More Seizures, and Finally: Epilepsy Surgery

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Finally, after 2 weeks of high stress and hundreds and hundreds of seizures, Savanna was in the EMU.  Tuesday morning, September 4, was a very busy day. By 8am, the EEG equipment was installed, an IV had been started, and the reality of her situation became apparent to all.  She was having a lot of seizures with increasing frequency and length.  The sense of urgency to control her situation was present in everyone around involved in her care, which had not been the theme of the past two weeks.  The sense of relief as a parent was overwhelming, for about 1 minute.  Then reality set in, that her situation is as bad as we thought.  Our doctor recognized how difficult our situation had been over the past couple of weeks after a short discussion.  I briefly explained our experiences in the EC and she remarked that an experience like ours it is not uncommon for a child like Savanna.  I found that comment to be really depressing, as that means many families like us are dealing with this situation.  Anyway, after about  3-4 hours of monitoring, many, many seizures were captured.  Intervention was often initiated , with high doses of chlonidine, ativan, versed, and valium.  Savanna’s seizures were proving to be refractory, however their presentation was always the same, clinically and electrographically.  While it was not good that she was having seizures, it was good that not only were all the seizures the same in terms of presentation, but the data correlated with data acquired in CA.  It seemed like we were finally starting to gain some traction.  The momentum toward epilepsy surgery was building quickly.  Finally, she was able to sleep soundly for a few hours after receiving enough medication to sedate several normal adults for many hours.  She was quickly moved to the imaging department where a high resolution MRI and MEG preparatory scan were performed.  EEG equipment had to be removed and then re-installed.  Down to the CT scanner for a PET scan.  This was then cancelled because this hospital doesn’t use GA (general anesthesia) for CT scans.  Our ultimate focus was turned to the MEG scan schedule.  A MEG study had great potential for Savanna to be a very compelling diagnostic tool.  We would have to wait on the scan this week, as for some reason the insurance approval is not quick for this type of test.  I would say too, that ‘logic’ and ‘medical insurance company’ should not be used in the same sentence.  Their business model is to make money by limiting reimbursement or simply disallowing reimbursement.  They accomplish this by making the billing so complicated and convoluted, that few can understand it.  To date I have spent ten’s or hours on the phone trying to straighten out tangles in our benefits.

[Sidebar:  When we left CA, we were using a CA based HMO – meaning a plan subscribed to by CA doctors only.  This meant that we had to either start over on Rebecca’s plan, or engage in Cobra insurance through my employer.  It appeared on the surface that it would be better to engage Cobra, as we had already paid the maximum out of pocket by family, and our additional payments would be limited to just a few thousand dollars, plus premiums.  My company is a small group, and as such they used ADP for payroll and medical insurance premium collection and payment.  This meant, I could not work with BCBS myself, I had to involve ADP and my employer.  We needed to select the PPO plan offered by the company to make sure we could get coverage in Texas.  There was a real problem getting ADP to talk to my employer to straighten out the offering, as they continued to only offer me the CA based HMO.  Now the deductible and out of pocket monies had to moved accordingly.  BCBS had some other billing problems still in play when this switch happened, and that seemed like a wrench thrown into the transmission.  It took several more weeks to straighten out the situation, and Savanna needed a lot of care in the meantime.  This meant a lot of providers pinging the insurance company for payment instructions, and I could not explain to these people what was going on.  It turned into an accounting and insurance headache that we did not need in the midst of this crisis.  To add to the problem, a system issue created a billing problem with the twins.  The hospital and other providers submitted claims on Savanna’s behalf, but the insurance company was recognizing the claims for Austin instead of Savanna.  Birth date is now a big factor with the new HIPPA rules in place and the BCBS system had a glitch with multiples.  This meant all claims were being paid based on Austin not having met any deductible or out-of-pocket expenses, not to mention no need for some of the extremely expensive testing that we were trying to undergo with Savanna.  What a mess.  I noticed the issue on the web portal and have been fighting it ever since.]

Wednesday saw the start of the ‘magical’ Keto diet.  There is not scientific proof of why this special diet works.  However, it can work, has proven to work, and now is considered a front line treatment option in many comprehensive epilepsy clinics for infantile spasms.  In some cases, when all else fails, it has provided relief from seizures.   Also, in many cases, there is no diagnostic proof that it will or will not work.   It is more of scientific herbal therapy in my view as the scientific manner in which is stops seizures is not known.  The field of genetics is also exploding right now, and eventually the severe metabolic disorders that enable the Keto diet to provide seizure relief, will be discovered.  The Keto diet has been around for many years, and it is similar to a Atkins style diet.  Basically, the intent is to change the fuel for the brain from glucose to keytones.  More information about the Keto diet can be found here, at the Charlie Foundation website.  Savanna’s titration schedule for Keppra accelerated to go to the maximum within a few days, rather than another week or so.  At this time, she was on schedule dose of 1.0mg of ativan Q6. (every 6 hours) and this was keeping her quite sedated.

Thursday, Keto implementation continued, and ativan dose was adjusted to 1.5mg Q4.  She was starting to get used to the ativan, so we had to increase the dose.  It was an overall good day.  No EEG equipment was installed, but I still could not hold her to console her as she was so agitated when awake.  Again, she was still having 2-3 seizures per hour, sometimes more.

Friday, she had a much better day.  The Keto diet was 100% in place now and she seemed to be tolerating it well.  She was still having several seizures per hour.  The video in the previous post is a short clip from this day.   The time between the seizures was not always so difficult.  This was a great relief to us and was very inspiring to see her more engaged and at least not so unhappy.   During all of this,  Rebecca had been maintaining a high-visibility work presence and was taking care of the big kids at night.  The stress of not being in the hospital with her daughter on top of being the primary breadwinner was immense.  I am not sure I would have handled it as well.  Again, much thanks to Rebecca’s Dad who was here through that week to help at home.

Saturday morning, Savanna was discharged in good health, but still having seizures.  She was on 9mg of ativan per day with orders to allow 18mg per day if needed.  It seemed like after a 1.5mg dose, she would be okay for about 3 hours.  Happy for about 1/2 hour, then have a few seizures, then sleep for about 2 hours.  When she awoke, she typically had seizures right away.  I don’t want to say you get used to the seizures, but there did come a time, where my concern was lessened as long as they ended in the normal time and she returned to baseline quickly.  The doctor felt she was a good candidate for the surgery and we had plans to meet the surgeon and complete the MEG scan too during the next week.  This is what we had been preparing ourselves for, and now it seemed like it was finally here.

