Absolutely Exhausted - Good News and a Fixed Tubie

We woke at 4:30am to start the drive up to Rochester for Nolan's upper GI. It is slightly over three hours to get to the hospital. We were checked in and in the waiting room by 8:30am.

Nolan wasn't feeling all that well and wouldn't walk. I was a bit concerned about the Foley at this point, and was very glad we had an appointment immediately after the upper GI.

Strong Memorial is a much better hospital than Buffalo Children's. The difference is astounding. At WCHOB, parents are separated from their children for all x-rays. At Strong, I was able to don a lead vest and stay with my child during the procedure. Instead of a crowded waiting room with broken toys and waiting for a ridiculously long period of time, we were in a quiet pediatric waiting area and were seen within minutes. They let him keep his hearing aids on for the test, since they were only x-raying his belly. I don't think I'll ever have another test run at WCHOB again. It's worth the extra 90 minute drive.

Nolan drank the barium and we got many images. The radiologist then told me the results, right in the x-ray room.

BIG SIGH OF RELIEF.

His fundoplication is intact. The vomiting is likely due to his delayed gastric emptying/gastroparesis. When his stomach decides to shut down and gets too full, then he will reflux past the fundoplication. This isn't due to a failure of the operation, however - this is just something that might happen periodically.

We also saw that the Foley catheter had migrated into his small intestine. He was in pain and we needed to get the Foley replaced with a g-tube quickly. We headed up to the sixth floor where the most wonderful nurse in the entire world (I'm not kidding) set aside plenty of time to help our family.

Nurse J knows that our current Home Healthcare Company (HHC) sucks. They don't do g-tubes (we were set up with them for C-Pap supplies initially). She looked up a good HHC in our area and is setting us up with the new company. She is also going to get us a pump and formula to start overnight feeds.

She also said we can ditch the dietitian, who was frankly the opposite of helpful.

We talked about bolus feeding (giving the Pediasure via tube in three doses), but since Nolan bloats with that amount of volume, I really would prefer to try overnight feeds. We would really like to keep him eating "regular" food, even if it only constitutes 1/2-2/3 of his diet.

I showed the nurse pictures of his bloating. She asked if he had had a gastric emptying scan (GES) recently, and I said that he had one at the age of 2, but hadn't had one since. We know there is some dysmotility going on - his esophageal bolus transit time is slow and the test in 2009 showed delayed emptying, plus he has the bloating and frequent bouts of uncontrollable diarrhea. The fantastic, amazing, wonderful nurse J suggested we might think about doing another GES. I am so glad someone is thinking about why his tummy is bloating/he won't eat instead of just trying to patch the problem.

If his emptying is normal, then maybe we can push the feeds a little more and help his tummy expand to accommodate the extra food. If his emptying is abnormal, there are other things we can do.

She changed out his Foley to a Mic g-tube. This was rather traumatic for Nolan, so we were glad to be past it and on our way out the door. Nolan was really unhappy for a while, poor kiddo. He was still upset over having to go through another tube change, and was also upset he didn't get a "button." We taped the tube to his skin really well, and that seemed to help him (he doesn't like the sensation of the long tube rubbing against his shirt or skin).

The g-tube is a standard PEG tube - the grandfather of the modern buttons. These are much cheaper than the button style (the hospital pays about $12 for them - we'd pay about $35 if we bought one on-line). The buttons are over $150 to buy online (and our former HHC was trying to charge us over $300 for the same item). Our insurance will cover the buttons now that we are feeding with them, so we should get a button in the mail soon.

We went to Panera Bread for lunch and Nolan was feeling much better.

We managed to really get the tube secured with tape. The life-saving Nurse J gave us an entire roll of tape before we left (really, I might send her flowers).

We ate lunch and then headed home. We made it home by 3:30pm, which is good because we have a birthday party tomorrow.

My house isn't clean. I don't have much planned or organized. Such is the life in a week of crazy - but hopefully our friends love us and won't care that we aren't having a "fancy" birthday party. Sometimes, it is enough to get together and simply enjoy each other's company on a happy day.

Surgery Scheduled

Nolan's surgeon called on Monday. Nolan's case had been presented to the GI team, and they reviewed all of his records. Nolan's reflux is very severe, but his records are a little confusing.

