Kindergarten Open House

We went to visit Nolan's classroom this evening. His classroom is very colorful, with lots of centers. It is a great contrast to Matt's Kindergarten classroom, which was very sterile in many respects (and had few centers).

Nolan's teacher plays the piano and has one in her classroom. I really love the inclusion of music and center time into the kindergarten day. I didn't get a lot of pictures of his classroom, because I was talking to his Teacher of the Deaf. She had his new FM system set up and waiting.

I will have to return the county-provided FM system, which is sort of a bummer. On the other hand, the school district is allowing me to take his FM system home, so I consider this a big WIN.

We can still use it at home, and I will set it up each morning and take him to school with it on, just as I did last year. This worked well for us last year, so we'll keep doing it again this year.

I did tell his TOD that his reporting skills were hit-or-miss. If both hearing aid batteries die, he will always say something. Since he is functionally deaf without hearing aids, two dead batteries really impact him. If one battery dies, however, he won't say anything. As long as he can hear something, he figures he's still good to go. If the FM isn't working, he'll often insist that it is - until you fix it and turn it on, when he'll declare, "I can hear you now!"

Fortunately, he has hearing aids so his occasional failure to report malfunctioning equipment can be checked - we can listen through his hearing aid/FM combination to be sure it is set correctly.

School starts on September 5 - we're all excited for a great year!

Emergency Foley When a G-Tube Falls Out

Oh my, it has been a week. Dennis and I managed to change out the ruined Mic-Key button with the emergency Foley catheter we had on hand. We learned a few things during the process.

1. People will give you weird looks if you go to a store and buy ace bandages and KY Jelly.
2. The resident on-call will tell you to change the Foley catheter, but omit vital steps that should be contemplated BEFORE the said change takes place.

The Mic-Key button was easy to remove - I tried to pull water out of the balloon and the syringe only returned gastric fluid. We pulled out the Mic-Key and saw why - it wasn't a slow leak, but the entire balloon had ruptured.

The balloon is on the end of the stem above, and you can see how it is split wide open. I think there was an intrinsic weakness to the balloon since I only added the recommended 5ml and it obviously had a catastrophic failure.

Anyhow, here are the important things the resident failed to mention:

1. The Foley has no clamp. Once you insert it, the tube is open and gastric contents are able to flow out. BEFORE you insert the Foley, cut a clamp off one of your extension sets and slide it onto the Foley. We didn't do this ahead of time, but managed to crimp the line with one of our extension-set clamps anyway - it isn't as secure as if it were on the catheter, but it will do for a short period of time.
2. Tape the Foley catheter up the belly. This allows gravity to help keep stomach contents where they belong.
3. Tape the Foley catheter well, so that it can't slide back into the belly. If it isn't taped well, it can slide back into the belly and the balloon can block the pylorus. If this happens, the child may start vomiting.

I found these problems (numbers 1 and 2) as we were doing the change. Fortunately, Dennis was able to take care of Nolan while I ran to the world's best medical advisers: other parents of complex kids. Within seconds, these amazing Parents of the Internet told me how to clamp the Foley and to make sure it was taped up. 

The third bit of critical information came from the nurse this morning. I called the clinic this morning and the nurse called back. We're set for an upper GI study at 8:45am in Rochester on Friday, so we'll go ahead with that study, then head up to the clinic where the nurse can change out the Foley catheter for a Mic-Key button.

In the meantime, we have a Kindergarten and First Grade open house to attend. Nolan is happy and feeling just fine, despite being taped and ace-bandaged to the hilt. His birthday party is on Saturday. On Sunday, we may collapse from exhaustion. 

I am mightily relieved that by this time tomorrow we should have a boy with a nice, secure Mic-key button in place and knowledge that his fundoplication is (hopefully) intact!

Because We Really Needed More Drama

Nolan's mic-key g-tube was three months old, and the balloon that holds it in place sprung a leak. Since the tube was falling out, I replaced it this morning with a new one.

I called the Home Healthcare Company (HHC) that takes care of Nolan's respiratory equipment (and has the prescription for the g-tube replacements) to order another new mic-key to have on hand as back-up. The HHC stated they are no longer doing mic-key buttons and referred us down to Hamot medical in Erie, Pennsylvania. I called Hamot, and they stated they are not taking new referrals, but to have the prescription sent to them and they would send it to Pittsburgh.

I called the surgeon's nurse (who must be rather sick of hearing from me) and told her the situation. She said she'd send in the prescription. She also asked if we had heard from radiology (we hadn't). She said she'd follow up on that again (they still haven't called).

In any case, I went to Nolan's kindergarten parent meeting tonight. Since Matt was in kindergarten last year, none of the information was new - but it was good to see his new teacher.

I got home and Dennis jetted off to hockey. I put Nolan in his pajamas and noticed that his new tube was hanging half-way out of his belly. Not good. I checked the fluid level and pulled out stomach fluid. The balloon has burst. Since I didn't have another back-up on hand, this was not a good situation.

