After one unsuccessful try to get up and walk with the PTs this morning, Dan was able to do so this afternoon and walk with the PTs one lap around the floor, and his heart rate never went over 115! We praise God for this victory!
We also enjoyed a visit from Joan and daughter Becky today, and they brought a wonderful goodie bag filled with all kinds of chocolate goodies. Joan is Dan's auntie's sister and she told great stories of spending many Thanksgivings with the Van Alstines and remembering Dan and his sisters as little kids running around and playing. We also enjoyed hearing them talk about their faith in God. It was a refreshing visit.
And thank you, Mr. Shamir, for your comment on yesterday's blog -- he is the author of the "Advice from an Eagle"! Visit his website at www.yourtruenature.com to learn more about his work to create a greener planet.
And today's funny: David, one of Dan's PTs, is the funniest guy. He introduced his partner Selena and himself today this way: "I'm 'Ex', she's 'Lax', and we're here to 'move' you."
Standing on God's promises,
Debbie and Dan
Sunday, September 28, 2008
Saturday, September 27, 2008
Saturday, Sept. 27th updates
Dan's back on the 3rd floor Intermediate Care Pod, and we are relieved. The care he gets on the 3rd floor is exemplary, we feel like family there, and nurses on the floor have stopped by to see us and share kind words...we're sure EVERY nurse on the 3rd floor has been assigned to Dan at some point during this month plus.
They did take out the airway and a number of other tubes, etc. before moving him to the 3rd floor. He still has the picc line in his upper right arm (for IVs, taking blood for labs), an arterial line in his inside right wrist (to constantly measure his blood pressure), and a central IV in his neck also on the right side (not sure what all they use this for). He also still has a catheter and both calves wrapped with a gauze dressing (for the open sores he's had since pre-transplant) and compression stockings covering them. The doctors want his feet in compression also to relieve the swelling he still has, hope they do this soon but gently since he has broken toes on both feet from previous injuries. Dan's breathing is still shallow since this last surgery, so he's on oxygen - the nose tube that wraps around his ears, and a mask when he's sleeping. Today's chest xray showed a little fluid in the bottom of the lungs, so he has to work harder with his breather to reinflate the lungs. Thanks to Dan's parents, he is also working hard at exercising his legs while in bed.
Yesterday and this morning, Dan got food - clear liquids, still thickened. The doctors then decided to increase his caloric intake and give him a regular diet, so lunch appeared -- spaghetti and meat sauce, zuccini, breadstick and butter, salad and french dressing, fresh pineapple, and iced tea with sugar and lemon. Quite a change from just a few hours previous getting broth, jello, and a protein drink. Dinner was just as good -- beef burgundy and rice, etc. He didn't eat everything, but did quite a bit.
And more thoughts for the day from a bookmark "Advice from an Eagle" (by Ilan Shamir):
* Let your Spirit Soar
* See the Big Picture
* Cherish Freedom
* Honor the Earth and Sky
* Keep your Goals in Sight
* Bald is Beautiful
* Fly High!
Soaring,
Debbie and Dan
They did take out the airway and a number of other tubes, etc. before moving him to the 3rd floor. He still has the picc line in his upper right arm (for IVs, taking blood for labs), an arterial line in his inside right wrist (to constantly measure his blood pressure), and a central IV in his neck also on the right side (not sure what all they use this for). He also still has a catheter and both calves wrapped with a gauze dressing (for the open sores he's had since pre-transplant) and compression stockings covering them. The doctors want his feet in compression also to relieve the swelling he still has, hope they do this soon but gently since he has broken toes on both feet from previous injuries. Dan's breathing is still shallow since this last surgery, so he's on oxygen - the nose tube that wraps around his ears, and a mask when he's sleeping. Today's chest xray showed a little fluid in the bottom of the lungs, so he has to work harder with his breather to reinflate the lungs. Thanks to Dan's parents, he is also working hard at exercising his legs while in bed.
Yesterday and this morning, Dan got food - clear liquids, still thickened. The doctors then decided to increase his caloric intake and give him a regular diet, so lunch appeared -- spaghetti and meat sauce, zuccini, breadstick and butter, salad and french dressing, fresh pineapple, and iced tea with sugar and lemon. Quite a change from just a few hours previous getting broth, jello, and a protein drink. Dinner was just as good -- beef burgundy and rice, etc. He didn't eat everything, but did quite a bit.
And more thoughts for the day from a bookmark "Advice from an Eagle" (by Ilan Shamir):
* Let your Spirit Soar
* See the Big Picture
* Cherish Freedom
* Honor the Earth and Sky
* Keep your Goals in Sight
* Bald is Beautiful
* Fly High!
Soaring,
Debbie and Dan
Thursday, September 25, 2008
Thursday, Sept. 25 updates
It's been a very long past few days. Results of the perecentesis showed more infection, plus Dan was in great pain and the confusion was back. The doctors decided it was time to do more surgery, this time go through the transplant incision, drain out any remaining fluid pockets, and then wash out the entire abdominal cavity with antibiotics. The plan was to do this surgery on Tuesday.