Then Brandon…, a fish feeder…, an Emergency Center visit…, and stitches…. As if things couldn’t get worse… I had been basically away from home for about 5 days with Savanna, and when I got home with her Saturday afternoon, the big boys wanted to do something with me.  I decided to take them fishing.  There are two docks on our lake where there are fish feeders installed.  They run twice per day. Inside the olive drab green box, there is an aluminum fan blade that runs while food is dropped into it from above.  The food is then discharged out into the water.  Yes, you can see where this is going…  So, I was helping Tristan unhook a fish and Brandon was behind me, within arm’s length.  The fish feeder starts to run.  It is empty so nothing is coming out.  I then here a ‘clunk’, and I thought to myself, “Hmm, I have never heard it do that before, though I have heard the feeders run numerous times?”  Then the scream, the unmistakable scream, when you don’t have to question the level of hurt.  The kind of scream you know requires medical attention.  Yes, Brandon (then 2 years old), decided to reach into the discharge end the running feeder.  The ‘clunk’ I heard most likely was the unit being stopped abruptly when his finger jammed the impeller.  I whip around and his finger is just squirting blood.  I could not tell how bad the damage was, as he would not hold still.  I pulled off his shirt and tried to soak up the blood so I could see the wound.  Yes, it was pretty bad, and yes back to the ER we went for some stitches – but it wasn’t that bad really.  I would agree with Brandon’s assessment, in that it probably hurt like a son-of-a-bi!@#.  He lost his finger nail and had a pretty good cut across his index finger.  Supposedly, his nail will grow back according to the ER doctor, (and a month or so later, it is).

Tuesday morning was the day for the MEG scan, and we headed out early to the medical center.  We gave her extra medications once there to try to keep her calm, but it didn’t seem to be helping.  The EEG technician installed the montage of EEG electrodes, the MEG electrodes, and registration blocks.  There was almost no room on her little head for anything else.  It was all glue and wires.  She was really upset and these folks were looking at me for a solution.  “Are you kidding me?”, I thought to myself, as I tried to console her.  I couldn’t hold her, or do anything with her, and was expected to hold her down onto the bed, while also holding her head a certain way. After about 45 minutes, I was sweating, the EEG people were sweating, Savanna was enraged.  The technicians were looking to me to administer something to calm her down.  It actually felt like the pressure was ‘the other way around’ this time, like normally we as parents are looking to the doctors for such relief.  Kind of bizarre.  I went through what she had been given today, calculated what was safely available, and went for it.  I administered another .05mg of chlonidine and finally, within about 15 minutes she was sleeping soundly.  After 30 minutes of sleep monitoring, they asked me to try to wake her up.  As soon as she started to wake up, she seized.  We were able to capture a 60 second seizure with great clarity.  It was wonderful news according to the doctors.   After the MEG scan, her doctor came down to see the results first hand.  I mentioned what I had given her this morning in terms of medicine.  We all agreed, Savanna would be really knocked out for another 2 hours.  Quick action to try to squeeze her into the MRI schedule was underway.  We moved swiftly to the imaging lab, and had the scan performed.  This was a repeat scan since the first one seemed somewhat fuzzy.  They actually used the words ‘Free of charge to you’, when describing the procedure.  I almost laughed out loud.  Two hours later, she was done, and I felt a sense of accomplishment that day.  According to our doctor, no other scans should be needed moving forward.

[Sidebar: The MEG scan itself is unbelievable.  It is amazing technology that has many applications and more information can be found here regarding MEG technology.  I was able to see the results right after the scan and it was phenomenal what can be accomplished in this day and age.  It identified the locations in the brain that were involved in the seizure with extreme time resolution, and three dimensional spatial resolution of around a millimeter.  That is truly unbelievable to me.]

Wednesday was a good day, but I did notice her seizures were becoming longer.  30-45 second events had become 45-90 second events.  We had increased her ativan to the maximum dose of 18mg per day, and it didn’t seem to be helping any.  This was a troubling development, and one that increased our sense of urgency for the epilepsy surgery.

Thursday, we finally had our appointment to meet the surgeon.  After an hour or so with him, we for the most part understood the major components of the procedure, what to expect during her stay, and what to expect during recovery and at home.  He was recommending a focal resection of her left hemisphere.  She would have a large section of brain tissue removed from the Temporal, Occipital, and Parietal lobes of her left hemisphere of her brain.  The plan was to remove the brain tissue involved in the seizure focus.  The ultimate goal was to stop her seizures, prevent development of Lennox-Gastaut syndrome, and allow her the capability to develop to her full potential.  The plan would have multiple phases, but all could be accomplished in one procedure if everything went a specific way.  They would first open her up to expose the brain, implant electrodes to measure brain activity right in the OR.  If activity confirmed and correlated with prior diagnostic testing, then the resection would occur right then.  However, if there is any uncertainty, electrocorticography would be put in place.  This is where a grid of electrodes would be implanted into the brain tissue covering the area indicated by diagnostic testing as the seizure focus.  Re-install the cranial section removed, move to the ICU, then to the EMU for monitoring.  This isn’t a bad situation, just another step in the process to make sure the procedure has maximum effectiveness, with minimum removal of ‘good tissue’.  After a period of hours or days, a final determination on where the dotted lines would be placed for tissue removal could be ascertained.  Back to the OR to perform the resection.  After a day or two in recovery, she would be discharged home, with very limited  restrictions.  Then, medication would be removed from the  equation in the order that it was added.  If she has seizures, we know they didn’t get all of the tissue in the focus, or the activity had kindled somewhere else in her brain.  There is some pause here, as she was diagnosed with Infantile Spasms, which is a severe and generalized seizure type .  This means her entire brain was in seizure.  The theory and hope now is that she was having a complex partial seizure onset, that quickly changed to a generalized seizure when she was so young.