I taped it in place and called the surgeon's emergency line. The resident eventually called back and instructed me to remove the mic-key button, put the emergency foley in, and tape everything in place. I'm to call the clinic tomorrow and try to get him in for a button change in Rochester.

I have a feeling I'll be making a three hour drive tomorrow - unless it can wait until Friday (which was when we were supposed to have his upper GI done anyway, if radiology can manage to call and schedule it).

Dennis is now at the store buying some KY jelly (lubricant to get the foley in) and an ace bandage to hold everything in place.

My blood pressure is through the roof.

In Which I Nearly Lose My Mind

With the bloating from the Mighty Milk causing Nolan pain, bloating, and diarrhea, I called the dietitian's office and left a message. I also sent a picture of his bloated belly to our surgeon, as this plan simply didn't seem to be working.

Besides the bloating, Nolan has stopped eating solid food with the Mighty Milk. He will eat breakfast, but lunch and/or dinner are not on the menu - he's simply too full and bloated to eat. Call me crazy, but chocolate milk is not a nutritionally complete meal option for a five year old child.

Our surgeon wrote me back and was concerned. The dietitian called me back yesterday morning. My concerns, and her responses, are below:

1. He isn't eating food with the mighty milk. Her response: keep at it and make him drink it. His stomach will grow with time.
2. He is bloating and uncomfortable. I am stressed because he isn't eating and he is in pain. Her response: keep at it, don't get stressed. If you get stressed, he will sense it and use food to control you.
3. We don't have the script for DuoCal. Her response: I decided not to give the script to the surgeon. I sent it to his pediatrician instead. His pediatrician knows him better.
4. He starts school in one week. I don't want him to miss instructional time due to leaving class for extra meals during the day. Her response: I'll write a letter to let him leave the classroom as much as he needs to, so that he can get food in the nurse's office.

I was so upset once I hung up the phone. She wasn't listening to the concerns at all - she isn't the one watching him bloat and have horrid diarrhea. She isn't watching him leave his lunch and dinner untouched due to the milk. She doesn't seem to care that he'll miss time in the classroom to accomplish her plan. 

Before meeting with the dietitian, Nolan didn't have any food issues. Sure, he didn't eat quite enough of it, but he likes a lot of different types of food. He ate salmon the other night, for goodness sake! With her plan, he is learning to drink only milk, and is getting sick off it. Instead of supplementing his meals, the mighty milk is replacing his meals. 

In fact, we can't even get 2 cups of mighty milk into him during a day. For the past two days, he has only had one cup. Yesterday, he refused to drink more than a quarter of a cup. It makes him feel bad, and he isn't stupid. He isn't going to drink something that makes him feel sick. The mighty milk is just a bad idea for him.

It isn't working. Plain and simple.

My intuition flickered at her note that she was now sending his prescriptions to our pediatrician. I had told her (in our initial meeting) that his pediatric group rotates doctors, so he often never sees the same one twice. In fact, he hasn't seen his "official" primary care doctor in approximately three years, as a nurse practitioner has been the one to see him for at least the past two well-child visits. Her comment that his "pediatrician knows him better" tipped me off that the surgeon might not agree with her assessment. She was purposefully avoiding talking to the doctor who had seen Nolan the most frequently over the past six months. Something wasn't right.

I decided to call the surgeon's office and schedule a follow-up appointment for the end of September, since that is when Nolan's "four week oral trial" will be finished. The office staff could tell I was a bit stressed, so I told her (in a slightly higher pitch than normal) that "Nolan-is-bloating-and-has-diarrhea-and-the-mighty-milk-makes-him-sick-and-I-don't-know-what-to-do-and-he-threw-up-in-California-and-I-think-he-might-have-reflux-again-and-I-am-really-stressed-out!"

I feel badly that she ended up with the call from the crazy, stressed out mommy. She was wonderful, though. Instead of telling me that I was silly, or overreacting, she took care of it. She told me that she would put him in for September, but also that she was going to page the nurse. The nurse would call me back.

I still felt a bit silly, as it wasn't really an emergency, but something just wasn't sitting right. The dietitian had insinuated that Nolan's intake was a behavioral issue. Having lived with the full brunt of Nolan's digestive tract for the past five years, I heartily disagree. 

I was walking out to the car to go to Nolan's sleep neurologist appointment when the phone rang. It was J, the surgeon's nurse. She was a great calming force.

"What's going on, Mom?"

I gave her the lowdown, from the issues the mighty milk was causing to the vomiting attack in California. 

By the tense tone in her voice, I knew she wasn't happy with the dietitian. Apparently, the dietitian had been told to order a pump, and refused to do what the doctor ordered. I told her,

"I might be overreacting, but I'm worried that the delayed gastric emptying is causing a big problem. And I'm worried that the reflux is back, with the vomiting being so severe."

She simply said, "This is why we wanted to do overnight feeds. Some children cannot physically, medically take in the right amount of food to grow. This isn't a behavioral issue, this is a child with a known history of severe GI tract issues who had a fundoplication and needs nutritional support."

