Day 29 - approximately 3 steps forward, 2 back

We began the day early with a 2am phone call from Daniel's attending doctor - Dr. Ba. (why do all his doctors start with W or B... it makes me keeping them anonymous, yet known to me trickier). Team Daniel had been talking through the evening and night about his blood pressure as it was dropping lower and lower. It was now time to act.

The request was to put in a central line in his leg to accommodate additional IVs that they would need to bring his BP back up and stabilize him. The central line allows you to plug in many IVs into a complex "accordion" that all flow into the large/wide central line that goes into a large vein like the femoral vein in a leg. All surgical procedures like this require that we approve it - thus the phone call. If there's anesthesia involved then that's another approval. [Naturally, if they could not reach us and there were an emergency they'd do it to save his life, then discuss after.]

Since the time we left last evening (I'm sure he was just missing us, yup that's it) his BP had started to drop. Daniel's attending Dr. Ba, his graft surgeon Dr. Wi., Dr. Br. (another attending), the nurses and support staff had been tracking and consulting all through the evening up to the time they decided to call us for the go ahead. The team felt that the short surgery Monday followed by the REAL long 6 hour surgery on Tuesday had been the main reason for his BP to drop and keep dropping.  Fun fact: During a surgery they discontinue all nutrition at midnight before until after he's back in his room. In Daniel's case he hasn't had much to "eat" since Sunday.

 At any rate the central line was inserted in his left leg (since that's the only place he's not burned). This is a fairly routine procedure, but it's done by a doctor not a nurse. The line uses a wire that guides the line up through and into the femoral vein. This wire is maybe 12" or longer and once the line is in place, then the wire is pulled back out. It's rare, but sometimes the pressure in the vein sucks the wire up further into the vein towards the heart. Well, that's what happened this time. This created a semi-emergency to retrieve it and redo the central line.

When we arrived in the morning for rounds that was the focus of the discussion - low BP, retrieve wire, redo central line, beef up his food intake. More procedural approvals and he's off to the IR lab. Wound care can wait until later. Dr. Ba. felt really really bad and apologized to both Dawn and I for the problem with the central line wire slipping loose and into Daniel's vein, but I don't see it so much as an error. It was an accident that happens one time out of 1000. We accepted his apology. Time to move forward.

The three giant steps we took forward this week are that his face, throat and neckline are all grafted from donor sites on his head (under his hair). We took a couple steps back due to the toll the surgeries took on his recovery and the subsequent problem with his BP.

This following paragraph is probably not entirely accurate or oversimplified, but here's what we're challenged with: The fallout from the past three days of surgeries 6 & 7 is a concern for the still-present fluid in his lungs turning to pneumonia. To treat the low BP they need to flush his system of the pain and sedative drugs used during surgery. Those drugs tend to dilate his cells and cause the low BP (among other things.) Because he's wiped out from the surgery and he has to limit his movement for the next three days (that gives time for the graft to bond to the new location) his lungs are likely to be a place where fluids will pool - so more coughing and hopefully deep breaths to help keep his lungs clear.

The next three days may look like this:

• Daily Wound care - We still need to tend to his wound care each day - that's a painful process so pain meds for that. 
• Limit movement (72 hours usually does it) to allow new graft to take hold.
• Push fluids to get his BP under control.
• Push nutrition to get him back to where he needs to be.
• Measure blood for clotting (too thick or too thin - both are bad)
• Watch for infection and treat.

--+

I mentioned Daniel's grafting yesterday during surgery 7 and described it a little, but I'll add more detail. 

Daniel's graft goes on part of his cheeks, then on his chin and all the way down to his neckline and a little below that onto his chest. They used donor skin from his head to graft with until they ran out for the lower portions. For that they used part of his left shin and meshed it like they did for his arms. All the grafting for this area was bolstered and stitched to him. So there are about 7 or 8 stitches to his cheeks holding the grafts and gauze in place. Then further down and around the graft site there are more stitches. I was imagining a tailor making a very contoured coat to cover the area and it amazes me how tricky it must have been to take fairly flat skin from his head and make it fit all the contours of one's chin and neck - and make it look so amazing. 

Dan's face and cheeks are swollen looking and his mouth looks like it's being pulled open slightly from the stitches. It doesn't look comfortable by any stretch (pun).

We are all anxious to see how it all turns out in a few day's time.