Our building enthusiasm was deflated when he stated that October 29th would be the surgery date.  It was like a 2 year old accidently popping a balloon at their birthday party.  The child would be not happy for a moment, but the larger situation would soon be realized and happiness returns.  He stated that he would be able to fit her in the 15th if his schedule was changed.  This wasn’t as daunting, but being 4 to 6 weeks away was really disappointing in a way.  We maintained the faith, as four more weeks of waiting was all that stood between Savanna and a hopefully life-changing event.   After lunch, we had another consultation with the epileptologist.  She decided to add onfi, another AED from the benzodiazepine family of drugs.

During the next week, we saw no real change in her seizure pattern, but she seemed overly sedated.  We started backing down the ativan.  Nothing changed in her seizure pattern, but the length of the events was increasing which had started even when on really high amounts of ativan.  We were charting all of her seizures, and we typically measured them in seconds for relative frame of reference.  Now we began measuring in minutes.  2-3 minute seizures were now the norm.  We were becoming desperate and anxiety of the surgery was increasing.  We purchased an apnea monitor so we would be alerted if she stopped breathing.

Another clinic visit the following Thursday resulted in doubling the onfi dose to 30mg per day, from 15mg.  This is high for such a small child, by anyone’s standard, but the doctor felt comfortable, and therefore, so did we.  The schedule was a one week titration up to the 30mg dose.  We had stopped the ativan completely by this point.  By mid next week, something changed.  Savanna was not having as many seizures, and seemed to be much more happy.  We had weaned her off the ativan completely.  By Friday the 28th, I sent an email to the doctor a with video attached with amazing results.  Savanna was laughing and engaged, and had stopped seizing – as far as we could tell.  Rebecca and I were beside ourselves.  It was a huge relief for us, as watching the seizures progress to 4-5 minutes was really difficult to experience.  Savanna was still experiencing seizure activity, but it was dramatically reduced.  It took some time for us to really hone in on the seizures now, as they were only lasting a matter of seconds, if you noticed them at all.

After the 28th, life became much more manageable in general.  While still tense, we were really looking forward to the 16th of October, which was the official surgery date.  While we still have a lot of mixed feelings and questions about “Why?”, there remains a strong resolve and faith that guides us during this journey.

[Sidebar: Why did this happen to her?  The ultimate question remains: why did her brain form incorrectly?  It’s impossible to be in this situation and not wonder if there was something that could have happened while Savanna was an embryo that might have been within our control.  While all doctors have said many tests have been done, and that is not the case, Rebecca will always wonder, did she work too much while she was pregnant?  Did she drink too much caffeine?  Did she eat lunch meat or hot dogs? Did the one glass of wine she had the entire time she was pregnant cause this?  I’ll wonder if the boys were too rough with Rebecca.  Did they hit her or kick her in the stomach while she was holding them?  Is this something that will only effect our girls?  She had 2 miscarriages before Tristan was born.  Maybe they were girls?  Maybe the only reason we have Savanna is because she was a twin and Austin was able to somehow keep the environment in the womb stable enough for Savanna.  Not sure we will have an answer for that in our lifetimes, but what we will most likely find is the etiology of her disorder.  As of now, she has an idiopathic diagnosis which means they don’t know why she is having seizures, or why more specifically she has a cortical dysplasia lesion in the part of her brain with a current seizure focus.  Genetic and metabolic testing has been performed, but it has been what they call ‘targeted’.  Meaning, they were only looking for known causes of the disorders that cause seizures, very specific mutations.  In today’s times, targeted testing is still the standard.  Tomorrow’s testing will be much more comprehensive.  They will most likely start sequencing the entire exome (or genome of the family) of a child like Savanna.  Here is a link to an article that caught my attention.  The article basically gives the history of a family with no known seizure disorders in the family, and a daughter who develops epilepsy.  Her seizures proved intractable, were generalized, and eventually took her life at the age of 15 as a SUDEP case.  The article describes the whole genome sequencing process and how they discovered, (and confirmed) a new de novo mutation that caused the child’s epilepsy.  They do this by analyzing the DNA of the mother, father,  sibling, and affected child.  After contacting the authors, I learned the deceased child was that of the geneticist.  I spoke with him in person, and we intend to send our DNA to the Hammer Lab at the University of Arizona for whole genome sequencing in the search of the mutation(s) that is responsible for Savanna’s epilepsy.  We will do this after the surgery, as we feel Savanna needs all of her blood volume in preparation for the surgery. ]

Amid all of this craziness, Tristan our 4-year-old, started T-Ball for the first time.  For parents who don’t take the ‘sport’ so seriously, t-ball with 4-year-old kids provides great comic relief.  For me, there is some emotional release when my child makes a good play, and I think this will probably be the case for some time.

Savanna and Austin celebrated their 1st birthday on the 20th of September.

Brandon celebrated his 3rd birthday on October 7th.

It has been very busy around our house.  I included a few pictures of those moments too in group.

Savanna’s surgery date is October 16th.  We could not be more anxious about this day.  We made plans for family to be here to not only help with the other kids, but to experience some of the hospital time with their granddaughter.  It is a very emotional time right now, and the more family that can be here to help the better.  We really feel fortunate to have family that can walk beside Savanna and with us during her journey.  Savanna is a strong little girl, and she has a lot of fight in her.  We don’t see any signs of her giving up.  She truly is an angel.  Savanna’s Journey now has turn that includes epilepsy surgery.

-mom and dad

(Ken and Rebecca Lininger)

Seizures, Seizures, and more Seizures

Savanna was discharged from the EMU at TMC on August 22nd after a bizarre EEG report indicated seizures with an onset in the right hemisphere.  This is not what we had seen to this point, and it was truly devastating news.  If confirmed, this would mean that the issue with her brain was not confined to the left hemisphere, and the surgical option may be off the table.

Savanna was not on phenobarbital, but now on Keppra, and still on Sabril.  She was still having complex partial seizures, but no cluster episodes or events that required intervention.   We were in a wait, watch, and see period again.  We were given a script for the diazepam rescue medication, to be used when she won’t stop seizing.  This in and of itself was a bit scary.  Her doctor was on her way out of the country to France for about 2 weeks.  We were told of her limited availability and the reins were handed over to her Fellows with oversight coming in the form of overnight email communication.  No back-up partner or pediatric epileptologist on staff meant few people available to make the difficult decisions to help her in crisis.  We had no idea how much of a headache this would be for Rebecca and I over the next 2 weeks.