His initial tests (in 2009, prior to diagnosis) were:

Upper GI Barium X-Ray: Entirely Normal (normal anatomy, no reflux noted).
Gastric Emptying Scintiscan: Delayed Gastric Emptying (gastroparesis) noted, normal for reflux.

The other tests from the ENT's office included:

Pharyngeal pH probe, done ON medication (Nexium): significant airway reflux detected.
Pharyngeal pH probe, done ON medication (Nexium + Zantac): significant airway reflux detected.
Upper GI Barium X-Ray (2011): Normal anatomy, one episode of reflux noted.

Fortunately, the remainder of Nolan's tests from the GI doctor's office arrived. Those tests included:

pH Impedence Probe (dual channel): Severe reflux, slow bolus transit time.
Endoscopy with Biopsy and Pathology report: Reflux esophagitis with cellular dysplasia (Barrett's Esophagus).

Whether Nolan has delayed gastric emptying or not is completely insignificant now, because he has cellular changes in his esophagus - these cellular changes are very, very rare in children. The severity of Nolan's reflux, coupled with the respiratory symptoms, is enough to warrant a Nissen Fundoplication. With the cellular changes evident at the age of two, a Nissen Fundoplication is the only real way to proceed.

Barrett's Esophagus is a condition that predisposes people to cancer. The cells exhibit specific changes, and over the course of time, can turn into esophageal adenocarcinoma. The average age of diagnosis for Barrett's Esophagus is 55 years - in other words, the average person with Barrett's is a senior citizen.

Since children with this condition are so very rare, many GI doctors will not see a child who has these changes in the esophagus. I'm not sure how Nolan's original GI doctor missed it, or why she didn't ever do a follow-up endoscopy and surveillance biopsy, but I suppose the point is moot. The GI team at Golisano's saw it, and that is what matters. His GI care will be in Rochester now, anyway, so the little guy will be appropriately cared for.

The surgery (Nissen Fundoplication with Mic-Key button placement) has been scheduled for March 7 at Golisano Children's Hospital (part of Strong Memorial). The surgeon will do a repeat endoscopy with biopsy prior to the surgery.

If the biopsy shows that his esophageal cells have reverted to normal, then we can rest assured that the Barrett's is gone. If the biopsy shows that the dysplasia remains, then Nolan will be scoped and biopsied every six months for the rest of his life. If a scope shows changes in the pathology of the cells (advancing stages of this pre-cancerous condition), then further action would be taken at that time (I won't go into that now).

I'm still flabbergasted that our original GI doc never did a follow-up scope. I know the condition is very rare, but surveillance is mandatory with dysplasia - the risks are simply too high to ignore.

I'm also kicking myself, because this was one of the very few reports that we did not have a copy of. We still don't have an actual copy of the report - I only remember being told (verbally) that the pathology report showed "ectopic gastric mucosa" and "blunted villi," not having any idea of what those two things meant (and searching the interwebs for useful information with those words was futile).

The good news is that there is now a team in place to follow Nolan and to monitor the histological changes. I can't express how grateful I am that we made the decision to transition to Rochester for Nolan's care. And, hopefully, the new biopsy will show healthy, normal cells that haven't been altered by repeated acid exposure.

There are a few research articles on Barrett's Esophagus in children - I'm posting this here for my own reference:

Barrett's Esophagus
http://www.nature.com/gimo/contents/pt1/full/gimo44.html

Barrett's Esophagus in Children: Diagnosis and Management
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1242875/

Endoscopic Surveillance of Children with Barrett's Esophagus
http://www.hon.ch/OESO/books/Vol_5_Eso_Junction/Articles/art282.html

Barrett's Esophagus in Children: A Study of 31 Children:
http://journals.lww.com/jpgn/Fulltext/2004/06001/P1048_Barrett_s_Esophagus_in_Children__A.1172.aspx

Phone Call

Another picture from the Strong Museum of Play

Nolan's surgeon just called. I've never had a doctor do that before.

The crux of the conversation? Nolan is weird.

Not the child, of course, but the medical history and test results.

He was looking at the upper GI bariums, which were normal (barring one episode of reflux). And the gastric emptying scintiscan, which is normal for reflux but shows delayed gastric emptying. And the two pharyngeal pH probes, which were done while Nolan was on medication.

He doesn't have the original esophageal pH probe or the biopsy report.

And so we have some issues.