Dan went to pre-op Tuesday around noon and we waited for Mayo to get a supply of Dan's special blood in case transfusion would be needed (turns out they had to do a national search). So they sent us back to Dan's room on the 3rd floor to wait since it would take hours. I went home to take a short break and when I returned, Dan's heart went afib again so they postponed the surgery to Wednesday if his heart rhythm was back down to normal. The goal for the rest of Wednesday was pain management and heart meds, he received morphine every hour until about 10pm, then about 4 more times the rest of the night. Dan could not be left alone and a nurse had to be present, later in the evening the nurse checked on him every 15 minutes or so. His heart returned to consistent regular rhythm about 2am.
Wednesday, the doctors decided to try for the surgery again, so it was back to pre-op around noon. Pain meds continued as well as anti-anxiety meds, to keep Dan calm and relaxed so the heart would also be calm and relaxed. He went for surgery around 3:15pm and it took 3 hours. The doctor (Dr. Mulligan, same one who did the transplant) told us they did the abdominal wash and also removed Dan's spleen as it was enlarged and diseased. Without a spleen, Dan will need various vaccines, some of which he already received. Then in recovery, his heart rate dropped suddenly. They stabilized him and he did 3 different scans to check for possible clots or other heart problems, all were negative. He spent the night in CCU sedated, with an airway, feeding tube, and a bunch of IVs, drains, etc.
This morning, the cardiologists came by, their findings showed Dan's heart is very strong and no defects or other heart problems although he is still afib and irregular heart rate. They hope to remove the airway sometime today, although the airway has been good in that it has been inflating all his lungs, he has been breathing so shallow since transplant. Dan actually looks better than even after transplant, he's awake and his eyes are very clear, like the mental fog is finally gone. We hope this is so - praise God!
Thought for the day: I've been thinking alot about the 23rd Psalm the past few days. What a comfort it's been to visualize God as our shepherd, loving us, leading us, and protecting us. I remembered the part about God leading us through the valley of the shadow of death, that's always a comfort when I think of our mortality and I've been thinking about it the past few days. One word popped out at me: through. God is leading us through the valley and God spoke to me with a vision of walking through a dark, scary valley with high mountains on each side blocking the sun; but after the valley are those green pastures and still waters and sunshine. Unfortunately, we sometimes have to walk through and the shadowy valleys of hard times when we would prefer to walk around them. But the rest of the verse promises our Shepherd will be with us to comfort and protect us, and we don't have to fear. Walking in the comfort and light of life feels better, but walking through the shadowy valleys brings a closer walk with God and each other, and unleashes amazing possibilities of growth and adventure.
Sheltered in His arms,
Debbie and Dan
Dan went to pre-op Tuesday around noon and we waited for Mayo to get a supply of Dan's special blood in case transfusion would be needed (turns out they had to do a national search). So they sent us back to Dan's room on the 3rd floor to wait since it would take hours. I went home to take a short break and when I returned, Dan's heart went afib again so they postponed the surgery to Wednesday if his heart rhythm was back down to normal. The goal for the rest of Wednesday was pain management and heart meds, he received morphine every hour until about 10pm, then about 4 more times the rest of the night. Dan could not be left alone and a nurse had to be present, later in the evening the nurse checked on him every 15 minutes or so. His heart returned to consistent regular rhythm about 2am.
Wednesday, the doctors decided to try for the surgery again, so it was back to pre-op around noon. Pain meds continued as well as anti-anxiety meds, to keep Dan calm and relaxed so the heart would also be calm and relaxed. He went for surgery around 3:15pm and it took 3 hours. The doctor (Dr. Mulligan, same one who did the transplant) told us they did the abdominal wash and also removed Dan's spleen as it was enlarged and diseased. Without a spleen, Dan will need various vaccines, some of which he already received. Then in recovery, his heart rate dropped suddenly. They stabilized him and he did 3 different scans to check for possible clots or other heart problems, all were negative. He spent the night in CCU sedated, with an airway, feeding tube, and a bunch of IVs, drains, etc.
This morning, the cardiologists came by, their findings showed Dan's heart is very strong and no defects or other heart problems although he is still afib and irregular heart rate. They hope to remove the airway sometime today, although the airway has been good in that it has been inflating all his lungs, he has been breathing so shallow since transplant. Dan actually looks better than even after transplant, he's awake and his eyes are very clear, like the mental fog is finally gone. We hope this is so - praise God!
Thought for the day: I've been thinking alot about the 23rd Psalm the past few days. What a comfort it's been to visualize God as our shepherd, loving us, leading us, and protecting us. I remembered the part about God leading us through the valley of the shadow of death, that's always a comfort when I think of our mortality and I've been thinking about it the past few days. One word popped out at me: through. God is leading us through the valley and God spoke to me with a vision of walking through a dark, scary valley with high mountains on each side blocking the sun; but after the valley are those green pastures and still waters and sunshine. Unfortunately, we sometimes have to walk through and the shadowy valleys of hard times when we would prefer to walk around them. But the rest of the verse promises our Shepherd will be with us to comfort and protect us, and we don't have to fear. Walking in the comfort and light of life feels better, but walking through the shadowy valleys brings a closer walk with God and each other, and unleashes amazing possibilities of growth and adventure.
Sheltered in His arms,
Debbie and Dan
Monday, September 22, 2008
One Month Today - Monday, Sept. 22
It's one month today that Dan has his new liver. And today, they moved Dan to the room where he was admitted back in June when I first arrived in Phoenix. The Intermediate Care pod is reopened today after being redone, and everything in the room is new, including upgraded computers and monitors.
