The Need for a Shunt

Today's post is about our experiences with the shunt. The shunt was developed by an engineer in the 1950's for his son.  Ironically his name was John W. Holter (Toby's Grandpa's name is John Holt). He and his wife had tried for ten years to conceive, and then their son was born with myelomeningocele and hydrocephalus. The device he invented - the shunt - helped his son live until the age of five, but then he passed away from complications related to his heart.  My information came from this article (they state his condition as "meningomyelocele").  

Hydrocephalus is a condition in which the ventricles in the brain are producing too much cerebral spinal fluid (CSF) As I understand it, and correct me if I'm wrong on this, Spina Bifida friends, but all ventricles produce CSF.  However, as a result of the open hole in the back in utero, the ventricles are programmed to overproduce fluid because it's leaking out through the open hole instead of recirculating though the CSF system.  Once that hole is closed after birth, the ventricles continue to overproduce CSF therefore causing the head to swell.  Not all kids with SB and hydrocephalus require a shunt, but Toby did.  His first shunt was placed when he was 4 days old.

Shunts are very fickle devices.  Some kids keep their first shunts into adulthood, others only last a few days. The device is a catheter (think straw) with little holes in it that is placed surgically into the ventricles of the brain.  It is attached to tubing that goes down the neck and ends into the abdominal cavity.  There the excess CSF is reabsorbed by the body.  There are risks of it clogging, failing, breaking, coming apart at the distal catheter, and also infection.  There are also programmable shunts and shunts that has tubing that ends in the region of the heart.  Toby's is a ventriculoperiteoneal (ends in the abdominal cavity), and his is not programmable.  

This site is where I found this picture of the shunt.  That same site also has a great MRI picture of the brain with normal ventricles and ones that are swollen with fluid.  Here is a link to more information on the shunt.

Toby's first shunt failure occurred when he went back into the hospital with his breathing issues around 2 1/2 weeks. He had his first shunt revision on January 25th, 2007.  He was barely a month old.  It was very obvious that he was in failure; just inconsolable - crying constantly.  I think the fact that he became hyponatremic (sodium drop), and is changes in blood pressure and temperature were also shunt related.

His second and third shunt revision wasn't until November 9th and 10th of 2010.  This was the first step in finding out whether Toby needed his spinal cord detethered.  The doctors typically explore the shunt first.  In Toby's case, he definitely needed this revision.

There have been other times when we've suspected it wasn't working - the mamas in the Spina Bifida community affectionately or unaffectionately call it SMP (Shunt Malfunction Paranoia).  Toby typically doesn't have the "normal" symptoms of shunt malfunction.  The last time he had a shunt malfunction completely turned our lives upside down.  I had been suspecting for awhile that something wasn't right.  He was impatient, ornery, and his nystagmus (eyes jumping) had gotten really bad.  I called our nurse case manager in the SB clinic that week telling her of my suspicions, so she had the doctors order a limited MRI along with his other tests for clinic that Friday.  

Before this, typically, CT scans were used to check shunts.  Unfortunately, this test exposes kids to large amounts of radiation.  I think I've read that one CT scan is the equivalent to 100 chest x-rays of radiation. The neurosurgeon Toby had at birth left to start an SB clinic in Arizona.  We switched to our current neurosurgeon and he prefers to use the limited MRI's to check brain ventricles for swelling. The benefit is the little exposure to radiation.  The downside is they are really loud, and Toby screams the entire time.  It's really hard on him.

After getting all of Toby's tests and waiting forever to see doctors that day in clinic, our nurse came in looking grim.  The MRI didn't look good - it showed swollen ventricles, and neurosurgery wanted us to head to the ER right away.  He had a few more tests, and then the resident dropped the bomb of trying out a new surgery on Toby called an ETV or Endoscopic Third Ventriculostomy.  The link explains this procedure much better than I can.  He was admitted and had surgery on March 17th, stayed a few days for observation and then went home.

