Wednesday, March 2, 2011

First Heart Catheterization

Every time Daphne’s oxygen levels have dropped, her doctors have weighed the benefits and risks of performing a heart catheterization (cath) to explore the problem. During a cath, a thin tube called a catheter is inserted at the femoral artery (located in the groin area) and threaded up to the heart, where it is used to inject a contrast dye that makes the vessels around the heart visible on an x-ray fluoroscopy image. While an echo can tell you only if there is blood flow, a cath can tell you the volume and pressure of the flow. Because a cath can be risky for a baby Daphne’s size, no one orders the procedure lightly. The biggest risk is permanent damage to the femoral artery, which can stunt growth or result in amputation.

When Daphne’s oxygen levels dipped in Alabama, her medical team considered doing a cath but, ultimately, decided that she was stable enough to fly and it would be better to get her home. When she was admitted to Primary Children’s Medical Center (PCMC), the doctors began mumbling that a cath might be in her future. Even though they didn’t commit to it right away, I knew they would probably decide to go that route. So when Dr. Williams arrived Monday morning to say that a cath had been scheduled for that afternoon, I wasn’t surprised. I was just grateful that we wouldn’t have to wait any longer for the medical team to make a decision.

During his visit, Dr. Williams explained that Daphne’s echo showed reliable evidence of blood flow through her right pulmonary artery to her right lung but inconclusive evidence of blood flow through her left pulmonary artery to her left lung. The medical team suspected narrowing caused by scar tissue or the disappearance of the ductus arteriosus. They would use the cath to determine the extent of the narrowing.

I wasn’t worried about how Daphne would do during the procedure, but when Will arrived around noon, I still became a bit emotional. To give us all courage, Will gave Daphne and me very special priesthood blessings. I won’t share many details, because the messages were so sacred. But I will say that Daphne’s blessing focused on her choice to come to earth, and mine focused on my faith. The Spirit was as strong as I have felt in my life. I was reminded once again that the Lord is mindful of us and we are in His hands.

Around 2:00 p.m., my mother-in-law and my father arrived to keep Will and I company during the procedure. Not long after that, we met with the anesthesiologist, Dr. Harnden, and the cath cardiologist, Dr. Day. Because the op team in Alabama had such a difficult time accessing Daphne’s veins to administer the anesthesia, I quizzed Dr. Harnden about how he would handle the sedation and whether he expected any delays. He was very patient and kindly assured me that inserting a new IV and putting her under wouldn’t be a problem. While explaining the procedure, Dr. Day suggested that Daphne might benefit from a blood transfusion, because it would increase the oxygen-carrying hemoglobin in her blood. This was the first time anyone had mentioned this one-time treatment option to us. He said that, if any of us wanted to donate, it would take a few days to process the blood.

At about 2:30 p.m., we followed Daphne’s crib down to the cath lab, where they gave us a pager that would sound when Daphne’s procedure was complete. When we returned to Daphne’s room, I felt very calm. Despite the risks, I knew that she would be okay. While we were waiting, I looked up information on blood types and transfusions. I was happy to realize that Daphne is AB+ and, therefore, a universal blood recipient.

We’d been told Daphne’s procedure would take about 2 hours. Based on her last surgical experience, I decided to multiply that by two before worrying. At about 4:45 p.m., the charge nurse arrived and hastily explained that Daphne’s sats had dropped during the procedure and the cath team had decided to send her to the CICU instead of returning her to the surgical floor as planned. She didn’t have answers to any of our questions, and her persistent smile seemed out of sync with her message.

With this news, my brain and body went on autopilot, locking up my emotions. Logic told me that we would be asked to vacate Daphne’s room right away, so I began organizing and repacking my things just to stay busy. I refused to answer any questions; I was stoic. My suppressed emotions felt like a solid mass running through my core.

A few minutes later, the pager went off. I felt like running to the cath lab but forced myself to walk, staying just a few paces ahead of everyone else. When we reached the lab, we were directed to an office to wait for the doctors. After about 15 minutes, Dr. Day and Dr. Williams arrived.

As Dr. Day began reviewing the cath images, Dr. Harnden and an assistant rolled Daphne’s crib right past the office. I couldn’t believe they would roll her past me without letting me see her. I freaked out. The solid mass of emotions exploded, propelling me out of my chair and down the hall. I rushed after them, sobbing and begging them to stop so that I could see my baby. Seeing that she was off the ventilator alleviated my fears; she looked a little puffy and yellow (pale for her) but, otherwise, really good. Will and I touched her little hands, and then they wheeled her away.

Back in the office, Dr. Day showed us images from the cath. He pointed out the BT shunt running between Daphne’s subclavian and pulmonary arteries, assuring us that it was clear and flowing well. When we asked about the left pulmonary artery, he identified the flow but indicated that it hadn’t been a focus of the cath. He quickly moved on to Daphne’s small subclavian artery. I wasn’t surprised to hear that the size of Daphne’s subclavian artery was concerning (Dr. Kirklin had reported it after her surgery, and I’d been asking every doctor who examined her if that could be the problem), but Dr. Day presented the information like it was unexpected. He went on to explain that flow through the subclavian artery beyond the BT shunt was almost nonexistent, meaning it was no longer feeding Daphne’s left arm. Instead, her body had compensated by developing a web of smaller vessels to the arm. This was new information.