We still remember the parents of the 19-year old boy whose liver lives on in Dan, and pray for their comfort and that will know what their gift has meant to us.
Dan continues to recover from transplant and battles the same things:
* He is getting another pericentesis this afternoon to remove more fluid from his abdomen.
* He received 2 more units of blood this morning, his hemoglobin was 7.4 this morning.
This morning, his scar was red and swollen, so the doctor made a small incision to drain the swollen part and took a sample to test for infection. They did this right in Dan's room. I have enjoyed learning about everything to do with Dan's physiology, HOWEVER watching a mini surgery was a bit much, even for me.
Funny for the day: The OT worked with Dan this morning in sitting up and doing some arm exercises. Prior to starting, she asked Dan his name and birthday, the same question every doctor or nurse asks Dan, which he answered correctly. She then pointed to me and asked him who I was. I stepped closer to him so he could see me clearly, he said I was Debbie. The OT asked if I was related to him. He said "no, she's Barbara Bush." Thankfully he then said "no, she's my wife Debbie." The OT told me I've been "promoted" but all I could think is that I must look 25-30 years older now. Gotta keep finding the humor in everything!
"Laughter 101" - Debbie and Dan
We still remember the parents of the 19-year old boy whose liver lives on in Dan, and pray for their comfort and that will know what their gift has meant to us.
Dan continues to recover from transplant and battles the same things:
* He is getting another pericentesis this afternoon to remove more fluid from his abdomen.
* He received 2 more units of blood this morning, his hemoglobin was 7.4 this morning.
This morning, his scar was red and swollen, so the doctor made a small incision to drain the swollen part and took a sample to test for infection. They did this right in Dan's room. I have enjoyed learning about everything to do with Dan's physiology, HOWEVER watching a mini surgery was a bit much, even for me.
Funny for the day: The OT worked with Dan this morning in sitting up and doing some arm exercises. Prior to starting, she asked Dan his name and birthday, the same question every doctor or nurse asks Dan, which he answered correctly. She then pointed to me and asked him who I was. I stepped closer to him so he could see me clearly, he said I was Debbie. The OT asked if I was related to him. He said "no, she's Barbara Bush." Thankfully he then said "no, she's my wife Debbie." The OT told me I've been "promoted" but all I could think is that I must look 25-30 years older now. Gotta keep finding the humor in everything!
"Laughter 101" - Debbie and Dan
Saturday, September 20, 2008
Saturday, Sept. 20th updates
Dan's doctors continue to be pleased with how his new liver is functioning. Plus the change from Procraf to Cyclosporin (anti-rejection meds) cleared his mental fog - yippee! And he continues to eat very well, still eating the pureed vegetables, except for the carrots - oh well. The doctor removed the staples from his incision today. I jokingly asked "so will you use a staple remover?" thinking about the one on my desk at work. He said "Yes!" and pulled out a staple remover that looked alot like mine except the part you hold looked like the finger holds on scissors.
He was in considerable pain the last few days in his lower abdomen, the doctor did a CT scan and didn't find anything wrong, they did see the kidney stone still in his left kidney but it's not moving and shouldn't be causing that pain. They did another peracentesis and removed 2-1/2 liters of fluid (that's like a big bottle of Mt. Dew). The pain med made him sleep most of the night, a nice break for him. They are testing the fluid for infection, results won't be back for a few days. This morning's labs showed a slight elevation in white blood cells, so Dan's getting a few new antibiotics, more to be proactive in case there is infection in that fluid. Labs also showed elevated potassium and low calcium, both of which were corrected with medications. The doctors suspect this is from the kidneys still not working at 100% and not flushing out the potassium, not sure about that calcium since he's drinking a lot of milk. He also got more lasix and albumin to push the kidneys more. And Rehab doctors did their assessment yesterday and said he's still not ready to move to Rehab, that's disappointing but I know it will happen in good time.
Ministry happens in amazing ways. Along with getting to know the doctors and nurses very well, we've gotten to know some of the other patients' families, a few have been here almost as long or longer than Dan. God's love has been shared with so many people and in so many extraordinary yet ordinary ways.
Oh how He loves you and me....
Debbie and Dan
He was in considerable pain the last few days in his lower abdomen, the doctor did a CT scan and didn't find anything wrong, they did see the kidney stone still in his left kidney but it's not moving and shouldn't be causing that pain. They did another peracentesis and removed 2-1/2 liters of fluid (that's like a big bottle of Mt. Dew). The pain med made him sleep most of the night, a nice break for him. They are testing the fluid for infection, results won't be back for a few days. This morning's labs showed a slight elevation in white blood cells, so Dan's getting a few new antibiotics, more to be proactive in case there is infection in that fluid. Labs also showed elevated potassium and low calcium, both of which were corrected with medications. The doctors suspect this is from the kidneys still not working at 100% and not flushing out the potassium, not sure about that calcium since he's drinking a lot of milk. He also got more lasix and albumin to push the kidneys more. And Rehab doctors did their assessment yesterday and said he's still not ready to move to Rehab, that's disappointing but I know it will happen in good time.