That week we were keeping a close eye on him.  With the ETV, a little more CSF stays in the ventricles than with a shunt.  The risk is also that the fenestration they make in between the third and fourth ventricle can close, so we were watching for that too.  The doctors also left the shunt in, and they had discovered it was indeed clogged.  They leave it in because it requires another surgery - another incision in a different part of the head to take the shunt out.  It can also work as a back-up in case the ETV doesn't work, even though it was partially clogged, some of the catheter was still draining fluid.

Then, Saturday morning around 6 a.m. I woke up to our nurse yelling, and Toby's pulse-ox was going off.  I ran into the room only to see our son's eyes rolling and immediately I knew he was having a convulsive seizure.  We checked to make sure he didn't need to be suctioned, and then we called 911.  That ride to the hospital was one of the longest in my life.  I remember arriving, being ushered into critical care.  By this time, Toby had stopped seizing, even though, I can't really remember when the seizure actually stopped because he was just staring off into space.  My first thought was that there was too much pressure in his brain, the ETV was not working, and he needed to immediately go into shunt surgery.  The medics got an IV in, and they drew blood to test for a variety of things.  The biggest thing that came back was his sodium was low - hyponatremia again.  It was 118.  They began to run high concentrations of saline but not too quickly or it could cause seizures also.  He began to seize again, and this time I can't remember what time it stopped.

I don't remember much after that, but here are a few memories:

*His sodium was corrected and he was still seizing....

*Bagging - I remember the RT's and nurses bagging him off the ventilator because his oxygen was dropping, and he was fighting the vent.

*A nurse with a face I don't remember hugging me as I stood watching them work on him, and I could only break down into sobs.
*Bruce showing up in the ER and he and I sitting on the floor watching them wheel him up to the PICU.

*An employee from admitting trying to get my insurance information as we tried to follow Toby up to the ICU - and a great feeling of wanting to smack her - this wasn't the right time.

*Being ushered out of the PICU as the chief resident in neurosurgery prepared to put in an ICP Monitor - basically they put a cathether in through the ventricle to test the levels of pressure.  

They ended up having to do this bedside as the OR was booked with other cases (It was the weekend).

*Sitting in a room waiting, praying, sobbing...

God was definitely with us through this entire process, even though I really questioned His wisdom in allowing this to happen.  I felt like He had moved His hand of protection from Toby - we hadn't had an emergency like this in awhile, and so I wondered why He had decided to allow this.  In the PICU that day, the neurologist on call for the hospital was sent by God.  She was/is so knowledgeable about seizures, and her approach to Toby's care was so family centered.  One of the rotating doctors in the PICU also had just finished up time with neurology, so I felt like they both had a plan.

I remember laying on Toby and crying out to God to stop the seizure as he continued to seize, medication after medication had been thrown his way, and still nothing was working.  He tremored every few minutes, which they said was still convulsive seizing, but his body was just too tired to do it all over.  I remember asking the doctor what would happen if they couldn't get it to stop, what would they do. Her response was anesthesia or some type of heavy sedation.  They finally had to use versed to get it to stop (a sedative).

Then, they put on the EEG leads to see if his brain was still seizing, but his body could no longer respond. The intracranial pressure monitor never did show an increase of pressure in his brain.  It was clamped most of the time (it's the yellow/orange tube coming out of Toby's head in the photo below).  The doctors couldn't really explain why this had happened.  We believe it was a reaction to the ETV surgery and his sodium dropping.  There were only a few cases of kids having seizures after the surgery, but Toby added one more to the medical literature.

The middle photo on the right with his one arm in the air, was the first time we saw him make a voluntary movement.  Bottom left was his first smile.  Middle were the incisions from the ETV, and the other was the intra-cranial pressure monitor.  

By the next evening, he did start to wake up and the EEG showed no seizure activity.  I'm not sure why, but seizures have always been one of my greatest fears.  The doctors haven't ever been able to give me a straight answer on how long he seized - we know it was between 4-6 or maybe even 7 hours straight.  I kept praying that I would hear his voice again, see his smile, and have him look me in the eye. I also realized how greatly I had taken those things for granted.  It reminded me again to be thankful.