Since the scintiscan shows delayed gastric emptying in the absence of reflux, a pyloroplasty would be performed along with a Nissen - it is likely his problems are primarily motility related.

He's also concerned about some cellular changes that are casually mentioned in one report. If true, he would need serial monitoring.

And the pharyngeal pH probes are rather cutting edge- since they aren't generally used in the pediatric population, he's putting those aside for the moment. Nolan obviously has airway reflux - heck, he CHOKES on the stuff, but the pharyngeal probes were done on medication and he'd rather have a traditional pH probe.

I will fax Nolan's original pH probe study to the surgeon tomorrow. He'll have to wait a bit longer for the esophageal biopsy results and the pathology report, because I don't have physical copies of those. I have to wait until we get the consent form from the GI doc and then I'll mail it back - once I do that, the GI doc will fax the medical reports directly to the surgeon.

So we aren't scheduling surgery yet. Things aren't so straightforward as the surgeon originally thought, and he's concerned there is some bigger, underlying issue with the progressive nature of the reflux and airway. His exact words were,

"These kids aren't always what they seem. We're learning more about them all the time and sometimes there's something bigger."

Great. I seriously don't want something "bigger."

On the other hand, what an amazing, wonderful, incredible doctor. Taking time at 6:00pm to call a parent to get clarification on medical reports that he is ACTUALLY reading. Trying to figure out the mystery that is Nolan.

Since the regular esophageal pH probe was done when Nolan was 2 years old (along with the gastric emptying scan), he really wants them to be repeated. Which would mean pH probe #4 for the little guy (this time an esophageal one, like the original probe) and GES #2. He would also like another endoscopy/biopsy to look at the little guy's esophagus.

But he's going to talk to the GI team at Strong Memorial first, to get a consensus. And he wants to review the other records.

Looks like things are going to be topsy-turvy for a while.

Pediatric Surgeon Consultation Appointment Made

It is crisp and sunny outside - I am VERY thankful that this winter is starting off on a mild note. I certainly hope it stays this way, at least through the beginning of January!

I made an appointment for Nolan's pediatric surgery consultation. We have an appointment for January 9th at Strong Memorial Hospital to discuss the potential Nissen Fundoplication. Rochester is a good three hours from our house, so we'll probably go up the day before and stay the night. The science museum looks like a fun side-trip, so we're thinking of taking both boys to the museum on the Sunday before the big appointment.

I am not sure what 'happens' at the consultation appointment, but I suspect we'll review his history and go over prior test results. It is possible that a few tests will be ordered (a gastric emptying scan and possibly esophageal manometry), and we will be able to ask our questions. I found a great article on Complex Child that suggests 10 questions every parent should ask before proceeding with a fundoplication:

1. Does the child have motility problems?

This is the biggest question we can't quite answer. Kids with motility problems do worse with fundoplications than kids who have no motility issues. Another gastric emptying scan and esophageal manometry will be able to help answer this question. Nolan had one GES over two years ago, which showed "borderline" gastroparesis (27% emptying time after one hour). The problem is that there is no national standard for pediatric gastric emptying times. In some clinics, Nolan's time would be considered "normal." In others, it would be considered flat-out delayed. We need to re-examine this angle.

2. Have all medical treatments been tried?

Yes. Nolan has been on adult dosages of a proton pump inhibitor and an acid blocker, and the reflux persists. When on certain antibiotics (which should improve potential motility problems), the reflux worsens or remains the same. He has failed medical therapy for reflux.

3. Has my child had the appropriate testing to rule out other conditions that mimic reflux?

Yes. There are many other conditions that mimic reflux (like cyclic vomiting syndrome, eosinophilic esophagitis, etc.). Other than the potential gastroparesis, Nolan has had all of the recommended and required tests:

a) A pH probe to demonstrate the presence of acid reflux, even on high doses of anti-reflux meds (this is the gold standard for diagnosing reflux).
b) Upper endoscopy with biopsies to rule out eosinophilic esophagitis. Nolan's upper endoscopy was performed two years ago, showed reflux damage, ectopic gastric mucosa, and blunted villi in the esophageal tract. Eosinophilic esophagitis was not present.
c) Gastric Emptying Scan. Yes. The gastric emptying scan was performed over two years ago and showed borderline delayed gastric emptying. This is a question that remains, which fits in with the first question regarding motility problems. He has never had manometry performed.
d) Upper GI Barium to rule out anatomical problems: Yes. Nolan has had two upper GI series performed, both of which showed normal anatomy. There is no malrotated intestines or hiatal hernia present.