Ministry happens in amazing ways. Along with getting to know the doctors and nurses very well, we've gotten to know some of the other patients' families, a few have been here almost as long or longer than Dan. God's love has been shared with so many people and in so many extraordinary yet ordinary ways.
Oh how He loves you and me....
Debbie and Dan
Thursday, September 18, 2008
Thursday, Sept. 18th updates
The last few days have been pretty good. Dan's liver and kidneys are doing better every day, his blood sugar has been just about normal and he is eating well. The doctors finally changed his Prograf to Cyclosporin, these are anti-rejection meds, in hopes of clearing up the confusion and quieting the tremors, both of which seemed better this morning. He has been up walking a lap with the PT and OT the past 3 days and no heart afib. Rehab will reassess Dan tomorrow to see when he can start rehab. And it's possible Dan will be taken off "intermediate care" tomorrow, we hope he gets to keep his room, we've gotten to know the nurses in this pod very well.
Soaring,
Debbie and Dan
Soaring,
Debbie and Dan
Tuesday, September 16, 2008
A Great Day - Tuesday, Sept. 16 updates
What a great day! Dan was able to sleep for 5 hours last night (me too!). And the PT and OT came by again this morning, and Dan was able to get up and walk around the floor one time, then sit up in a chair for an hour, all without any afib! The cardiologist thinks they have the right medicine and timing, however he said the afib might come back, but we are grateful for a good morning. He is eating very well. Get this, part of his breakfast this morning was a high protein chocolate shake! Where do we sign up?!
The doctor ordered the catheter to be used again to help the kidneys a little longer with the fluid retention. And the wound nurse decided to replace the dressing on his 2 leg sores.
Funny of the day: A few nurses were helping change Dan's bed and helping him clean up while I was out of the room chatting with Dan's folks. We walked back in a few minutes later and the nurses told us that Dan had been flirting with them! I looked at him and he was grinning. I told him "the wife leaves for a minute and you start checking out the nurses." He nodded and said he has the prettiest nurses and told them so. Leave it to Dan to keep everyone laughing.
Praise God who gives songs in the night,
Debbie and Dan
The doctor ordered the catheter to be used again to help the kidneys a little longer with the fluid retention. And the wound nurse decided to replace the dressing on his 2 leg sores.
Funny of the day: A few nurses were helping change Dan's bed and helping him clean up while I was out of the room chatting with Dan's folks. We walked back in a few minutes later and the nurses told us that Dan had been flirting with them! I looked at him and he was grinning. I told him "the wife leaves for a minute and you start checking out the nurses." He nodded and said he has the prettiest nurses and told them so. Leave it to Dan to keep everyone laughing.
Praise God who gives songs in the night,
Debbie and Dan
Monday, September 15, 2008
Monday, Sept. 15 updates
Today is Dan's 3 week "re-liverance day" anniversary and it's been a busy one already. He had breakfast, then the kidney doctor came by - Dan's creatinine level is down to 2, that's the lowest yet, so good news there. One of the liver transplant surgeons came by, the liver is still doing well. The speech pathologist helped him with his breakfast and his swallowing is doing better, liquids are still thickened and food is still pureed (don't tell him I told you, but he is actually eating pureed vegetables, including peas!). The PT and OT came by to try to get him walking, and sure enough, his heart went afib again, so it's back to bed. The afib lasted longer this morning, they gave him the heart medicine in pill form first, then in his IV. It took a few hours, but his heart rate finally slowed by lunchtime. They also removed the catheter which was causing a lot of pain, and no wonder, they found it was clogged probably after being in for 3 weeks. Hopefully the pain "down there" will go away now.
The doctors ordered a Paracentesis and ultrasound to see if he needs a Thoracentesis (google these to get more info, basically it's draining fluid from his abdomen and between the lungs and chest wall). My mom has had thoracentesis several times, it's a little painful but sure helped her breathing. I don't think there is a part of Dan's body that hasn't been poked, scoped, imaged, or connected to sensors or wires or IVs. And I am continually amazed at the grace God has given Dan to handle everything. He is my hero.
Calgon, take me away...
Debbie and Dan
The doctors ordered a Paracentesis and ultrasound to see if he needs a Thoracentesis (google these to get more info, basically it's draining fluid from his abdomen and between the lungs and chest wall). My mom has had thoracentesis several times, it's a little painful but sure helped her breathing. I don't think there is a part of Dan's body that hasn't been poked, scoped, imaged, or connected to sensors or wires or IVs. And I am continually amazed at the grace God has given Dan to handle everything. He is my hero.
Calgon, take me away...
Debbie and Dan
Sunday, September 14, 2008
Sunday, Sept. 14 updates
Dan is enjoying getting to eat again, meals are pureed and low sugar, and liquids are still thickened to a nectar consistency (Hawaii ohana, think POG juice consistency). His heart has been fairly stable, just a few afib "blips" last night and this morning, and a few flutters as the cardiologist called it. The PT should be back this afternoon and hopefully his heart will remain stable so they can get him standing up and then sitting in a chair for a while.
PTL for the 2 wonderful nurses last night, who came in every few hours or so to change Dan's position in bed and massage his back - that really helped his back feel better and he was able to rest better.