On Thursday, August 23, the situation seemed manageable.  She was very sleepy from all the activity and this was normal presentation after EEG equipment is removed.  We witnessed a few seizures, and at that time it was of great concern to us but we couldn’t do much about it.  Rebecca and I were already contemplating the future, second guessing our decision to be in Houston, trying to re-engage her doctor in Orange County, CA.  I was the lead on choosing this particular doctor, and I was feeling like I made the wrong choice.  Internally, it was really starting to bother me.

Friday the 24th, Savanna had a really great day.  Her demeanor was wonderful.  She smiled, laughed, and was engaged at times.  Then she would have a seizure and our hearts sank as it took our breath away.  We were very concerned, and wondered if this may really be the new normal.  We were not ready to accept this paradigm shift.  We noticed as the afternoon progressed, she became increasingly agitated.  That night, this agitation grew to inconsolability and we were up with her the most of the second half of the night.

Saturday the 25th, she just would not stop crying and screaming.  It was exhausting for everyone involved.  We clinically could not determine if she was even having seizures due to her extreme fussiness.  When she would finally tire out and sleep, the big kids wanted to play or do something that Rebecca and I had little energy for meaningful participation.  We noticed Tristan’s level of comprehension had increased as we tried to explain Savanna’s condition.

Sunday the 26th, was a really difficult day.  Savanna would just not stop crying.  She was rigid with her body, would not take feeds anymore, and was completely non-responsive to Tylenol or Ibuprofen.   We were not even able to hold her she was so upset.  She had to stay in her crib, in a bouncing seat, or on the floor.   We contemplated the next direction with respect to her care as we did not feel it was going well.  For a moment, we were lost.  Our natural instinct was to take her to an emergency room at a hospital.

[Sidebar:  It was Sunday, and we knew we could not to go to any emergency room as they were unable to help her due to the complexity of her case.  Emergency departments exist to stabilize a patients with immediate life-threatening situations.  Despite the catastrophic damage happening to her brain in terms of development, Savanna was not in an immediate life-threatening situation (as long as she wasn’t in status).  As parents, we felt her future capabilities were being threatened by her continued uncontrolled seizures.  This is how it was explained to us in the beginning of this journey.  Her condition and presentation was changing rapidly.  Without the presence of our doctor who could directly admit her to an EMU, the only way to permeate the membrane surrounding in-patient services is through the Emergency Department.  But, many people use the ER as their primary care, and thus it can be a concentration point for a wide variety viruses.  Illness can greatly reduce the seizure threshold for someone like Savanna.  This is a subject I have thought a great deal about, and there should be another ‘way in’ for someone like Savanna.  Recognizing these factors, we decided to manage the situation at home with the medications we had on hand – right or wrong.]

Monday, August 27, we consulted with the Fellows on her team, and the conversation resulted in re-starting the phenobarbital as they felt she may be experiencing symptoms of withdrawal.  We administered the medication, watched, and waited.  Monday night seemed to go better, but by Tuesday midday, we felt confident that phenobarbital withdrawal was not the problem.   Under their advisement we, took her into the ER on Tuesday afternoon.  I was told she would be a direct admit (meaning we would check in to ER and then move immediately to the EMU). Tuesday afternoon, I packed our suitcase and headed for the hospital feeling anxious but relieved that we were going to get help managing her situation.

Once there, a fiasco ensued.

I thought we were headed to the EMU, but the ER personnel didn’t get the memo and started a complete work up for infection and injury.  They had plans for a lumbar puncture and CT scans with contrast of her head and neck.  Complete blood panels were drawn, despite the fact that this was just done a few days ago.  I thought we would be admitted to the EMU, and she would get help right away.  Wrong.  Once again, nothing I said mattered.  Patients like Savanna are few and far between.  I could hear the conversation out of the room simply dismissing my assessment and presentation of her history and physical condition.  They were actually going down a path that Savanna was having febrile seizures, which meant provoked seizures brought on by high fever – not epilepsy.  She didn’t have a fever.  She hadn’t had a fever in months.  There was one particular attending physician, who recognized us from the visit during the prior week.  He was the only one who knew even a little bit of the magnitude of the situation and finally stepped in to change the course of care.  After two attempts, one of the nurses was successful at installing an IV.  But, Savanna was clearly altered and in state of wild hysteria.  I simply could not hold her or control her at this point.  She managed to get the end of the port in her mouth, and with only 2 teeth on the bottom jaw pulled the IV out, tape and all.  Yes, blood was everywhere.  She was having seizures all the while during this activity.  Finally, they decided to install ambulatory EEG equipment, and they observed complex partial seizures, but she was not in status.

While they attempted a 3rd IV start, she started a cluster of seizures that lead to one seizure where she simply did not come out of it.  She laid there limp, almost like she was dead.  After 4 minutes, I told the nurses we had to stop for a moment – they agreed-, and I administered my first dose of diazepam.  I was sweating at this point.  She remained in a state of seizure for a solid 2-3 more minutes.  A nasal injection of versed was administered.  Finally she came out of it.   By now it was around 8 pm and the on-call neurologist made his way to our area.  I felt like he understood the situation better than most as he had a lot of experience with babies even though his focus was on older children now.  After a consult with her previous neurologist in CA, the plan was to optimize the Sabril dose, and sedate her in a controlled and scheduled manner.   It finally felt like she was being helped.  Then, like releasing a fish back into the water, he vanished.  I was never able to talk to him again that night.  She was finally admitted to the in-patient ward at around 12am.  The plan was to administer scheduled Ativan for sedation.  Initially, they were going to give her .5mg every 8 hours.