Next, Dr. Day pointed out Daphne’s right ventricle–dependent coronary veins. In normal heart anatomy, the heart is fed by vessels coming off the coronary artery. In some people with single-ventricle anatomy (like Daphne), the heart is fed by some veins that originate from the damaged ventricle. These veins are unstable and can cause unpredictable, fatal fibrillations (similar to a heart attack). Since the only solution is a heart transplant, they make Daphne’s condition much higher risk. I was also aware of this abnormality before the cath, but again, Dr. Day didn’t seem to know it had been previously reported.

After Dr. Day’s presentation, Dr. Williams explained that Daphne’s BT shunt appeared to be an inadequate solution for supplying her body with oxygen. To remedy this, he recommended placing a new BT shunt in a different location, using a larger branch of the aorta. This time, the surgeon would go in through Daphne’s chest, making it possible to ligate the original BT shunt if necessary (too much flow to the lungs is as bad as not enough). This news was disappointing but not unexpected. Before the cath, we knew that something needed to be done, and surgery was really the only option.

Throughout the meeting, I became more and more upset. I sat on the edge of my chair, staring at the screen. As before, I felt the anger as a solid, tense mass inside my body. I wasn’t angry that the doctors had performed the cath (it had provided some new and valuable information) or about the outcome (it was relieving to have an action plan). I was angry at Dr. Kirklin for relying on that small subclavian artery. I was angry that the Utah doctors hadn’t really looked at what they had told me they were going to look at (partly because it meant they had been wrong, and partly because it meant they hadn’t explained all of their objectives). Mostly, I was angry that they had announced the size of Daphne’s subclavian artery and her right ventricle–dependent coronary veins as if they were new discoveries. I had known about these things. They should have known before they went in. They should have reviewed the files from UAB, and if they didn’t have them, they should have obtained them. And if they couldn’t obtain them, they should have listened when I tried to tell them what they would see.

Honestly, I didn’t have any problem with the procedure itself or the results, but I was enraged to feel that they went in without preparing. I wouldn’t have cared one bit if they had ordered the cath to confirm and explore. I just wanted to hear someone say, “We saw what we expected to see here and here, and this is what we learned.”

During the meeting, I held my tongue, because I knew my feelings might change in a few hours and I didn’t want to say anything I would regret. But after the meeting, I unleashed a fury of words to anyone who would listen. A few well-meaning people tried to help me see things from the doctors’ point of view, but I had to ask these people just to let me be angry. The rage stayed with me all evening, even after I was with my daughter.

The following morning, when I felt calmer, I discussed my frustrations with Dr. Williams. He was very understanding and patient with my complaints, and he went out of his way to obtain a file that hadn’t been transferred from UAB. Later, a friend helped me see that my anger was an active response, a way to keep fighting for my daughter. Sadness, despair, discouragement—these passive emotions would have left me feeling helpless.

Initially, in the CICU, they had a little bit of trouble detecting a pulse in Daphne’s leg, so they started a Heparin drip to thin the blood and improve circulation. With time, the leg’s color improved, the toes warmed, and the pulse returned to full strength, relieving lingering concerns about damage to the femoral artery. To improve Daphne’s oxygen levels, they gave her a blood transfusion, and over the next 24 hours, her supplemental oxygen requirement dropped from 3 LPM to 0.25 LPM—the lowest it had ever been.

On Tuesday morning, Daphne had to endure a sweat chloride test for Cystic Fibrosis. PCMC had received word from UAB that Daphne’s initial screening test had come back positive, so a follow-up test was required. For the test, the phlebotomist placed electrodes on her legs for 5 minutes to stimulate the sweat glands; then he placed gauze on her thighs and wrapped them in plastic, heat packs, and blankets to make her sweat for 30 minutes. I believed the test would come back negative, but I still worried that a positive result would disqualify Daphne from a transplant down the road. Later that evening, we received the results of the test: negative for Cystic Fibrosis.

Before the test results came back, Daphne was transferred back to the surgical floor to await her second operation. She was on just 0.25 LPM of supplemental oxygen, and she was sating in the mid 80s. On Tuesday night, I slept at home with Will and Shelby, and my dad stayed with Daphne. Sometime during the night, they took Daphne completely off of oxygen.

I returned to the hospital on Wednesday morning in good spirits. When Dr. Williams arrived to discuss a timeline for Daphne’s surgery, he was surprised to see her sating in the high 70s and low 80s on room air. When he saw this, he recommended we hold off on repeating her surgery, since it wouldn’t be able to improve these sats. He felt that, if she could maintain these levels, she would be able to go home without receiving a new BT shunt. Then we would aim to help her maintain her sats for about 6 weeks and do an early Glenn when Daphne is 3 months old. He confessed that he’d never seen a blood transfusion make such a dramatic difference, but we’re both hopeful that we’ll be able to avoid a second BT shunt surgery. Will and I know that Daphne’s incredible improvement is a blessing from our Heavenly Father in answer to the many prayers that have been offered on her behalf. Thank you for keeping her in your prayers!

1 comment:

  1. I've been anxiously waiting for an update. And we've been praying constantly for Daphne. Love you guys.