The doctors are considering changing one of his anti-rejection meds from Prograf to Cyclosporine, hoping this will calm the hand tremors and take away the confusion that still is there.
I visited the chapel at Mayo early this morning, very peaceful environment, encouraging scriptures all around, confortable chairs with kneeling benches, a prayer journal anyone can write in. I spent some time reading scripture and praying with a kneeling bench. I felt very Catholic! But there is something to be said for kneeling humbly before God. This is one of the verses displayed in the chapel, and it spoke to me this morning: "My health may fail, and my spirit may grow weak, but God remains the strength of my heart; he is mine forever." Psalm 73:26 (New Living Translation). The Contemporary English Version says it short and sweet: "My body and mind may fail, but You are my strength and my choice forever." Amen!
Debbie and Dan
PTL for the 2 wonderful nurses last night, who came in every few hours or so to change Dan's position in bed and massage his back - that really helped his back feel better and he was able to rest better.
The doctors are considering changing one of his anti-rejection meds from Prograf to Cyclosporine, hoping this will calm the hand tremors and take away the confusion that still is there.
I visited the chapel at Mayo early this morning, very peaceful environment, encouraging scriptures all around, confortable chairs with kneeling benches, a prayer journal anyone can write in. I spent some time reading scripture and praying with a kneeling bench. I felt very Catholic! But there is something to be said for kneeling humbly before God. This is one of the verses displayed in the chapel, and it spoke to me this morning: "My health may fail, and my spirit may grow weak, but God remains the strength of my heart; he is mine forever." Psalm 73:26 (New Living Translation). The Contemporary English Version says it short and sweet: "My body and mind may fail, but You are my strength and my choice forever." Amen!
Debbie and Dan
Saturday, September 13, 2008
Saturday, Sept. 13 updates
Dan went last night without pain meds, even though his back is really really sore. The doctors wanted him to go as long as possible without the pain meds so he can be more "awake" mentally. He had a few hours sleep last night, then off and on from 1am on. I got him to lie on his side so I could massage his back for a while, Dan's dad did this yesterday afternoon and it seemed to help, so I tried it last night. Dan says some crazy nonsense things from 1am on, things like "the little horses are our friends", "saguaro cactus are beautiful", "my mom is watching the fights", "Debbie, call your mom and ask her to change the oil". I can't wait to tell him this stuff when he's more "awake".
The PT and OT came by this morning and got him up and sitting on the side of the bed, that will be his big activity for the day. His heart rhythm was stable. He also got to eat lunch, the first he's eaten since his surgeries this week. If all goes well, the PT and OT will be back tomorrow to help him stand up and then sit in a chair.
Amy, Adam and Swen go back to Yuma tomorrow morning. We will really miss them, but they will be back in a few weeks, Adam has another trip in October. Adam enjoys his job with Kiewit, and he has been commended by his boss and others higher up, saying he is the best maintenance engineer in the region. Great job, Adam!
Aloha from the desert,
Debbie and Dan
The PT and OT came by this morning and got him up and sitting on the side of the bed, that will be his big activity for the day. His heart rhythm was stable. He also got to eat lunch, the first he's eaten since his surgeries this week. If all goes well, the PT and OT will be back tomorrow to help him stand up and then sit in a chair.
Amy, Adam and Swen go back to Yuma tomorrow morning. We will really miss them, but they will be back in a few weeks, Adam has another trip in October. Adam enjoys his job with Kiewit, and he has been commended by his boss and others higher up, saying he is the best maintenance engineer in the region. Great job, Adam!
Aloha from the desert,
Debbie and Dan
Friday, September 12, 2008
Better days
Thank you for your prayers for Dan. God has answered!
1- The doctors said the kidneys are functioning better now than they have in days and the swelling is almost gone. They told us they expected the kidneys to be seriously harmed because of the dye used in the surgeries, and they fully expected to have to do a few days dialysis. The doctors told us they could not explain how this happened (but we know why!). God is good!
2- They were able to do the 2nd surgery yesterday - their was a narrowing of the bile duct and they were able to insert a stent to keep it open and functioning - they do this endoscopically (down the throat - how in the world to they get to the liver that way?). The procedure went very well, and this morning his liver counts were the lowest yet, the ultrasound looks good, even the creatinine level went down more showing his kidneys are working even better.
Please keep praying for Dan's heart. He went afib yesterday morning and again this morning, both times when he was getting up to use the bathroom. So the cardiologists are back doing further testing, giving him diltiazem IV to slow down the heart. The doctors would like to get Dan up walking again, so we appreciate your prayers specifically for his heart.
Great is His faithfulness,
Debbie and Dan
1- The doctors said the kidneys are functioning better now than they have in days and the swelling is almost gone. They told us they expected the kidneys to be seriously harmed because of the dye used in the surgeries, and they fully expected to have to do a few days dialysis. The doctors told us they could not explain how this happened (but we know why!). God is good!
2- They were able to do the 2nd surgery yesterday - their was a narrowing of the bile duct and they were able to insert a stent to keep it open and functioning - they do this endoscopically (down the throat - how in the world to they get to the liver that way?). The procedure went very well, and this morning his liver counts were the lowest yet, the ultrasound looks good, even the creatinine level went down more showing his kidneys are working even better.
