Wednesday, July 20, 2016

74

I figured out what happened with the Ativan that we were trying to get for Drew's PICC placement last week. His doctor had tried to place the order for it through EPIC for me to pick up at the local pharmacy but because its a controlled substance, you need to physically pick up the prescription from the doctors office and hand the paper to the pharmacist in order to have it filled. Keep in mind that I was getting .25ml, a quarter of a milliliter of Ativan, to help a kid relax. When I had her paged from the pharmacy at the hospital, after searching  high and low for the prescription she told me she had called in, to send a new prescription down while she was in the middle of a clinic, she didn't have the option to send, but only to print. Even within the hospital, she couldn't send an order for .25ml of Ativan to the pharmacy for me to pick up to give to him. You may wonder why they didn't just have her order it and have someone from the hospital administer the medication while he was in the OR for the PICC? Well, there isn't a doctor or nurse whose care hes under unless he's admitted to the hospital. So for an outpatient procedure like a PICC placement, the only way we can swing it is for me to get the medicine and take responsibility for him when I give it to him. If only the different parts that make this whole work would talk to one another before making arbitrary rules. This system is so f'd up. I digress.

As I've blogged about before, we've survived a week on IVs. That means dosing at 7am, 8am, 3pm and 11pm - cleaning hands, putting on gloves, cleaning trays, scrubbing the PICC, counting supplies, hooking up the medication, letting it run for an hour, cleaning the PICC again and then tucking it away until the next dose. Add to that mix phone calls from the pharmacy and nurses about levels of medication in his bloodwork, schedules for deliver of new medication and supplies, nurse visits to change the dressing on the PICC and draw labs, and the other interruptions of everyday life. I shouldn't complain about being tired because he sits through all of this and takes it like a champ. There is no swimming, no running around, no sweating. We play games or watch movies, but its a whole lot of inactivity and boredom for a 6yr old.

The hardest part this time around is trying to convince him to take one more medicine, to do one more treatment, interrupting his play to sit through one more dose of IVs when he's feeling absolutely fine. We try to explain that we are doing this to try to get his lungs healthy, to try to get that number back up, and he cries and tells us its not gonna work, mostly because all we've done so far hasn't worked. Maybe he can feel that nothing is changing, or maybe he's just frustrated like us. Either way, its hard to get him to do this all when he doesn't feel like anything is wrong.

What's most disappointing here, and alarming, is that his numbers continue to drop. His normal lung function is in the mid 90's. In the middle of June it was down to 87. Then we tried an oral antibiotic and rechecked and it had gone down to 79. We tried a week on a steroid and it went down to 78. The we went in for the kill with the IV's and after a week, I'm sad to report that he's now down to 74. He's down 20 points in 4 weeks and that's not cool. Just for reference, typically around 30% lung function is when people are discussing the options for transplant.

It's so hard in CF to determine the cause of the problem, like a constant crap shoot. I usually know the symptoms that merit an intervention, whether its a steroid or some IV's, and he hasn't shown signs of needing either of these things this time. We know his lungs are colonized with a drug resistant bacteria called Achromombacter but that doesn't seem to be whats currently causing the problem, otherwise the many different stabs we've taken at this problem would have likely caused the decline to stop, and hopefully turn the other direction. I've had a suspicion from the start that there could be a fungus causing this problem. The last time he had a bronchoscopy, he cultured a lot of fungus in his lungs. People with CF get fungus in their lungs sometimes, and we got it. Was it because he's always on an inhaled antibiotic that he needs to treat symptoms? Did it come from the inhaled steroids he's been on to help him go longer stretches with good health? Is it just something in the environment that he caught because that's how unfortunate having CF can sometimes be? We have no idea. We treated it with 3 months of an anti-fungal medication called fluconazole and it seemed to help his ever so slight increase in cough go away. The thing was that there were no symptoms that alerted us to the fact that he had this problem in his lungs. Last year he wasn't yet doing pulmonary function tests to tell his how his lungs were functioning because he was too young. But could this again be the culprit? Could the fungus we treated have not really actually gone away and now be causing this rapid decline in his lung function? It's our next best guess but there's only one way to find out - time for another bronchscopy.

When Drew learns to cough out the mucus his body produces, we will be able to take a sample of that to the lab to get tested to see specifically what type of bacteria and fungus grows in his airways and more specifically target therapies to help him. Until he is able to do that, he has this procedure done called a bronchoscopy where they put him to sleep, and they squirt saline liquid into his lungs to "wash" them and then suck out the water and test it to see what kind of bacteria or fungus they've found. We can't do this when he's on IV medication or an anti-fungal or the medication will skew the results of the test. So effective today, we stopped all antibiotics and will take him in for a bronchoscopy on Friday afternoon to see if we can figure out what else could be in his lungs that we are missing, and then hopefully figure out how to treat it.

I spent two hours with his doctor yesterday talking through all the options and symptoms and possible outcomes, and I requested that we start him on this anti-fungal drug and think about the bronch when we return from vacation, something we are scheduled to leave for this coming Saturday. She didn't want to start him on something for fear that when we return and do the bronch it wouldn't give us a true picture of what's really going on because of the medication in his system. She also didn't want to wait much longer to try to get to the bottom of this because losing lung function this quickly just isn't good. She also put him back on the steroid with the hope that we can knock out some of the inflammation before the bronch to try to get a really good wash of his lungs, stating that there was little risk [except to his life as me or one of the other kids might strangle the devil child he becomes when he's on a steroid] associated to trying the steroid for another short period of time.

In the meantime, Drew is acting perfectly fine. You would have no idea that anything was going on with him, as he's skipping around here just happy as can be, a little annoyed and sad that he's gotta do so many treatments and take so many pills right now, but otherwise with his normally cheerful and passive attitude about life. I'm hopeful that we will figure this out and  be able to regain much of the lost lung function with the right treatment. While we won't have results on Friday since it takes time for a culture to grow, we will have a different treatment option to try and will have answers (hopefully) the following week. Regardless of whether they are good or bad, at least we should have a better idea of what we are dealing with. Thanks for all the thoughts and prayers. While we can't answer everyone individually, know that we appreciate the support and well wishes and will try to keep you posted as we know more!

This video was taken 15min before I wrote this post - as you can see he seems to be feeling just fine!
video

1 comment:

  1. I'm so very, very grateful we have the tests out there to track something like this 20-pt drop in lung function these precious four weeks, telling the team something is going on and worsening so the right intervention can be found (sooner would be nice!) -- and I'm grateful Drew is still inspired and dancing away the parts of his summer his is able to be away from the IVs.

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