As a side note, the dietitian also lied to me. She told me that overnight feeds were not possible with the C-Pap. After conferring with other parents who have children who require both, I found that this was patently untrue. Children CAN receive overnight feeds and use C-Pap (or BiPap) at the same time - as long as a nasal mask is used in case they vomit. His sleep neurologist confirmed this at our appointment later that day.

I especially loved the nurse because she had a plan. I didn't have to continually fret over something that wasn't working. Her plan is:

1. Do an upper GI barium to ensure the fundoplication is intact and functioning. If it isn't, this is the cause of his vomits and feeding problems. If it is, then we can relax about that portion and focus on step #2.
2. Get a pump and do overnight feeds. This will allow him to eat normally during the day, won't cause him to miss classroom time, and will allow him to grow with a nutritionally complete formula (as opposed to chocolate milk).

The upper GI will be done this Friday. I am waiting for the hospital to call with the time. They can put the barium through his g-tube, so the procedure will be extremely simple for him. In the meantime, he is eating regular food and is happy to stay away from the horrid mighty milk.

Five

I'm not sure how it happened, but somehow my baby has turned five years old. Five. I'm pretty sure there has been a rupture in the space-time continuum, because there is no way five whole years could have elapsed from this:

 to this:

Man, I am lucky to have this kid in my life. I'm not sure how I deserved the awesomeness that is Nolan, but somehow I won the lottery.

He totally cracks me up. "Mom," he said, "take a picture of me like THIS!"

"And THIS!"

"And THIS!"

He is hilarious, brilliant, quirky, and fun. I'm so glad I get to be his mom.

Back to School Shopping

In less than two weeks, school starts. Nolan's kindergarten information packet has arrived, we have his teacher assignment (Mrs. H) and his supply list. His teacher seems pretty wonderful and has already called to see how things are going for us.

Instead of worrying about how we're going to keep Nolan fed in school, I buried myself in retail therapy today. I took the kids to Erie, PA and we went to Target in a quest to find backpacks, lunchboxes, and school supplies. Apparently, kids in Pennsylvania start school before kids in New York, because the backpack section was wiped out and they were not re-stocking. I did manage to get everything else, though, so I'm calling a huge WIN on the shopping trip.

After the necessary supply shopping, I took the boys to the mall to find the Crazy 8 store. For those who aren't aware, the store is owned by Gymboree and the clothes are adorable and low-cost. I managed to get several really cute outfits for both boys - the shirts were about $4 each and the jeans were $7 for Nolan.

The shirts run big at Crazy 8, so I picked up some 3 year old size shirts (Nolan normally wears a 4T). I absolutely love this dinosaur outfit:

Nolan's Giant Tummy of Bloat is a bit better today than yesterday. His surgeon already wrote me back and asked if the bloating was from air (he asked if he had been crying a lot, if he liked the milk, etc). I told him that he hadn't been crying and simply got too full - he likes the "mighty milk" taste. The surgeon suggested venting him if he bloats and draining off the excess so that he remains comfortable. Even though we might lose some of the calories by doing this, we can't have him in such distress.

Sorry for the details, but this blog is as much a way for me to keep records as it is for keeping friends and family up-to-date. Stop reading now if you don't want a blow-by-blow account of What Nolan Ate. It's dreadfully boring.

Instead of making waffles for breakfast this morning, I gave him some dry cereal with the mighty milk on the side. This let him get in his 8 oz. without too much discomfort, since he had an empty stomach. We drove to Erie and ate lunch at Panera Bread - he didn't eat his macaroni and cheese at all, and only ate a tube of yogurt. We went shopping and came home - he had a little bit of bread, but really hadn't eaten anything since breakfast.

He did eat dinner well -one stuffed shell, some green beans, and a small clementine. He drank the last 8oz. of mighty milk and then had some orange juice. He was bloated and uncomfortable, so I vented off some air and a small amount of fluid.

We're looking forward to the weekend and Nolan's birthday on Monday. I can't believe my baby is five!

Mighty Milk

Since Nolan didn't like the Pediasure, the dietitian suggested adding 1/3 cup powdered milk to a cup of chocolate milk. They call this "mighty milk" and it has double the calories of a regular glass of milk. We went out and bought some carnation powdered milk and added it to a cup of chocolate milk - Nolan liked the taste, so that was a big win.

Yesterday, he ate breakfast (one and a half waffles) and then I gave him his morning "mighty milk" snack at about 10:30am. He would drink a little and then be done for a while, then drink a little more. I spent most of the day chasing him with a sippy cup, trying to get him to drink the entire volume. It took until 4:00pm, and he didn't eat his lunch or much of dinner because of it. We still had one more cup to get into him, so we sat over him and didn't let him move until he had downed the entire cup of milk.

He drank this one over the course of an hour, and didn't feel well. His stomach bloated and he was "too full."

He then had severe diarrhea and, while still bloated, seemed to feel a bit better.

For comparison purposes, his stomach is typically flat and not tight-as-a-drum and bloated:

I have emailed the surgeon and I am waiting for some direction - I can't make the kid sick like this, but obviously he needs more calories.

I really wish they'd look into the "why" of the bloating, because maybe we could treat that and have a boy who is able to eat normally without all of this craziness!