Even though, Toby was waking up and was moved out of the PICU. He could barely hold his own head up, so the doctors began to talk of moving to the Rehabilitation unit.  This way he could get consistent therapy and learn to sit up, move, write, and eat again.  We did move to that floor after about a week.

Toby was learning to throw a ball again he could barely hold himself up or his arms over his head; he was so weak.

Toby only spent about 5 days in rehab.  You could tell by the end of the week that he just needed to go home.  In two days it would be Easter, and I couldn't handle one more day being in the hospital.  He was discharged on Good Friday!

I read Psalm 31 over and over during this hospital stay.  The verse below rings out its' truth over and over:

Psalm 31:4-5a "But I trust in you, LORD: I say, "You are my God."  My times are in your hands..."

Just last month we had a follow up appointment with his neurologist.  The same one that was there in the chaos, the same who happened to be on call for the hospital.  We talked about the seizure again, and I asked her to pin down for me how long he actually seized.  It was going to take too long to dig through all of his medical records, even electronically (that's scary), but she reminded me that once someone convulsively seizes for 20 minutes it's too long.  After that they risk damage to their hippocampus in their brain.  The amazing thing, and this is God's healing, is that Toby's MRI right afterwards, and every one since has shown no damage to that area of his brain.  I am reminded that our times are in His hands - our very life and breath. He knows all.  So much good has come out of that situation:

*A reminder to me that I am not in control was one of the biggest, a renewed trust in God's faithfulness.

*Deeper thankfulness for the abilities that Toby does have, instead of focusing on what he cannot do.
*A renewal of our full nursing hours; this sounds crazy, but right before this our insurance tried to cut them and then because of this situation, they couldn't justify it.

*The ability to declare God's healing in Toby's body and brain.
*In many ways I think it prepared us for the road ahead with the multiple surgeries on Toby's back/scoliosis.

*We saw the body of Christ reach out to us through a brand new church we had only been attending for a few short weeks before this situation...and it led us to stay there - a church that has a passion/gift for reaching families of children with special needs. 

Two times in Toby's life his sodium has dropped below normal levels and both were closely related to shunt failure. The condition is called hyponotremia. Just last week a neuro-ophthalmologist told me that at the base of the third ventricle in the brain is the hypothalamus, which controls sodium levels/hormones, etc. It's possible that too much pressure there or a cut as in the case with the ETV messed with his sodium levels and caused them to dip.  It was interesting to learn this bit of information.

Some may ask if we had do make the decision to do the ETV all over again, would we?  I think we would, we made the best decision we could with the information we had at the time.  Even though there are days, I still question whether it's working properly, it has taken away some of the worry whether or not the shunt is working.  This is only what I can think of right now, although I know there may be many more in years to come as God reveals His purpose as He sees fit.  He has a way of bringing back these situations and we can say, "Oh, that's why that happened." To God be the Glory, Great things He has done.

Learning to Speak

If I had to choose between Toby being healed enough to walk or talk, I would choose the latter any day. When any person gets a trach, they lose the ability to talk with their mouth.  The trach bypasses the throat/vocal cords in breathing through the mouth and nose so the vocal cords aren't vibrating to produce sound.  When I made that realization, it was pretty devastating.  There were days when we had to rely on the ventilator alarms or pulse oximeter to let us know when he was upset because the high pressure alarm would go off or his heart rate would be so high from crying that alarm would go off.  Watching your child cry with no sound coming out broke this mama's heart every time.

After Toby began to be able to hold his head up and sit up with some support, we began to teach him sign language.  I just "happened" to come across the Signing Time DVD's at the library, and we were hooked. Rachel Coleman's personal story is one that many mothers of special kids can relate to - I personally connected with her not only because of her daughter Leah, who was born deaf, but also her daughter Lucy, who has Spina Bifida and Cerebral Palsy.  The first video we watched was "My Favorite Things", and at the end of the video there's a song called "Shine". I remember sitting in front of the television with tears running down my face.