Please keep praying for Dan's heart. He went afib yesterday morning and again this morning, both times when he was getting up to use the bathroom. So the cardiologists are back doing further testing, giving him diltiazem IV to slow down the heart. The doctors would like to get Dan up walking again, so we appreciate your prayers specifically for his heart.
Great is His faithfulness,
Debbie and Dan
Thursday, September 11, 2008
New development - please pray
The results of Tuesday's ultrasound and biopsy showed a blockage or restriction in Dan's hepatic artery, so they did an angioplasty yesterday, a catheterization going through the hepatic artery, then inserting a balloon to open the artery (similar to how they do it for the heart). The results were complicated and the surgeon said they have not seen such a complicated case before, and if you know Dan, this is not at all surprising.
1- Dan's hepatic artery, the one that delivers blood to the liver, was not getting enough blood so the liver was not getting enough blood, which could be causing the tiredness and confusion. The artery that supplies blood to the hepatic artery also supplies blood to the spleen - think of a V in the road. Turns out there wasn't a blockage in the hepatic artery, but the speen artery had greatly enlarged and was getting all the blood, this happened in the last few days and they don't know why. So to help the liver, they blocked the speen's artery so all the blood will flow to the liver, this leaves the spleen essentially "dead" and it may have to be removed at some time. The spleen fights certain infections, but they have immunizations they can give Dan for this.
2- There is a restriction in Dan's bile duct and the plan is to insert a stent via endoscopy sometime today depending on how Dan is doing.
3- The dye used in the angioplasty harms the kidneys, and his kidneys are not functioning well anyway, so they gave him medication during and after the procedure, but they may have to do a few days of dialysis to help the kidneys along and get rid of the fluids he still has.
We just got a call this morning that Dan's heart rate started racing again, so I'm headed up to Mayo now. They did move him back to the Intermediate Care pod on the same floor. I will blog more when I get more info, but for the meantime, please pray. Actually I know you are praying all along, but if you could pray specifically for these new complications, we would be grateful.
More later....
Debbie
1- Dan's hepatic artery, the one that delivers blood to the liver, was not getting enough blood so the liver was not getting enough blood, which could be causing the tiredness and confusion. The artery that supplies blood to the hepatic artery also supplies blood to the spleen - think of a V in the road. Turns out there wasn't a blockage in the hepatic artery, but the speen artery had greatly enlarged and was getting all the blood, this happened in the last few days and they don't know why. So to help the liver, they blocked the speen's artery so all the blood will flow to the liver, this leaves the spleen essentially "dead" and it may have to be removed at some time. The spleen fights certain infections, but they have immunizations they can give Dan for this.
2- There is a restriction in Dan's bile duct and the plan is to insert a stent via endoscopy sometime today depending on how Dan is doing.
3- The dye used in the angioplasty harms the kidneys, and his kidneys are not functioning well anyway, so they gave him medication during and after the procedure, but they may have to do a few days of dialysis to help the kidneys along and get rid of the fluids he still has.
We just got a call this morning that Dan's heart rate started racing again, so I'm headed up to Mayo now. They did move him back to the Intermediate Care pod on the same floor. I will blog more when I get more info, but for the meantime, please pray. Actually I know you are praying all along, but if you could pray specifically for these new complications, we would be grateful.
More later....
Debbie
Tuesday, September 9, 2008
Tuesday, Sept. 9 updates
Happy Birthday to our Amy! Her name means "blessed one" and she is that to us. We are grateful that God allowed us to be her parents, and now that she's 23 and a wife and mother herself, we are blessed to call her friend. Her presence during Dan's recovery time has been a delight and we are grateful for every moment spent with Amy, Adam, and our grandson Swen.
Dan's kidney CT scan today did show a small kidney stone in his left kidney, however the placement and size would not cause his back pain. So the doctors are convinced the pain is still from the fall and also from lying in bed for so long. So the doctors and PTs have decided to push Dan a little in sitting up more and walking. He walked 1 lap today around the floor, sat up for about an hour then sat up for all 3 meals today. Hopefully these activities will help his back get stronger and lessen the pain.
Meds and meals were more in sync today and his creatinine level didn't change from yesterday, the doctors will still monitor and they are hopeful the kidneys and liver are getting more in sync. His blood sugar is still high though not as high as yesterday. Dan is enjoying reading his new book "Take The Risk" by Dr. Ben Carson, a neurosurgeon at John Hopkins and a man of faith. He's also reading "The Few and the Proud" by Larry Smith, stories from Marine Corps Drill Instructors. It's great that he's able to read again.
Aloha,
Debbie and Dan
Dan's kidney CT scan today did show a small kidney stone in his left kidney, however the placement and size would not cause his back pain. So the doctors are convinced the pain is still from the fall and also from lying in bed for so long. So the doctors and PTs have decided to push Dan a little in sitting up more and walking. He walked 1 lap today around the floor, sat up for about an hour then sat up for all 3 meals today. Hopefully these activities will help his back get stronger and lessen the pain.
Meds and meals were more in sync today and his creatinine level didn't change from yesterday, the doctors will still monitor and they are hopeful the kidneys and liver are getting more in sync. His blood sugar is still high though not as high as yesterday. Dan is enjoying reading his new book "Take The Risk" by Dr. Ben Carson, a neurosurgeon at John Hopkins and a man of faith. He's also reading "The Few and the Proud" by Larry Smith, stories from Marine Corps Drill Instructors. It's great that he's able to read again.