4. Does my child have a history of vomiting, gagging, or retching?

Possibly. Nolan occasionally goes through vomiting cycles, similar to what is seen in kids with delayed gastric emptying. He often gags and/or chokes on reflux. He does not retch. Again, this ties into possible motility issues that will have to be investigated prior to consenting to a fundoplication. Since Nolan's type of reflux is not typical GERD but is LPR (extra-esophageal), motility medications will probably not help his situation greatly - both sphincters malfunction and the reflux ends up in his airway. In this case, ruling out motility issues will simply help us decide if the fundoplication will cause more harm than good, though when the lungs are affected, a fundoplication is nearly always indicated.

5. Does my child aspirate his secretions or food?

No. Nolan does not have aspiration problems with his saliva or with food. Kids who aspirate their own secretions have a harder time following a fundoplication - and a fundoplication cannot "fix" this problem since the aspiration is of secretions above the level of the reflux. This is not an issue with Nolan, fortunately.

6. Does my child have a history of neuro-irritability, visceral hyperalgesia, or chronic abdominal pain?

No. Nolan is often nauseated, but doesn't seem to be in acute pain very often. This is often seen in children who have neurological impairments, and a fundoplication may worsen abdominal pain in these children. This doesn't apply to Nolan.

7. Has a GJ Tube been tried?

This question was written primarily for children who are receiving a fundoplication for reflux associated with failure-to-thrive issues. In these children, a G-tube is often already present, and the child is not feeding orally.  For these kids, a GJ tube can bypass the stomach entirely and prevent reflux, with fewer side effects than a fundoplication, particularly for children with neurological issues.

In Nolan's case, this is non-applicable. While on the low end of the weight charts, he is not failure-to-thrive. His reflux causes apnea and airway issues, but we have the weight issue under control. He eats orally and does not have a gastrostomy tube, so trying a GJ tube is inappropriate in his case.

8. Does my child have a history of esophageal atresia?

No. Kids with esophageal atresia often perform poorly with fundoplications. This is non-applicable to Nolan.

9. Does my child have dysphagia or feeding problems?

Not really. When in the middle of a bad reflux flare, Nolan will avoid solid food. He was dysphagic as a toddler (difficulty swallowing) due to the reflux, but this has improved greatly with medication. In general, he doesn't have feeding difficulties. There are still questions about his esophageal motility, which ties in to the first question on this form.

10. Is my child under two years of age?

No. Kids under the age of two often "outgrow" reflux. Children over the age of 3 or 4 are nearly all severe, chronic, life-long refluxers. Children under the age of two should not have a fundoplication unless the reflux is life-threatening (apnea, airway, or severe failure-to-thrive are present). At the age of 4 years, 4 months, Nolan's reflux has only gotten worse with time. He will not outgrow the reflux, and faces lifelong high-dose medical therapy, which has proven to be ineffective for him.

The questions provided by this article are great, because it helps us to narrow down the relevant questions prior to consenting to the surgery. Really, the biggest outstanding question is regarding motility issues - we need to get more definitive information on this problem, particularly since Nolan had a questionable gastric emptying scan and a longer-than-normal bolus transit time on his last pH probe.

Upper GI Results

After playing a bit of phone tag, I finally got the results to Nolan's Upper GI Barium study. As expected, his anatomy is entirely normal. Since barium studies are not intended to diagnose or evaluate reflux (scintiscans and pH probes are far better, and only a pH probe can diagnose the severity of an acid reflux disorder), we didn't expect to see any reflux on the X-rays. Nolan's first upper GI barium study was entirely normal, but they did manage to catch a reflux event during the most recent test.

After talking to the nurse practitioner with our ENT clinic, I found that they do Upper GI studies routinely prior to fundoplications. The pediatric surgeon needs to verify normal anatomy (or abnormal anatomy) prior to embarking upon the procedure. In addition, certain conditions (like hiatal hernias) are repaired via a fundoplication.

If (and that is a big IF) we decided to proceed with a fundoplication, the first studies are completed: we won't have to go through all these tests once we visit the pediatric surgeon (if we didn't do them now, we would have to visit the surgeon, then do the tests, and then return to the surgeon again).