Sometimes I see you stuck
For such a long time 
A daily nothing new
Pretend I don’t mind
With lists of things you’ll never do 
Until somehow you do 
And you do — you do — you shine

The days and months and years, 
they run together
Is it just one day? Or is this forever?
You’ve taught me in your lifetime
More than I’d learned in mine 
And you do, you do, you shine

Shine Shine Shine Shine Shine
Shine your light on me
Shine Shine Shine Shine Shine
everyone will see
Shine Shine Shine Shine Shine 
I’m so glad you are mine
And you’ll shine in your own time

Well, maybe I’m too close to see you clearly
Or is it now my role to simply believe?
You’re just one of those mysteries
That may never be solved in time
But you do — you do — you shine

And Sammy will do what Sammy will do when Sammy is ready to do it 
And Trevor will do what Trevor will do when Trevor is ready to do it 
And Lucy will do what Lucy will do when Lucy is ready to do it
And they’ll do it in their own time

This song made me realize that Toby would "shine" in his own way and in his own time.  He was going to pave his own path, and God's plan for Toby was just that - just for Toby. In some ways it took the pressure off.  It didn't matter if he was developing as quickly as his siblings or meeting that list of requirements on the developmental milestone list you get from your pediatrician's office.  Toby is uniquely "Toby" just as Conor, Garrett, and Caris are uniquely themselves, and God's plan for their lives is individual to each of them.  I've also learned that for our family - our main goal is to SHINE the love of Christ to others - so they can know His hope, His love, His plan for their lives, and God was and is doing that through Toby.

So between 20-22 months of age, Toby began to make noise around his trach.  He had a bit of an air leak, which means some air would go over his vocal cords, and he began to babble. We were constantly getting the camera out to take video, and as you can see her - this is what Toby thought of us trying to get him to talk!

Slowly, slowly we began to hear some words.  He said  "baby" and "mama" around 26-27 months - so he was well over two before he really began to "talk".

I remember the first time we had to tell him to "be quiet!"  I never imagined that we would tell him that. I also want to take a moment to thank his speech therapist.  He began working with Miss Jen when he was around 2 1/2 years old; I remember specifically asking our ENT Nurse Practitioner if there was a speech therapist that knew how to work with kids with trachs in teaching them how to talk.  Enter: Miss Jen. She has been working with Toby for almost 6 years now, and he has come so far under her therapy. Another reason he's done so well is his ability to wear a passy-muir valve.  This is a special device that can be used in ventilator tubing or directly on the trach.  It forces the person to move that air up through their mouth and nose.  When he used it in his ventilator tubing, he didn't do very well.  The high pressure from ventilator breaths was too much for him to handle, but once he began to wean from the ventilator, he tolerated the valve really well.

Toby's Grandpa Holt loves to sing and play the piano.  He would come over even and he and Toby would practice singing - even before Toby had the breath support to sing a full sentence.  Now, Toby can sing an entire song, and has the breath support to do so.  His one vocal cord still doesn't move exactly like it should, which causes his singing to be off key at times, but it doesn't matter.  "Make a joyful noise unto the LORD!"
The first time we heard Toby sing "Jesus Loves Me" with Grandpa - there wasn't a dry eye in our house. Enjoy this video also (I wasn't able to put it in the blog - so here's the link to youtube).

Mobility and Independence

Spina Bifida is a diagnosis with varying degrees.  Some kids walk with very little bracing, some walk with more support and a walker or crutches, and some can't walk at all.

Some of you may be wondering if Toby will ever walk, so today will answer that question.  Our hope and prayer from the very beginning was that Toby would learn to walk.  A lot of his movement (rolling, sitting, crawling) was really delayed not just from the paralysis in his legs, but also from restriction of being connected to the ventilator tubing.