Aloha,
Debbie and Dan
Monday, September 8, 2008
Monday, Sept. 8 updates
Happy "De-Liverance and Re-Liverance" Day to Dan today -- it is 2 weeks today that Dan received his gift of a new liver and an extension of life.
Results of yesterday's back xray were normal, nothing broken or out of place. Dan's dad remembered his recent kidney stone problems and maybe that is causing some/all of the back pain, so we mentioned that to the doctors and they will be doing a kidney ultrasound tomorrow morning to check on that.
Results from the liver biopsy showed several things. One, he had a slight rejection issue which raised the liver counts and the bilirubin which explained the jaundice yesterday. Also there was concern about imflamation or something with his bile ducts, but after further review of the biopsy, doctors decided all is well there. For the rejection, they increased his anti-rejection meds and his steroids, and by this morning the jaundice was gone and the labs looked good. However, his kidney output was down a little and his creatinine was up, most likely from the increased anti-rejection meds and the anti-fungal and anti-viral meds they are still giving him. And his blood sugar went very high, up to 375 this morning, also due to the increased meds.
Today was a crazy day with meds and meals. They brought Dan's breakfast, but he couldn't eat because the doctors made med changes, meds that must be taken 2-hours before or after meals, plus the timing of eating is also based on a blood sugar test then the appropriate dose of insulin is given, then he needs to eat, so he finally got to eat his breakfast at 11am. Then as luck would have it, his lunch arrived at 11:30, but he wasn't hungry then so lunch was held till 1:30, again after all the meds protocol, so the PT and OT had to come back later to get him up and walk around, which he did only 1 lap around the floor today due to the back pain. Dinner came at the usual time and Dan's folks were there to help him while I took a little break. He rested most of the evening while we watched Star Trek Next Gen on Sci-Fi channel. Sure hope tomorrow things can be more "normal" for meals and meds, whatever normal is these days. And now it looks like rehab will be delayed until end of the week, they are waiting for his kidney and liver function to be stable and in sync.
More lessons from everyday things: I'm reading this great book by Francine Rivers called "The Priest". It's another Biblical novel, this time about Aaron and Moses. As I read about the Hebrews praising God one minute and then grumbling the next, how God answered their prayers for freedom in His time, how He provided for their needs one day at a time, how He led them to the promised land the long way through the desert rather than the quick way through the land of their enemies, which the Hebrews didn't understand. I can see how God is doing the same thing for us. He answered our prayers for a new liver for Dan in His time, He is providing for our needs one day at a time, He is leading us to our promised land (Hawaii nei!) the long way through the desert of recovery challenges, rather than the quick way which might have been through the land of our "enemies" of pride and self-sufficiency. And funny how we are actually in the Phoenix desert as well. Our "desert" road leaves us with no self-sufficiency, we only have open hands to receive each day's strength from God, and open arms to praise Him for it. So, it's time to rejoice and remember Dan's "De-liverance and Re-liverance" Day, and to not be dismayed by the long recovery process but expect and receive God's gift of strength for each day.
Now I'm having a 70's flashback..."I've been to the desert on a horse with no name..." Was anyone else an America fan?
Debbie and Dan
Results of yesterday's back xray were normal, nothing broken or out of place. Dan's dad remembered his recent kidney stone problems and maybe that is causing some/all of the back pain, so we mentioned that to the doctors and they will be doing a kidney ultrasound tomorrow morning to check on that.
Results from the liver biopsy showed several things. One, he had a slight rejection issue which raised the liver counts and the bilirubin which explained the jaundice yesterday. Also there was concern about imflamation or something with his bile ducts, but after further review of the biopsy, doctors decided all is well there. For the rejection, they increased his anti-rejection meds and his steroids, and by this morning the jaundice was gone and the labs looked good. However, his kidney output was down a little and his creatinine was up, most likely from the increased anti-rejection meds and the anti-fungal and anti-viral meds they are still giving him. And his blood sugar went very high, up to 375 this morning, also due to the increased meds.
Today was a crazy day with meds and meals. They brought Dan's breakfast, but he couldn't eat because the doctors made med changes, meds that must be taken 2-hours before or after meals, plus the timing of eating is also based on a blood sugar test then the appropriate dose of insulin is given, then he needs to eat, so he finally got to eat his breakfast at 11am. Then as luck would have it, his lunch arrived at 11:30, but he wasn't hungry then so lunch was held till 1:30, again after all the meds protocol, so the PT and OT had to come back later to get him up and walk around, which he did only 1 lap around the floor today due to the back pain. Dinner came at the usual time and Dan's folks were there to help him while I took a little break. He rested most of the evening while we watched Star Trek Next Gen on Sci-Fi channel. Sure hope tomorrow things can be more "normal" for meals and meds, whatever normal is these days. And now it looks like rehab will be delayed until end of the week, they are waiting for his kidney and liver function to be stable and in sync.