In the meantime, Nolan is coughing and gagging a lot - his blasted reflux seems to get consistently worse rather than better. We can hear his stridor increasing, and he complains about getting "throw-up" in his mouth. Reflux can flair up randomly, so I'm hopeful that this recent flair will dissipate soon. Ugh.

Easy Peasy

Nolan's first upper GI barium test was a little bit of an ordeal - he wouldn't drink it, so they had to administer the barium via NG tube, and then we had to wait around for a while to make sure the barium cleared his system. Plus, the radiology waiting room was way overbooked, so there was nowhere to sit or stand while waiting for the test.

This time was a complete 180 from the first test. There was no-one in radiology except for us (and one other family completing an upper GI), and we were called back at exactly 9:30am for the test. They did one "pilot" X-ray of Nolan's empty stomach, and then called him back for the barium test. While I can't stay in the room during the actual test, we had talked about the procedure over the weekend.

Nolan agreed to drink the barium while standing up (the table rotates to accommodate this), and was absolutely brilliant about the whole thing. He didn't seem to mind the barium much - his Zantac tastes much worse, and as long as he didn't have to get a "tubie," he thought drinking the barium was just dandy.

The test was so fast I could hardly believe it - within 15 minutes they said they were done and sent us on our merry way. We pulled out of the parking garage by 10:30am, and headed to the Buffalo Zoo. We spent a lovely afternoon as a family, looking at the elephants and gorillas.

The report will be at the ENT's office by tomorrow afternoon. It is most likely normal: his first scan was also completely normal, even though he had extremely severe reflux. For some reason, Nolan's reflux is off-the-charts severe on the probes, but never seems to show up on the scintiscans or the upper GI series.

At least it is one more appointment done and over with. The rest of this week slotted with lots of outdoor play and soccer games!

We Love Wonderful Summer Weekends

The weather hasn't been that wonderful in our neck of the woods. The temperature is above freezing, however, so we're not complaining. We have spent most of this past weekend fishing on our local lake: Nolan and Matt both caught lots of little sunfish, perch, and even a small bass!

Tomorrow we head back up to Buffalo Children's for Nolan's upper GI series: he can't eat after midnight, and we have to keep him happy for the 2 hour ride up to Children's. Hopefully he'll drink the barium this time - last time he refused and they had to thread an NG tube (a tube that goes up the nose and into the stomach) to administer the barium. We've talked about it a bit, and Nolan agrees that he'll drink the white "medicine" tomorrow. He hates "tubies," so there is a good chance that he'll cooperate this time.

If he gets out of there on time, we'll get to go to the zoo afterward. I'm not promising that yet, though, because sometimes they take quite a few "pictures" after the initial study (i.e. I'm not sure if they're doing a small bowel follow-through tomorrow).

It'll make for a long day, but at least he can eat as soon as the X-rays are completed. Hopefully we'll be home in time to go swimming and play outside a little tomorrow afternoon!

A Busy Week Ahead

Nolan's preschool field trip to the Fire Station

This week is a little busier than most:

Monday: Matt's preschool, Nolan's speech therapy, and Matt's second preschool.

Tuesday: Drive to Buffalo for a hearing test, and to adjust Nolan's FM system. Matt's first soccer practice.

Wednesday: Matt's preschool, then drive to Erie for an ophthalmologist appointment (we get to find out if Nolan gets to rock the fashion world by sporting a patch and going pirate-style). Then Nolan has a soccer practice, and Matt has swimming lessons.

Thursday: Nolan's last day of preschool, and his "birthday" during class. I have a mothers of preschoolers steering meeting, and Matt has preschool.

Friday: Matt has an end-of-year picnic for pre-K at a local amusement park, so we will be spending the day having a ridiculous amount of fun in the sun!

I love the summer months, but June does get a little insane with the end-of-school parties/events, and then we have a bazillion doctor appointments for Nolan. He sees urology on the 16th (this is routine, and we are hopeful he will be discharged from this specialist). The sleep neurologist is scheduled for the 21st, and the upper GI is scheduled for the 27th. At least one trip a week to Buffalo Children's is on tap for the remainder of June: if only the drive were shorter!

The good news is that preschool ends on the 24th of June (for Matt), so July should ease up a bit with the schedule. I plan on spending a lot of time at the local parks, municipal swimming pools, and on "field trips" to the beach!

