I could probably call this post bump # 4, 5, or 6 after all the little setbacks we’ve had since Jody’s transplant two weeks ago. However, as you read in my last post, we’ve had our fair share of triumphs too, and we can’t forget those. Unfortunately, the last two days were those where the setbacks seemed greater than the recovery, and we need your prayers (although I will say that today was a better day than yesterday).
Before I begin let me give you a very basic science lesson. Our immune system is designed to protect our health. It recognizes things found in the body that do not belong there and works to attack or fight them off. The problem with organ transplantation is that the body does not differentiate between bacteria or viruses that should be fought off, or a newly transplanted organ(s), which should not be attacked. This means, that the body would fight to get rid of the new organs just like it would fight to get rid of a bacterial or viral infection. Since one doesn’t want the body to fight a new organ, transplant recipients must take immunosuppressants which basically trick the body into thinking the organ belongs there. My understanding is that of all the organs that are transplanted today, the lungs require the highest doses of immunosuppressants. Unfortunately this makes one at high risk for infection because it lessens the body’s ability to fight off the bad germs or bugs they encounter.
Since surgery Jody has been hit hard with all sorts of medications. He’s on huge doses of steroids and immunosuppressants to knock out his immune system and prevent his body from recognizing his new lungs as foreign and attacking them. As I mentioned above, this puts him at high risk for developing infections. Hence the gown, glove and mask we must wear. On Monday (9/29) the docs noticed Jody’s white blood cell (WBC) count, an indication of infection, had more than doubled (from 12 to 26). Because clinically he had no other signs of infection they figured it might have been a fluke thing and said they’d recheck it the next day. Yesterday morning (9/30) the WBC’s jumped to 28. At that point the team felt it was time to start searching harder for signs of infection. Up to that time all the cultures that were sent (blood, sputum, urine, stool, etc.) had all been negative, meaning no signs of infection. They looked at all of the lines and tubes he has as a potential source of infection but everything appears normal to the naked eye. They did culture a few more sources just to be on the safe side. For the most part Jody looked and felt fine so there was no real concern. I did notice he seemed a little more short of breath during his am walk but Jody contributed this to increased chest tube pain and I didn’t think much more than that.
As the day went on I noticed it seemed like Jody was getting increasingly more short of breath. His pulse ox or O2 saturation (a measurement of the oxygen level in the blood) stayed around 95%. The pulmonary team rounded early afternoon and they could see Jody was working harder to breathe, but noted that his O2 sat had remained unchanged. He looked and felt lousy. It was a stark difference between the way he looked and felt the day before, when he walked a total of three miles. The pulmonologists discussed how odd it was that his oxygen level was unchanged. If there were signs of infection, rejection, etc. they would expect to see his O2 level go down. About 45 minutes after they left it did (down to 82%-88%). Dr. Shah is adamantly against putting oxygen on his lung transplant patients and so they just watched his numbers. They did give him a dose of IV Lasix to help pull off any extra fluid that could have been causing the problem. This didn’t seem to make a difference. Dr. Shah also ordered a bronchoscopy for first thing this morning.
Overnight last night Jody’s oxygen saturation remained in the range of 82-88%. As an OB nurse I often hear parents say they had a difficult time sleeping because they felt the need to watch their baby to make sure he or she was breathing. This is how I felt about Jody last night. I could hear his slightly labored breathing and the seemingly constant sound of the monitor, quietly beeping to alert someone of his low oxygen level. It’s weird to me that the doctors were okay with his O2 level being so low and didn’t feel the need to give oxygen (although I will say he didn’t appear to be in a lot of distress). I think perhaps the nurses would have liked to have given oxygen, but they have learned the hard way, that Dr. Shah doesn’t like it. Instead they just watched him. Jody remembers waking up more than once to multiple nurses standing still over him just watching him breathe. I did that a time or two myself too.
We were woken up bright and early this morning so that Jody could go down for his bronchoscopy. We were anxious to find out what this procedure would show. In pre-op the anesthesiologist looked at Jody’s O2 levels and felt they might need to intubate him and put him on a ventilator (breathing machine) in order for him to tolerate the procedure. If that happened he would probably need to stay on the vent for a period of time after the procedure and might have even transferred back into the ICU. I wasn’t expecting this news and became very tearful at the thought of Jody needing to go back on the vent. When the pulmonologist arrived before the bronch I heard her telling the anesthesiologist that the procedure would be quick and that she didn’t feel endotracheal intubation (breathing tube) would be necessary. Keep in mind the anesthesiologist was basing his opinion on Jody’s low O2 sat on room air (without seeing how he would respond to supplemental oxygen). I hoped the pulmonologist was right and thankfully she was, Jody tolerated the procedure without difficulty. I was told his lungs still look healthy on the inside and that there wasn’t a lot of mucous or junk built up. That being said, they washed and cleaned out what they could. The doctor reassured me that this first month post transplant is really hard but that Jody is going okay and is going to get better.
It wasn’t long after the bronch that Jody was transferred back to his room. Shortly thereafter we were told the doctors ordered a CT scan to rule out a pulmonary embolism (blood clot in the lungs). During this time his O2 sats stayed low so they did finally get permission to give 2L of oxygen. Around lunch time Dr. Shah stopped by briefly to see Jody. He said that the CT scan showed that both of his lower lobes are looking pretty “beat up,” and much worse than a week ago. He seems to believe that Jody could be experiencing what is called ‘silent aspiration.’ This occurs when secretions, food or liquid enter into the airway (and in turn the lungs) and no cough, throat clear or distress occurs. Think of a time that you swallowed something wrong. Most likely you began to cough and immediately knew you swallowed incorrectly. Because of Jody’s impaired ability to cough he could be aspirating without any outward signs of having done so. The issue with this is that it can cause serious complications, such as pneumonia. If Jody is aspirating it could also be the result of reflux of gastric contents.
Who knows what caused this sudden, drastic change in Jody’s condition? Is it infection? Results of today’s cultures are still pending. Is it Rejection? Dr. Shah doesn’t think so. Dr. Shah’s theory of aspiration sounds like a reasonable one, especially since Jody began eating on Friday, his WBC’s jumped on Monday, and by Tuesday his symptoms began. Maybe I was wrong about Jody’s ability to swallow (although he did pass his last test with flying colors)? Either way, tomorrow they will be taking him for a fourth swallowing evaluation.
Today when we learned the results of Jody’s CT scan we asked Dr. Shah if this is something that’s going to resolve and go back to the way it was with Jody breathing easily on his own and his O2 sats in the normal range. He said he hopes so but there are no guarantees. There is no way to know if his lungs will recover 100%. Obviously this is a scary thought for us. We prayed for these lungs for so long. We prayed for Jody’s recovery. We prayed for new life. Jody’s been given this gift and somehow it feels important, especially for his donor and his/her family, that these lungs work and work well. We know that God is bigger than any of this and we pray that we’ll get over this bump just as quickly as it came. We pray full restoration of the damage done. We pray his oxygen levels will return to normal (I want to see that awesome 100% again). We also pray against some of the negative side effects Jody is having which result from some of the medication he is on. Please pray sincerely that God would hear our prayers and bring the healing that Jody needs to move forward.