We began using these pedi-wraps to straighten his knees and give him stability in his legs.  You can see here, he's hooked up to his ventilator, but still practicing his standing.  After this we had to advocate very hard with the physical medicine doctor to write him a prescription for braces.  It took several months to convince her to give Toby a chance, instead of deciding for him that he would never walk.  His first set of braces were HKAFO's (Hip, Knee, Ankle, and Foot Orthotics).

Toby seemed to be making some progress, but he really has little knee or foot movement, so all of it comes from his hips.  We realized pretty early on, that he would either need a really strong upper body to do a swing through gait or reciprocating gait by using his hip flexion to move one leg and then swing the other leg. He also has a significant leg length discrepancy where one leg is longer than the other, so he's also had to have his shoes adjusted.

Then, he outgrew his first set of braces, and we moved and switched therapists.  This time they decided to try HKAFO braces where the knees were completely stiff and couldn't bend.  It seems great in theory because it gave him so much stability, but they weren't practical at all.  For instance, he can't ever wear them outside of therapy or in practice walking because the knees were always bent:

The process of getting casted for braces can appear medieval in some ways, but it's painless, and doesn't take very long!

Toby's also had a mobile stander that we purchased used to help him put weight on his legs.  He loves it when we get him into it, but alas last week we sold it and passed it on to another family who needs it.  Toby's leg length discrepancy is too great.

In the past year, with his severe scoliosis, and the titanium rods holding his spine in place, we have realizing that most likely Toby isn't ever going to walk independently.  I'm learning to accept that he's going to be a full time wheelchair user, but I have to be honest it's really been a struggle.  With each back surgery, he's lost a lot of function even in being an independent mover - sitting up on his own, going from lying to sitting.  The permanence of it has been very difficult to accept.

After February of this year (2014) when the surgeon attached some screws into his spine to secure the left rod, things finally began to look up.  He made it through that recovery - 2 long months of now sitting up or moving his wheelchair on his own.  Now, he's sitting up on his own, getting dressed again independently (for the most part), and pushing his wheelchair. Some mornings I find him doing push ups in his bed while sitting, and he can lift his entire body off of the bed with his arms! He also started playing sled hockey. I really wanted him to try it, but was so afraid because of the chance that a rod would break.  Do you know what his orthopedic surgeon said, "Toby has to be a kid, and if that happens, we will deal with it when it happens!"  That was so freeing for me.

We are thankful for these new opportunities and I've learned that independence in his mobility is also very important. Just recently, we got a prescription for a motorized wheelchair. It's something that I fought with every breath the last several years, but then this summer I watched as every time he would want to go next door to play with the neighbor kids.  Someone had to push him, someone had to take him.  It was so heartbreaking to see him sitting in his chair, a bystander, while other kids played tag and climbed their play set. I knew then that it was time to at least get a motorized chair for outside play and independence.  I want Toby to be as independent as possible, however we can teach him that or allow him to have that, we will!  He will still use his manual chair for in the house and other smaller areas to keep him active and fit, but now we will have another option for independence.

Bladder Infection Yet Again

We might have a possibility of filling our night nurse position - we're hoping to interview her some time this week; we'll keep you updated. Toby also might have a bladder infection again (I'm about 95% positive he does). We took a sample today and they will test it; we should know by Wednesday. It frustrates me that he will be on yet another antibiotic, but this too is in God's hands.

Lastly, Bruce and I are starting the process of looking for our next place to call home. Please be in prayer as we search for a home that will incorporate Toby's mobility needs as he gets older. We're trying to take this into consideration, which obviously limits our choices, so your prayers with us on this would be wonderful. Some days I think that our search is hopeless, but I also hear God continuing to ask me to trust HIM. He will provide, and the only way that we will be able to explain it is that God did it and not us!

More Milestones - Getting Wheels!