Upper GI Results

After all the "ear" stuff, you would think

Nolan would know where the otoscope goes. Apparently not!

The ENT office called me this morning to give me Nolan's Upper GI test results. From the radiologist's report, it is completely normal. This means that his eating issues stem primarily from the borderline gastroparesis, and not from some unseen anatomical anomaly. I'm not sure if this is a "good" thing or not- an anatomical anomaly might have been easier to "fix," but at least there isn't anything else wrong!

In the meantime, Nolan is eating more again. By "more," I do not mean "eating like a typical 2 year old." An example of today's ingested material is:

2 tablespoons of oatmeal
2 bags of Yogos
3 french fries

24 ounces of whole milk

2 cups of diluted fruit juice

The Yogos might take some explaining- we found a food that Nolan will eat, so we're giving him some Yogos to keep him chewing and swallowing. Some kids begin to prefer an exclusively liquid diet and don't want to chew anymore, so we're giving him these as "chewing practice" and not for any nutritional value.

He has spit up twice this week (like an infant- white milk) and has had some good eating days and poor eating days. We see the gastroenterologist on Monday and will have a better idea of how to proceed. Right now we're officially "dealing" with resolved PUV's, hearing loss, gastroparesis, and head lag. This new doctor is an MD/PhD and specializes in complex medical cases, and our ENT is hoping she'll be able to come up with a comprehensive diagnosis. Of course, it is always possible that Nolan has a bunch of unrelated, rare problems. But it is more likely that everything stems from a common cause. All I really care about is getting my kid to eat again, and to eat enough to gain weight. A 22 pound two year old is pretty skinny, and we can't find pants to fit him. He's in a size 9 month for the waist, and needs a size 18 month for the length.

We may be investing in suspenders in the near future.

Upper GI

Since Nolan isn't a big fan of solid food, he is quite hungry when he wakes up in the morning. He usually cries until he gets his "nilt" (or milk, for the uninitiated). I knew this morning wouldn't be fun, but I also figured that his extreme desire for milk would cause him to drink the barium without incident.

We arrived at Buffalo Children's by 7:45- early for the procedure, but since we were the first ones on the list, I figured we might get in a tad early. Which was a good thing, since Nolan was screaming "NILT!" to anyone within earshot.

The technician took us back for the first X-ray (just a clean shot of his tummy, no barium involved yet) and I had to wait outside the door while Nolan freaked out and had his "picture taken." Then she gave him back to me, and we went to wait for the radiologist to show up so we could do the barium part of the procedure.

The technician told me that if he refused to drink enough barium, then they would have to insert an NG tube to get all the images they needed. I had all my fingers crossed that Nolan would drink that barium like crazy once they took him back for the scan.

The actual procedure takes about 30 minutes, and parents aren't allowed anywhere near the X-ray room during the process. The radiology tech came to take a history prior to the scan, and was shocked to see his weight. She said, "does he have a g-tube?" Yikes! No, he doesn't, but that set me on edge. Then the radiologist came in, saw the gastroparesis diagnosis, the failure to thrive, and the refusal to eat solid food. He said, "does he have a mickey?" The nurse said, "No, no g-tube." The radiologist shook his head and asked me why it had taken ten months to get a failure-to-thrive child in for an upper GI. I didn't want to go into the whole, "the pediatrician thought he would grow out of it" thing, so I told him that we had a very dedicated ENT who had pushed the work-up through.

They took Nolan and did the procedure, and then brought him back to me with one hearing aid out and covered in barium. Note to parents of hearing aid wearers who are getting an upper GI: take the aids out or protect them with Ear Gear! Luckily the aid is fine, though I think there might still be some barium residue in Nolan's ear. Turns out that Nolan is not enamoured with barium. They did have to use a naso-gastric tube to finish the scan.

We had to wait another half hour, then take another X-ray to ensure that the barium was moving out of the little guy's system. The tech had told us we would get the results the same day as the procedure, but after the procedure was run she told us that we would have to wait for the report to get written and then sent to our ENT. This means the results won't be available until Monday at the earliest, since the ENT will have to review them before I get the report over the phone.

We were finally free to go, and Nolan was happy to get some diluted fruit juice. After barium, I'm pretty sure that apple juice tastes pretty good!