Sunday, July 27th - Lots and Lots of Vomit

Sorry for such a late post. To put it mildly, Kinley had a bad day and therefore the blog is playing catch-up.

Kinley has a new nurse today, Lynn. When I arrived Lynn informed me that Kinley was having a bit of a rough morning. At 6:00 am she threw up around 5 ccs of milk and then at 8:00 am she threw up again. The 8:00 am vomit was right after she had received her sodium chloride (electrolyte), erythromycin (stomach and intestine motility) and multi-vitamin with iron supplement doses.

I had arrived after rounds so Lynn gets me caught up on the changes I missed. Today we are going to try and feed Kinley all 90 ccs by bottle. Whatever she doesn't take by bottle will be given through her NG tube. This seems like an awfully large jump considering the most she has ever taken by bottle has been 15 ccs. Another big change is that they are going to move her methadone doses from every 12 hours to every 24 hours. All of her other medications will stay the same, but they will start to give her her multi-vitamin with iron at different times than her other medications in case that is too much for her stomach to handle.

At noon, it was time for Kinley's first attempt at a full feeding (90 ccs) by bottle. She took 35 ccs without any problems so we took a small burping break to try and get rid of any excess air in her stomach. After 4 or 5 pats on the back Kinley threw up just about everything she had just eaten onto my lap. (Good thing my jeans are so absorbent. We hardly had to get any towels dirty.) Lynn and I decide that we should probably give Kinley 75 ccs of milk (still being fortified to increase the calories to 22 per ounce) through her NG since she threw up most of what she had gotten from the bottle. While Lynn is getting the NG feed set up I head home to change my clothes.

I returned in time for Kinley's 3:00 pm feeding. While I was gone Kinley overfilled her diaper so much with poo that she had to have her outfit changed. Also while I was gone, Delores (nurse practitioner) came by and said that she did not want Kinley to take more than 20 ccs by bottle and have the remaining 70 ccs given through the NG tube. Kinley and I sat down for her 20 cc bottle and she ate every drop. She also kept it all down when I burped. My clean clothes were very happy about that.

Right around 5:00 pm (30 minutes after her 3:00 pm feeding had completed) Kinley woke up from her nap and vomited more than she had all day. Lynn and I were guessing that it was at least 30 ccs. My gut feeling is that this was from withdrawals because she was asleep right before it happened. My next thought was that she had too much air in her belly and that caused her to throw up. I know I have not said it in this post yet, but Kinley had been screaming her head off a good portion of the day and understandably so. She had just vomited for the fourth time today. Whenever Kinley screams she gulps air between yells and a portion of that air goes into her belly forcing it to expand. If her belly becomes too expanded her body will relieve the pressure by pushing it out and making her vomit. This option is a bit less likely since Kinley was asleep right before it happened. No matter what my thoughts are, the cause is still unknown. So an abdominal x-ray is ordered to try and help us figure out what is ailing Miss Kinley Melcher.

Delores and Dr. O had already left for the day so Ann, another nurse practitioner, and Dr. S had to review Kinley's x-ray. They notified Lynn that something in the x-ray was abnormal and that she should not give Kinley her 6:00 pm feeding. They also said that they would come over to Kinley's bed station to discuss the abnormality. Needless to say, this left a lot of horrifying thoughts floating inside my head. It felt like forever before Dr. S and Ann arrived. Kinley had been screaming at the top of her lungs the entire time, most likely due to hunger pains from throwing up a good portion of her 3:00 pm feeding and not receiving her 6:00 pm feeding. Dr. S explained that the abnormality was that one loop of Kinley's bowels was dilated. This means that there could be a bowel obstruction and they may need to do a barium study to find out for sure. But before they do that they will wait and take another x-ray after shift change to see if the dilated area has changed at all. In the meantime they had the charge nurse, Jennifer, place a peripheral IV in Kinley's right foot so they can give her fluids while she is not eating. They also ordered some IV methadone to give Kinley since she cannot have anything through her NG tube until her bowels look normal again, but the IV methadone will take a while to arrive. Dr. S moved Kinley's methadone doses back to every 12 hours in case she is having withdrawals.

After shift change we returned to find Kinley getting her x-rays. Kinley's methadone dose arrived during shift change and she seems much calmer now. Dr. S has reviewed the new x-rays and she came by Kinley's bed station to tell us what she sees. Kinley's bowel looked much better. The contents of the dilated area of bowel were now spread evenly throughout her bowels. Dr. S also informs us that Kinley has a hiatal hernia. This is brand new news to us, but apparently the surgeons noticed it when they were doing Kinley's diaphragm repair surgery, but no one told us about it until today. A hiatal hernia is when the hole in the diaphragm, for the esophagus to pass through, does not fit snugly around the esophagus. This leaves space for a portion of the stomach to push through causing reflux and vomiting. Hiatal hernias are common, even in healthy individuals, and for now, according to Dr. S, there is nothing we can do about it. (Sofia Miller, Kinley's CDH mentor, recently found out that she has a hiatal hernia also. Her parents found out that if the hiatal hernial is severe enough that medications cannot control its side effects then there is a surgery to fix it, but it is permanent and has a lot of possible complications with nasty side effects of their own.) Lastly, Dr. S tells us that Kinley will receive another x-ray in the morning to determine if, when, and how much Kinley might get to eat tomorrow.