We went up to the ninth floor of Memorial Herman Hospital in downtown Houston in the middle of the night.  This is not where you want to be as a parent of a patient like Savanna.  We might as well have gone to another hospital.  After an hour of presenting her life story, again, to the attending pediatrician on the floor, they attempted to start another IV.  They failed.  Then I was told that without the IV, they would not administer the Ativan.  I found that really inconsiderate with regard to Savanna’s care given what we had been through and her condition.  The Valium (diazepam) was wearing off, and she was really inconsolable now.  Padding had to be added to the inside of the crib to keep her from hurting herself.  After another hour or so, I could sense another large seizure episode and when it started, I did not wait to use the diazepam this time.  I administered it quickly so she didn’t have another 10 minute seizure.  I also provided relief from the seizures for about 4 hours.  After being berated by the attending pediatrician for administering it myself 5 hours after the previous dose, I knew it was time to go.  Help just seemed far away until the pediatric epileptologist was back on the case.  The attending pediatrician was intent on letting her seize for at least 10 minutes before helping.  They didn’t even have diazepam prepared on the floor.  It was completely negligent in my opinion.  This was simply not acceptable to us after what we had learned that past few weeks.  Her presentation during her complex partial seizures was a-tonic and for a baby that simply looks like she is sleeping.  I actually had heated exchanges with that attending about the seizures and she simply didn’t want to listen.  Savanna had seizures while I was talking with that doctor, and she simply did not agree.  I knew we had to get out in order to get help which seems completely counter-intuitive.  But, we had more ability to get medication outside the hospital in this case.  Our plan was to get her home, get the Ativan, and administer it at home and deal with consequences.

Wednesday August 29th, Savanna was discharged and had a significant seizure event that required intervention.  I did see the Fellow on her case, and he indicated they were going to give us a script for Ativan that we would administer at home.  He also agreed the situation was less than ideal.  We received a seven day supply of .5mg pills (one pill per day).  Friday night we got the script filled and used it for the first time.  We were nervous about using them at first.  They did seem to provide Savanna some relief to the agitation and anxiety she was experiencing.   [Over the next 2 weeks, when her epileptologist was back on the case, we would give her 9mg per day and some days 18mg in an attempt to manage the seizures.]

Thursday into Friday September 1st, were all about the same.  Savanna was not happy, and having at least 75 seizures per day.  We started charting each event, looking for a pattern.  I was spending at least 30 minutes out of every hour sitting and watching her.  It was overwhelming.  I felt like I couldn’t do anything unless she was right there in visible sight.  Andrea’s capability was reduced to simply just sitting and watching her for about 6 out of her 8 working hours.  Frequently, we would see a cluster pattern, and have to administer diazepam.  It became a very intense situation.

Saturday September 2nd, she was the same, but Rebecca really got a chance to witness big events.  It was devastating to her.  The situation seemed completely out of control to us.  We decided to take her to the ER, against all out loud conversation about what we thought would happen.  We were banking on our doctor being reachable by phone now, as she was supposed to be back in the country.  It turned out to be a bad bet.  Anyway, once at the ER, another idiotic waste of time began.  I actually had a conversation face to face with a young neurologist, whom I asked this question, “If your child was having five to ten uncontrolled seizures per hour with the history of my child, would you sedate your child heavily?”  He responded, “Yes, but I won’t sedate your child. It is not in our protocol.”  At that moment he walked away, and I knew again we had to leave if we couldn’t get into the EMU.  It was a waste of time to be there.  I was communicating with Rebecca during this, and we could not have felt more lost as parents at that moment in time.  Out daughter was having 5-10 seizures per hour, and we could not access services that would be helpful.  It wasn’t just perplexing, it was unbelievable.  Meanwhile, Rebecca’s Dad was on an airplane coming to help us.  After further consultation with Rebecca, we decided as a last resort to try Texas Children’s ER and see if we could get some traction.  I got Savanna out of the Memorial Herman ER and drove the 1/2 mile down the street to the Texas Children’s hospital. (Yes, they are all in one place in Houston.) After 4 long hours, it became clear that they were not going to help either.  They didn’t even have a neurologist attending, only on-call.  That went nowhere.  Rebecca and her Dad arrived in the ER around 1am, and a near argument takes place between Rebecca and I about Savanna’s care.  These are really difficult times and we each have our moments where we think we know what is best.  Once we heard the on-call neurologist recommend no changes to her care and to come see him in a month or so, I knew we were definitely in the wrong place.  Waiting overnight to see a neurologist that was only going to say the same thing in person the next day, wasn’t going to help either.

At this point, what do you do as a parent in this case?  I invite all of you in the medical field to chime in and tell me where we went wrong.  Tell me how to getting help for our daughter would have been easier.  We are on our knees begging for help, yet no one is listening.  We seriously contemplated catching the next flight back to CA to have her original epileptologist take her care back over.  We called CHOC and they said they would admit her immediately, but strongly advised against flying, as she could die if she went into status, and emergency care was not immediately available mid-flight.  We asked if it was possible for our former epileptologist to direct her care from CA at a hospital here, but that’s just not the way these things work (due to the potential for liability).

We were exhausted and desperate.

Admission to the EMU on Tuesday September 5th, could not come soon enough.  Savanna’s doctor is back in country and on the job and we could be more relieved. I knew we just had to gut it out until then.  These are really difficult learning moments in life.  I commend Rebecca’s Dad for stepping in to help, but it takes time to absorb seeing a baby in such a condition.  While we know it was overwhelming at times, he was very helpful and we thank him for his sacrifice.

Sunday September 3rd, was more difficult.  We got a much needed refill of diazepam at the local CVS and felt like we could make it to Tuesday.  We had a conversation with our doctor and she was prepared to admit her to the EMU over the weekend, but also said she would not be there to manage her care.  Tuesday September 5th, was now the scheduled admittance, as Monday was a holiday.  We have come to dread the holidays, as these seem to be the times when Savanna needs the most help, and yet the resources to help her are least available.  Savanna was to start the Keto-genic diet that week as a last resort to control her seizures.  Rebecca and I were contemplating our choices and what would be best for Savanna.

[Looking back, I made a mistake.  Not having all of her official records in one place, and ready for review wherever we went, was a mistake.  A person at the Hospital in CA recommended we do that, and while I had many discharge notes from hospital stays and pediatrician notes, they really did not tell the entire story.  Since then, I have acquired all of the official neuro output notes, lab results, test results, EEG reports, MRI reports etc.  I have parsed them into separate PDF files and make sure they go with us everywhere.  While this may or may not have altered the course of history, it could not have made it worse, that is for sure.]