Toby began to really grow and change; he was finally hitting some milestones, and he began to get ornery.  A ventilator has auditory alarms, so if it becomes disconnected or has too much or not enough air pressure you will know it. I can't even remember how old he was, but he learned around 16 months or so how to cause too much air to come through his ventilator tubing to set the alarms off so we would come running and see what was the matter.  He also would untie the ties that held his ventilator on to his trach so we would see what would happen.

Some of his favorite play things were his suction tubing, suction catheters, and ventilator tubing, etc. I love these above photos because he was sneaking into his suction bag to see how much he could unload out of it.

His favorite play things!

We also learned fairly early on that Toby had a really fun sense of humor.  He would laugh a lot, and even now he says a lot of really witty things that just crack everyone up in the family.

In this picture, Toby hid his pacifier inside of his onesie, and you can tell by the middle photo that he thinks it's very funny.

At first when Toby came home from the hospital on a ventilator full time, I had little hope that he would ever be able to walk or handle a manual wheelchair.  With all of that equipment - where in the world would you put it on a manual chair?  Our first chair was an Otto Bock Kimba.  It was a medical stroller that had a ventilator tray underneath; a place for the HUGE car battery we needed to give the ventilator power (before lithium ion batteries for ventilators),  oxygen tank holder, etc.  It was great, but it was very heavy.  I do remember being so excited when we graduated from the double stroller - with Toby in back and ventilator in front to the Kimba.

Here's the Kimba; and oh my goodness those cheeks:

Around the age of 22 months we began to talk to Help Me Grow, who did therapy in our home through the county about a manual wheelchair.  They worked it out with Columbus Medical to outfit a manual chair with a ventilator tray on the back.  Some doctors, etc. had told us that it couldn't be done; but the guys there work miracles.  Today, a new friend's son has this chair - it's actually been passed on to two kids we know in the area with Spina Bifida.

Now, that ventilator weighs about 17-18 pounds.  It's heavy, so at first it took him awhile to be able to move that chair very well, but he did it.  When Toby was a little over 3, and we had to give the chair back to Help Me Grow (they graduate out at the age of 3 and are then serviced through the counties' board of developmental disabilities); we began to look at other chairs for Toby.  At the time, I will admit that I didn't do enough research, and just accepted what they told me insurance will cover. Toby was just coming off of his ventilator for short periods during the day time, so they did outfit this chair so it would also support a ventilator. We had to plan for the "what-ifs" at the time, and unfortunately it made the chair extremely heavy.
This is also the chair he has now, although it's been modified recently to make it lighter. Stay tuned, tomorrow we're going to share about walking and talking!

Milestones

After Joshua led the nation of Israel across the Jordan River, God commanded one man from each tribe to take one stone from the Jordan and pile them up where they stayed that night.  Joshua 4:6-7 says, "that this may be a sign among you.  When your children ask in time to come, 'What do those stones mean to you?' then you shall tell them that the waters of the Jordan were cut off before the ark of the covenant of the Lord. When it passed over the Jordan the waters of the Jordan were cut off.  So these stones shall be to the people of Israel a memorial forever."

In the same way, God has taught me to take the time to "remember all the times He's told us loud and clear - I am with you and I'm for you!"...to remember His promises.  During the times of doubt and darkness, we can look back and remember the times He has carried us through.  Even looking back to those dark days in the PICU, I forgot how bad it was - how many times we almost lost him.

Today I want to walk through a few of Toby's milestones.

His first several years were full of doctor's appointments, therapy, bladder infections, G/J tube replacements in Interventional Radiology, sleep studies, CT scans, bladder testing, ventilator checks, blood gases, urine cultures, x-rays, an EKG, loads of antibiotics and blood tests!!  He also had a lot of digestive and belly distension issues.  This is something that would be an overwhelming problem for 6+ years until he got his cecostomy (July 2013).  He had barium swallow studies, upper GI scopes, and even a rectal biopsy testing for Hirschsprung's disease.

When Toby was around 6-7 months old, he finally began to smile - and he hasn't stopped since.  His smile completely lights up a room.  One of my nicknames for him has been "Sunshine" because even on our darkest days, all I have to do it look at his smile and it makes the clouds go away - truly...just look at these pictures:

This was one of his very first smiles!

