in a lifetime thing]
(1:25:11 AM) jon-lappy: We are still about half a step away from the blog entry I assume you are referring to. [The last blog entry] [He also is not in a coma, dealing with a failing mitral valve, among other things.]
(1:25:30 AM) jon-lappy: In a few hours (probably under 24) we'll know whether things are getting really bad or not.
(1:25:54 AM) jon-lappy: Septic shock does not move slowly. It comes in fast and goes out fast when you get out of it.
(1:26:23 AM) jon-lappy: In essence, it is all of your vital organs shutting down as the body hits the point where it cannot deal with the infection anymore.
(1:26:35 AM) jon-lappy: So the infection either gets cleared up or it doesn't.
(1:27:08 AM) jon-lappy: When any organ starts going haywire the rest start to follow in general, so going the bad way it is like dominos.
(1:27:26 AM) jon-lappy: Going the good way everything just starts working again as the immune system kicks in again.

To give some analogies:

• If you have a heart attack everything else shuts down rapidly due to lack of oxygen.
• If you get pneumonia everything else becomes less effective as your body fights the pneumonia while not getting as much oxygen as it needs in the first place, which can lead to more problems.
• If you have liver or kidney problems, the rest of the body starts getting poisoned as the toxins that are normally filtered out start to recirculate.

Like these examples it can be a vicious circle. When any vital organ fails to operate normally it puts more stress on the rest of the system -- including the immune system -- which causes greater stress and so on. However, when the antibiotics start to work the body has extra help fighting the infection, hopefully giving it enough power to restore normal, if minimal, function to everything else.

Answers/Up All Night

Given the pace at which events are changing I'll probably be up all night and probably on a plane Monday.

To answer Abby's question:

Do the docs still think he has pneumonia as well as septic shock??

Yes, both of those things are symptoms, which leads to Arthur's question:

Jon, how can it be septic shock without serious infection? Can you explain?

Odds are that there is an infection. We just don't know what it is yet.

We've been here before, and going back helps outline what we are looking at. On December 12th, 2007 we wrote:

The main issue so far is controlling the infection. So far TJ may not be responding to the antibiotics that he has been given, and, as noted, the pneumonia has started moving into the right lung.

[...]

Basically, the sepsis dilates the blood vessels and makes the lungs "leaky." This leads to [congestive heart failure], which means that the heart isn't pumping enough blood and can lead to a drop in blood pressure. An analogy, the blood vessels are pipes which have expanded, but have the same amount of fluid is flowing through them so they no longer have the pressure that they should.

The sepsis can also evolve into septic shock, which is mostly simply defined as sepsis that is severe enough that fluid starts leaking into the lungs, the person becomes confused, and eventually myocardial dysfunction will occur (heart attack). If septic shock occurs it can clear in as little as 24 hours, or stay for days. Depends.

The next day we wrote:

Tj is in septic shock and a primary concern here is the loss of blood pressure. During the night his blood pressure dropped below 80 several times. The doctors are very concerned with the pulmonary edema (fluid in the lungs) because it can lead to respiratory failure.

We will be looking at the same things here, hence why he was so rapidly put on Vancomycin, to control whatever infection is there. TJ's blood pressure has not dropped below 80 so far (at least so far as I know) but it wasn't far from it last time I had a number (around 6:00pm).

A moving pneumonia would be quite scary here (all we have is the baseline right now, so whether it is moving or not is undetermined) possibly indicating a move further into septic shock, which has a mortality rate of about 50%.

So, yeah, we are officially into the "very concerned/scary" stage of things. Past this we are getting to the "scared of death" stage. I made such a remark a year ago and was later chastised for it, it made a lot of people upset. But it was the truth. We aren't there yet today, but only moving in that direction and rapidly.

Possible Intubation

K, just got this text from Chip in Thailand:

If he doesn't respond well and quickly to the antibiotics they will have to intubate him.

This is not going well... Please pray that they do not have to intubate him. We really don't want that. Again.