She was not stable and traveling was against all doctor’s recommendations.  Her doctor was still away in France and just not reachable in a reliable fashion.  We mulled the decision on ‘what to do’.  Starting over with another group was more or less out the window after a lot of discussion.  Diagnostically, they would accept the records, but would without doubt want to run their own sets of tests.  Rebecca and I started to realize that Savanna may need surgical action sooner than that schedule would allow.  We spread out our medicine on hand, even if just mentally, and I told Rebecca I felt like I could make it back to CA with what we had in terms of rescue medicines (assuming I could get her on the plane).  Savanna was having 5-10 seizures per hour now, and we felt completely helpless.  This was when we really realized how special her doctors were, and how few of them were spread amongst the population.   We decided to gut it out, watch the seizures, and go with the advice of our doctor here in Houston.  Formal second opinions would have to wait until she was stable.

We did our best to stretch the medications, but Tuesday around 1am, we administered our last dose of diazepam.  We were out of Ativan too.  We had exhausted our medication cache, and we were out of options.  The only responsible place to could go was to the EC at MH.  I packed her up and we took off for the emergency center downtown.

Once there, even though we were on the list for admittance, I still had to go through the EC.  The poor nurse taking triage information had no idea what was coming.  I was so infuriated after 30 seconds of answering her check box questions that we got into an argument.  After I told her that I just gave her 1mg of Ativan and 5mg diazepam to stop her seizures 2 hours ago, she proceeded to ask me if Savanna had ever had seizures.  Steam was coming out of ears, and thank goodness a doctor intervened, and moved us to a room, because I was about to unload on that poor person.  It was such a pointless act of futility but one that must take place during each EC visit.  You are at their mercy and they know it.  The doctor understood, and once we had a 1 minute conversation with him about what we had been through, the amounts and types of medicines she had been given (at home), that was the end of our hassle in the EC.  No other person bothered us with the exception to make sure we didn’t need more medicine, until it was time to move to the EMU.  I thanked that doctor for simply listening to me and taking me seriously.  Even though he himself was not a parent, I think there was genuine empathy for Savanna’s situation.  His professional common courtesy and respect for my knowledge of Savanna’s needs was refreshing.  I am certainly not a doctor, but I have become an expert in her general daily care and management.  At 3 in the morning about 2 weeks after the start of this ordeal, I finally felt like we were on a path to getting some help.  It had been a really long and difficult period in which our respect for pediatric epileptologists grew immensely.

We really just didn’t take a lot pictures during this period.  But, I do have a couple of iphone videos that are interesting.  One shows our oldest boys, Tristan and Brandon, as Daddy is at the house in the morning getting ready to head down to the hospital and take over for Rebecca.  We were sending Mommy a video text to let her (and Savanna) know we are coming.  The second is a rare moment during this time period when suddenly she seems ‘okay’ or at least a little happy.  We are in the EMU, 2 days into the Keto diet and on 9mg of ativan per day (that is a lot for a little baby) in this video.  It doesn’t entirely fit with this post, as I have not written about this stay just yet, but I have to put up something 🙂

-Mom and Dad

Ken and Rebecca Lininger

The Honeymoon Period

So a few weeks after the final dose of ACTH, some of the major side effects are dissipating.  She still has a NG-tube in her nose, but no cannula taped to her head as she no longer needs supplemental oxygen.  Her blood pressure is returning to normal even as we titrate her hypertension medication down.  Her mood and disposition are improving, and her awake times are increasingly filled with happiness.  There still exists daily periods of inconsolable crying and fussiness.  I think as we embrace the probability of this activity, it somehow seems easier to manage.  Now that her brain activity is stable, she has started to develop again, and it almost seems like we are starting over at day one, but she is nearly 4 months old.  This good response with dissipating side effects in the world of pediatric epilepsy, is commonly referred to as “The Honeymoon Period”, as it is filled with joy, development, and seizure freedom (or at least good control).

We are struggling with bottle feeding a consultation with the GI doctors results in the decision to install a permanent G-Tube.  She isn’t aspirating, but her suck is weak and she tires quickly which shortens the feeding cycle.  The doctors feel she isn’t getting enough nutrition, and as a result, decide accelerate the procedure timeline.  So, a Monday morning clinic visit transformed into a 3 day hospital stay. The process was multi-staged.  She first had a temporary g-tube installed where the tube was inserted into her stomach through her mouth, and then out the newly created hole to the outside world.  The end of tube in her stomach has a large disc that cannot be pulled through the hole and aids in creating compression in the tissue layers.  This apparatus had a fixed length of tubing that we had to manage with tape.  This was left in place for about 2 months while the tissue fused together fully to create a clean hole directly into her stomach.  At this point, back to the hospital to remove that tube and install the peg style tube we have now.  It is inserted into the hole and then a balloon is inflated on the end of the peg inside her stomach with water through a special port on the device.  It is quite ingenious.  It is low profile, and while still odd to the inexperienced caregiver, very durable and easy to operate.  [Looking back, it was probably the single most helpful prophylactic measure we took for Savanna’s health.  It was great advice from honest doctors, and we were really fortunate to have listened to their council.]  Savanna never liked taking medications orally, so all daily medications go through the g-tube.  her discomfort from the procedure was minimal in the grand scheme of things.  A day or two of pain, but after that, very easy to maintain.

As we entered this Honeymoon period, she continued to respond well to the medications and began to thrive.  There were certain times that were still difficult, but we really needed to take full advantage if these ‘good times’.  She clearly had significant developmental delay that was global in nature, and it was time to start occupational and physical therapy.

So, therapy includes working on gross motor skills such as rolling over, reaching for things, sitting up etc.  She really dislikes ‘tummy time’, and she struggles with putting weight on her arms and legs.  To this day, it is a significant focus of her care.  We also work with her on fine motor skills, such as holding toys in her hands, switching a toy from hand to hand.  Cognitive development is stimulated with texture books, musical toys with lights that require input to function.   While all different, many if these skills are combined when working with her.  In addition, we will have to work on her social skills, language, and feeding.  While safe for her to eat thick baby foods, she has a pretty strong aversion to having those foods in her mouth. 

Seeing her smile at us and begin to follow us with her eyes was the best feeling in the world.  Rolling ever came easily and quickly with our other children, but was a huge milestone for her that we celebrated.  To see her refuse to put weight on her arms and legs is increasingly frustrating.  With each passing day, the real magnitude of her delay and her ability to learn is becoming clear.  Many milestones that Austin, her twin brother, breezes through are major accomplishments for her.  In spite of her challenges, Savanna honestly appeared as though she was experiencing some level of happiness at times, and it was great to witness.