He loved to fall back on pillows; even  now he loves to go fast and be twirled around; he loves roller coasters.

I can't help but laugh out loud at these pictures.

At first, it felt like Toby was always behind.  He didn't like therapy very much...well you can tell by these photos what he thought about it at first:

Oh my goodness, just look at that face!

Learning to sit up on his own.

 He often had his pacifier in his mouth because he cried all through therapy!

Starting to like therapy; this was before those ZipZac chairs - Help Me Grow therapists brought this out to help him get used to wheeling himself around.

One thing that really bothered me was that he couldn't eat by mouth.  Eating is more than just, well, eating...it can be a social event too.  After being around other mommies of kids with special needs that were similar to Toby's, we began to learn different things.  We heard about Cincinatti Children's Hospital amazing Aerodigestive Team. It's a team of doctors made up of ENT, Pulmonary, GI (Gastro intestinal), plus nurse practitioners, speech and occupational therapists, nurses, etc. that collaborate together to help kids with complex airway and digestive issues.  Toby definitely fit the bill on that one.  So, we made plans to go down there.

At 15 months of age, Toby had a huge list of testing down at Cincy Children's.  It included a FEES test, Upper GI (checking reflux), x-rays, a Bronchoscopy, and an overnight Impedence Probe to look at reflux also.  The biggest findings were Toby had a lot of airway issues - trachealmalacia, bronchialmalacia - basically a floppy airway.  They also said he had a short trachea, but the best news of all was that Toby was SAFELY SWALLOWING by mouth and could start eating.  We started with just tastes of baby food, and then it led to eating a teaspoon, tablespoon, etc.

On the left was the photo I took after three days in Cincy.  In the middle are his feeding tubes.  The white one is the feeding tube going into his small intestine with formula.  The green one was coming from his stomach, and it meant he had safely swallowed the green bananas.  They colored them green so we would know if he was aspirating or not because we would suction green out of his trach. On the right was a few weeks later - trying it out at home.  Those are also green bananas!  Maybe that's why his favorite color is green!

This is what Toby thought of the therapist feeding him, but he gradually progressed to the far right...then this:

Feeding himself for the first time.

Today - eating pancakes!

Another thing they thought they found in Cincinnati was a bowel malrotation, where basically the intestine is twisted around and can possibly cause a bowel obstruction or even death.  They suggested he needed surgery to fix it.  After a lot of back and forth between Cincy and Columbus, we decided to come back to NCH and talk to our own surgeon..  She wasn't so sure he had the malrotation.  She and the radiologist here in Columbus, both thought that it just appeared that way on tests because of the way the J-tube was going into the small intestine. We decided to go ahead with an exploratory surgery anyway, and in the mean time Dr. C (who is now retired) decided to do a nissin, so we could treat Toby's reflux and possibly get rid of needing the J-tube altogether.  In surgery they in fact found that he had NO malrotation, BUT one positive that came out of this was Toby could now have food into his stomach instead of his small intestine.  This meant less time hooked up to the feeding pump - he eventually graduated to just at night, eating baby food during the day, and about 3 years ago got rid of the pump altogether when he began to eat enough pureed food by mouth all the time.

Nissin Surgery; oh my sweet boy.

This was when Garrett said that "they cracked Toby open.

Toby still has a ways to go with his eating.  Just in the last month, I have been able to order him his own kid's meal at Chick-Fil-A. I'm almost felt like crying. He's also been out to breakfast with daddy as a father/son thing Bruce does with the kids, and it's wonderful.  When I lament how many milestones he hasn't reached on time, I just have to look back and realize how far he's come and I am so thankful!

Siblings and Spina Bifida

One question that we get a lot is how to Toby's siblings handle having a brother with a disability.
Today I would like to answer that question.