During this time we made big life decisions that included moving the family to Texas, and buying a house.  Rebecca had the ability to make a lateral move within GE,  so we decided I would stay home to raise kids and manage Savanna’s care.  This seemed like the natural progression for our family, but it has been a significant adjustment for both Rebecca and I.  We made the move to Houston mid-June.  [We have looked back a few times with respect to Savanna’s care.  Her case is so complex, that there needed to be a transition period between the neurology teams.  Fortunately, her doctor in CA is genuinely concerned for her well being, and has provided  guidance and leadership through consultation a number of times as Savanna’s condition has changed significantly since moving to TX.]

We are starting to get the house settled and it definitely feels like the right move overall.  Tristan and Brandon are enrolled in a faith-based preschool program that allows me a couple of hours a day to focus on all aspects of Savanna’s care.  They met new friends and are really enjoying our new home and nearby lake.  Austin has just taken off with his development.  He is right there with the big boys throughout the day and is on the cusp of walking.  The boys truly are a joy and really help keep the keel of our ship even.  So, we knew we were going to make a big trip back to CA for David and Brittany’s wedding.  Not knowing who Savanna’s Epileptologist would be in TX or if we might experience a lapse in care, we had scheduled a routine 36 hour video EEG at CHOC where we have already spent so much time.

So, we knew we were going to make a big trip back to CA for David and Brittany’s wedding.  Not knowing who Savanna’s Epileptologist would be in TX, or if we might experience a lapse in care, we had scheduled a routine 36 hour video EEG at CHOC, where we have already spent so many hours.  We were really looking forward to that, as we would also get to consult with our Epileptologist about our current situation in TX.  So we were excited on all fronts to make the trip.  After all the preparations, Rebecca arrives home from a short shipping spree at the dollar store with the boys after school,  and we are off.  It is a long, long drive to CA from Houston, and this is where Savanna’s journey takes a somewhat unexpected left turn.

We arrive in CA, and on the first evening unfortunately witness Savanna have a seizure.  We both say it and knew right away what we saw.  We saw both eyes deviate to the left and complete loss of tone.  It escalated rapidly, and she began to have cluster episodes over the coming days.  Fortunately, we had the 36-hour VEEG test scheduled so we did not have to penetrate the thick membrane in the bowel of the hospital to receive appropriate care (otherwise known as the emergency room/center).  We were warned that this would probably happen to Savanna, but what transpired after that day no parent can plan for emotionally.  It was devastating.  We both knew what the future could bring for Savanna and often wondered what path’s she will take on her journey.  Not knowing when her situation was going to change, keeps us in a constant state of heightened awareness, and it is exhausting.  Apparently, the time for some change is now.  As we drove to the hospital together August 16th, the moment was somber and old emotions about our new situation were bubbling up from many moons ago.  Even though the words weren’t spoken, we both knew ‘the Honeymoon was over’.

-Dad

 

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(Ken Lininger)

Life on ACTH therapy and Vigabatrin for Infantile Spasms

Savanna had been on the ACTH for about 8 days when she experienced her last Infantile spasm.  When she did not have a cluster on December 28th, we were beside ourselves and honestly didn’t know what to think.  She was healed, right?  Wrong.  A routine EEG would confirm lack of hypsarrythmia, lack of discontinuity, presence of normal sleep patterns, but also some abnormalities.  Savanna was still experiencing some clinical events typically effecting her eyes and head.  Even though we were just reaching the highest dose of the ACTH, it was decided that its affect on Savanna (the good part anyway) was at or near maximum.  She was started on Sabril (Vigabatrin) January 1, 2012.  That was the second front-line medication intended to treat the Infantile Spasms.

Within a couple of weeks of the start of ACTH, Savanna had lost most milestones she had reached as a result of the seizure activity.  She stopped smiling and laughing.  She was considered low tone clinically.  She slept the majority of the day, only awake about a half hour out of every four hours.  At least half of that time, she was really fussy.  She appeared to be blind, as she did not track anything with her eyes, and never seemed to be ‘looking’ at anything – just blankly starring. We were told her pupils were normal, and the problem with her vision was her brain.  It was a very dark period for us as a family.  Trying to understand why God allows such suffering was a recurring thought in my mind. 

By the middle of January, Savanna was about half way through the ACTH therapy when her health turned for the worse.  We noticed she was having an increasingly difficult time feeding.  She had now lost command of the breathe/swallow muscle control and was aspirating feeds into her lungs.  She had grown enormously in her face and legs.  Her cheeks were the widest part of her face.  Her hair had turned wiry and was growing fast.  She began to grow facial hair.  One day I came home from work and sat down to give her a bottle, which was our normal routine, and she didn’t  take the feeding as she seemed really congested.   She was coughing a lot and seemed almost like she was choking.  I administered a dose of inhaled albuterol, and it seemed to make the problem worse.  I opened her outfit to look at her respiration rate and was shocked to see her belly contracting inward so hard.  (This in the end, was the result of chronic and increasing aspiration of feeds combined with her inability to adequately clear the fluid due to her low tone.)  She was in respiratory distress and we had act quickly.  I hastily packed a bag, and took off for the children’s hospital.   

Once there, it did take some time to penetrate the membrane that surrounds the ER and in-patient facility.  Triage took all of 15 seconds as the nurse listened to her and said she was in real trouble.  I was told I would be taken back very soon, despite the overflowing waiting room.  An excruciating 45 minutes later, the calm before the storm was over.  I walked quietly through the doors to meet doctors, nurses, technicians into what seemed like utter chaos.  More or less dismissed as an important person in her care, I finally met the doctor orchestrating this effort involving at least 20 people, and I could see the genuine concern for her well being in his eyes.  Within a few hours, she was admitted to the children’s hospital where the gravity of the situation became more clear.  Her respiration rate was steady in the high 80’s, and she could not stay saturated without a strong flow of oxygen.  What became the next 18 days, was a very difficult experience as a parent.  Getting a successful IV started was in and of itself a significant event, as what normally takes a couple of people a couple minutes, took teams of PICU and NICI nurses hours.  It was painful to watch.  

In and out of the PICU, the helpless feeling was ever present. The doctors seemed to have few options left as the treatment eventually became a wait and see event, (of course with a plethora of drugs being administered around the clock).  Depending on which doctor you spoke with, the consolidation in her lungs was probably bacterial pneumonia according to some, and viral pneumonia according to others.  She was given 3 different strong antibiotics, a lung drying agent, and stronger blood pressure medication.  She contracted a fungal infection so bad on her rear, that the Infectious Disease team became involved.  We lived at the hospital, and it was a real strain as we each tried to maintain a presence at home and in our workplaces.  Being ‘fun’ for the other kids was very difficult after a night at the hospital and then a day at work.  Rebecca and I barely saw each other for 3 weeks and the strain on the marriage was significant.  More than once I found myself in that dark hospital room late at night with tears in my eyes trying to grasp the magnitude of the overall situation.  I found myself weak in the face of some of the adversity in front of me.  The effects of those 3 weeks permanently changed my perspective on certain aspects of human existence. 

As if it wasn’t difficult enough… I remember getting a call one day near the end of this particular ordeal at about 8 am from my boss.  He was wondering where I was and when I  was coming in to work, as though I had slept through my alarm.  I had just dropped the big kids off at daycare after Rebecca and I made the early morning switch at the hospital and I knew at that moment something had to change in our lives. While I was working a lot overnight remotely from the hospital, it went mostly unseen.  It did not replace my presence in the facility.  I remember that phone call feeling very cold and inconsiderate.  Over time though, I gained an understanding of  the other side of the relationship.  Once this happens to your family, you experience a paradigm shift while those around you do not as normal life does go on for everyone else.  Recognition and acceptance of this fact is critical in order to move forward.  Your perspective changes (along with your circle of friends) over time.  You see things around you that you may not have ever seen before.  You see other families with special needs kids living life at times, and this becomes an area of interest rather than something you ‘look through’ when observing from afar.  This is an evolving process and we are still learning as Savanna is changing.

Savanna finally went home in early February with oxygen tanks, a pulse-ox monitor, a nasal-gastro-intestinal tube installed, a feeding pump, and a significant panel of medications. The day before she went home, I was with her, and witnessed a smile and almost laugh that we had never seen before.  I captured it on my phone and will never forget it.  The feeling was like your first breath after being underwater too long.  It was a glimmer of hope for us. The next few days saw the final ACTH injection and numerous medications discontinued.  While the side effects from the ACTH were present for months afterward, her neurological progress was remarkable. 

Looking back, we initially had to manage a situation that was very task oriented while coming to grips with reality.  We had not yet started any occupational therapy or physical therapy, so the magnitude of her global developmental delay was still somewhat hidden.  We were being prepared emotionally (and didn’t know it), as the trivial tasks such as medicine compounding and delivery would transform into learning how to be Savanna’s best therapist.  At first I found this more difficult, but now find it very rewarding.

Dad
(Ken Lininger)

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A Christmas Angel

Christmas Eve….. I sat quietly on the fifth floor of CHOC hospital with Savanna – our Christmas Angel – as she continued to battle with significant hypertension, a side effect from the ACTH.  The silence was suddenly broken around 10:45 pm by that familiar ring tone indicating a text message had arrived.  It was a message from some friends that had moved north but were following her story, asking if we were home yet.  They probably just finished putting presents out for their little ones, probably saying a prayer for Savanna.  I was touched but replied simply “not yet” as not to unload on them in a number of run-on text messages.  I began recounting the week’s events and it was overwhelming.  The moment was  solemn and the reflection was chilling.  I replayed the conversations with all the doctors about the situation, and the bottom line was this was the only treatment available with a chance to have good results, whatever the collateral cost.  We were told by the Neurological team, the primary issue as that we learn to administer the medication and that we procure the medication prior to discharge.  We have since learned that the Neurologists tend to be 40,000 foot people with bedside manner.  Meaning, all the minor details like ‘otherwise okay’, well, it just a detail.  The weight gain was significant, nearly a pound the first five days (almost 10% of her weight).  The sleepiness was significant, as she seemed to barely be awake throughout the day.  But the hypertension became dangerous and ultimately was keeping her admitted until under control.  Seemingly under control from my view, I decided at that moment Christmas Eve we had enough of the hospital I was going to take her home for Christmas.

The next morning came and I remember talking with the attending physician about Savanna’s case and stating I wanted to sign the waiver for her discharge.  Looking back, while in the end okay, I was somewhat off-base with my arrogance, but I was convinced it was for her better good and the good of the family to have her home for Christmas.  Her blood pressure was down to around 90 (still high), but low enough that they felt she could be discharged.  Regardless, I was prepared to sign the waiver.  At 11am I walked out of CHOC, 8 days after our ordeal had begun.  I packed her up, fired up the F150 and away we went.  Having lived in CA for nearly 10 years, I had never been there on Christmas Day as we typically traveled East to see family.  Driving home, I thought I was in the twilight zone.  Did the Apocalypse happen, and I missed it?  There was no one on the roads.  No one was walking the sidewalks.  Few stores appeared to be open.  It was really, really weird.  I thought maybe I missed some kind of ‘Stay Inside’ warning from the government?  That was definitely the sleep deprivation kicking in there.

I knew the reality of 2 and 3 year old boys at Christmas that I was walking into, and had to put on a charade of happiness and excitement at some level.  The gravity of the situation really changes your perspective, especially in the moment.  Somehow Rebecca managed to stay strong through Christmas morning for the boys and celebrate with them.   The feeling of arriving home with Savanna on Christmas was intense.  All I wanted to do was have some time with Rebecca to connect, but had to instead had to be very attentive to the big boys and their new toys.  I remember praying to God to let me have the strength to be excited and happy with the big boys as I knew I didn’t have the fortitude to do it on my own.  Yes, I was happy for the boys, buy it just seemed like the magnitude of Savanna’s situation just overshadowed anything else that was happening around me.   Amazingly, the sight of innocent joy exuding from my boys playing in the driveway upon our arrival became infectious.  Rebecca was celebrating Christmas as best she could with the big boys along with Rebecca’s parents who left behind the majority of their family to be with us in California.   The feeling of bringing her home was filled with many emotions happy and sad.  The second best moment of the day was feeling the genuine love conveyed in the hugs from my boys as they were overwhelmed with excitement and just could not hold it in.

The best moment of the day was delivering our Christmas Angel to Mommy, and one I will never forget.  There were some tears shed and prayers said, and for a moment all was well and right in the world.

-dad

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