I would like to think that they do really well - at least it seems from my perspective.  Our kids were very blessed to be around Evan so much when Toby came home with all of his equipment, they were sort of "used to it."  It wasn't a big surprise to them.

This is a set of my favorite pictures of Conor and Toby together.  I think Toby was trying to get his glasses!

One part of my personality, whether a blessing or curse, is needing justice and fairness in my life and the lives of those around me.  I try to keep things equal for the kids.  I know that at times this is dangerous and very impractical, so God is teaching me that everything in life isn't fair (obviously - we are living that out), but also that we need to teach/correct/instruct/rebuke our kids based on their personalities and learning styles.  I'm learning (focus on learning) to show my love to them according to their love language.  I'm also learning how to home school according to their learning needs. HOWEVER, one advantage to this, is we try very hard not to allow Toby's hospital stays to interfere too much with their own events - like sports or birthday parties, etc.  We try to allow them to have their own interests/lives outside of Toby.  In a gentle way, we also point out to them the many things they can be grateful for.  They have experienced many fun and exciting events because of Toby. They have had opportunities beyond anything most kids experience at their age - Blue Jacket hockey games, Crew soccer games, even our trip to Disney last year with make a Wish, and being on the television show - Tanked, etc.  So, even though some days can be really tough as Toby's sibling, some days are really fun too!

Each of the kids has a unique relationship with Toby.   Conor is his protector and a bit bossy, which lately has been a good thing.  He's been the one sibling who can motivate Toby to eat his solid food at every meal. He's good at thinking of ways Toby can participate (he's also good at this with his friend Evan).  When he first came home, he loved holding Toby - would read to him, and wanted to always be with him.

When Toby came home, Garrett was so little, so he didn't care too much about holding him, but that later changed.  He is our empathetic, bleeding heart. One time when Toby had surgery, and they came to visit he said, "They crack Toby open" and  "It's not fair."  He wanted Toby to come home from the hospital, and he was 3 1/2.  One time, Toby was crying during a trach tie change (those white ties that keep his trach in his neck), and he thought we were hurting him.  He said, "The nurse made me mad!" He's also my kid that runs from the room with a queasy stomach if too many secretions come flying out of Toby's trach.  Garrett is also the one that I think the instability of those first few months really affected him the most.  He turned 2 when Toby was in the hospital, and emotionally it caused too much instability.  I really have to work hard to communicate with him all that is happening when Toby goes in the hospital, so he doesn't fear the unknown.

Just a few months ago, I had to sit down and explain what Spina Bifida is, why Toby has a trach, a feeding tube, and a ventilator.  I just assumed he knew, but he was too small to remember when Toby came home with all that equipment.  I have to remember NOT to assume anything when it comes to Garrett - he has to talk things out.

Caris is Toby's playmate.  She is pretty mature for her age, and Toby is immature in some ways, so it makes it a perfect fit for them to play together.  She likes to pretend, and I can see how developmentally she has really helped him a long.  Sometimes, I laugh and cry when I compare their writing and Caris' handwriting is much neater than Toby's.

When Toby saw Caris at birth, it was love at first sight.  We were so nervous about it because prior to this Toby was afraid of babies and toddlers...but his little sister was a completely different story.

Toby used to HATE having pictures taken with his siblings.  He would cry and cry.  I also laugh looking at the middle photo because Toby looks as if he's ready to rip out his g-tube!

Two years ago, I attended the National Spina Bifida Conference, and sat in on a sibling panel.  It was amazing to hear those teenagers' stories.  They opened the panel up for questions, and you could tell that each of these brothers and sisters were so thankful for their sibling with Spina Bifida. It had taught them so much - most of all to give to others and how to be unselfish.  Hearing their perspective caused the tears to flow; it was a very emotional session, but also helpful to hear their perspective, and I pray that when my kids are grown, they will also be thankful for each other - and for Toby, and what God has taught them through him in their lives.

I would also predict that at least one of our kids, including Toby, may end up in the medical field with all the medical terms and procedures they know!