More lessons from everyday things: I'm reading this great book by Francine Rivers called "The Priest". It's another Biblical novel, this time about Aaron and Moses. As I read about the Hebrews praising God one minute and then grumbling the next, how God answered their prayers for freedom in His time, how He provided for their needs one day at a time, how He led them to the promised land the long way through the desert rather than the quick way through the land of their enemies, which the Hebrews didn't understand. I can see how God is doing the same thing for us. He answered our prayers for a new liver for Dan in His time, He is providing for our needs one day at a time, He is leading us to our promised land (Hawaii nei!) the long way through the desert of recovery challenges, rather than the quick way which might have been through the land of our "enemies" of pride and self-sufficiency. And funny how we are actually in the Phoenix desert as well. Our "desert" road leaves us with no self-sufficiency, we only have open hands to receive each day's strength from God, and open arms to praise Him for it. So, it's time to rejoice and remember Dan's "De-liverance and Re-liverance" Day, and to not be dismayed by the long recovery process but expect and receive God's gift of strength for each day.
Now I'm having a 70's flashback..."I've been to the desert on a horse with no name..." Was anyone else an America fan?
Debbie and Dan
Sunday, September 7, 2008
Sunday, Sept. 7 updates
I took another day off yesterday (Saturday) to rest from this pesky cold, and I am better today and back at the hospital. Thanks to Dan's folks and sister Debbie for spending long hours at the hospital yesterday and keeping me updated.
They moved Dan to a different room on the same floor yesterday, due to needing to consolidate patients as they are doing some construction or maintenance on the floor. So we lost his "suite" and got a smaller room, which is close to the heated blankets "oven", so I can get blankets whenever Dan or I need (yes, it's cold in the rooms).
Today, Dan is having another liver ultrasound and biopsy, along with that lower back xray. His kidney function is lower, so they decreased his anti-rejection meds which improved the kidney function and lowered the liver function/raised the bilirubin so he's a little jaundiced today. Based on the results of the ultrasound and biopsy they will probably increased the anti-rejection meds for the liver. It's interesting how with a new liver they have to give anti-rejection meds, which can cause infection so they give antibiotics for that, which can cause other problems with kidneys etc. so they give more meds for that, and it goes on and on, until his body adjusts to all the changes and grows stronger, thereby reducing the need for the additional meds. Because of all this, his move to rehab may be delayed a few days.
Tomorrow will make 2 weeks since his transplant and a long 2 weeks in bed in the hospital. So many things have happened in that time, we are so grateful for the gift of life for Dan and continue to pray for the donor's family. The funeral is probably over, the out-of-town family probably leaving soon, and life will have to go on for the donor's parents. They may start going through his/her room and continue dealing with feelings of loss. Thanks for joining us in prayer for the family. We will be sending a thank-you letter to the family via the hospital, since we will not be told their names. I think at some point in the future, that option may be given, but for now, we trust them to God.
More updates to come. Enjoy your day of worship and rest today, and enjoy the first Sunday of the NFL! We have a new interest this year in the Redskins, since Colt Brennan from UH is there. And of course, we continue to cheer on the Vikings, hopefully this will be their year.
Debbie and Dan
They moved Dan to a different room on the same floor yesterday, due to needing to consolidate patients as they are doing some construction or maintenance on the floor. So we lost his "suite" and got a smaller room, which is close to the heated blankets "oven", so I can get blankets whenever Dan or I need (yes, it's cold in the rooms).
Today, Dan is having another liver ultrasound and biopsy, along with that lower back xray. His kidney function is lower, so they decreased his anti-rejection meds which improved the kidney function and lowered the liver function/raised the bilirubin so he's a little jaundiced today. Based on the results of the ultrasound and biopsy they will probably increased the anti-rejection meds for the liver. It's interesting how with a new liver they have to give anti-rejection meds, which can cause infection so they give antibiotics for that, which can cause other problems with kidneys etc. so they give more meds for that, and it goes on and on, until his body adjusts to all the changes and grows stronger, thereby reducing the need for the additional meds. Because of all this, his move to rehab may be delayed a few days.
Tomorrow will make 2 weeks since his transplant and a long 2 weeks in bed in the hospital. So many things have happened in that time, we are so grateful for the gift of life for Dan and continue to pray for the donor's family. The funeral is probably over, the out-of-town family probably leaving soon, and life will have to go on for the donor's parents. They may start going through his/her room and continue dealing with feelings of loss. Thanks for joining us in prayer for the family. We will be sending a thank-you letter to the family via the hospital, since we will not be told their names. I think at some point in the future, that option may be given, but for now, we trust them to God.
More updates to come. Enjoy your day of worship and rest today, and enjoy the first Sunday of the NFL! We have a new interest this year in the Redskins, since Colt Brennan from UH is there. And of course, we continue to cheer on the Vikings, hopefully this will be their year.
Debbie and Dan
Friday, September 5, 2008
Friday, Sept. 5th updates
Dan is doing so well. He started reading and writing today. And he got to eat real food for all 3 meals today, along with drinks mixed with the thickener, though still no thickened iced tea - yuck. His doctors are very pleased with his progress.
He did only 2 laps with the OT today, his lower back is sore from that fall a few days ago, the doctors have ordered an xray just to be sure nothing is broken. Dan really enjoys visits from the OTs (occupational therapists). They get him up and to the sink for grooming activities, walking his laps, then arm exercises with a towel. The hard stuff comes next week when they move him to rehab - 3 hour workouts with short breaks, but Dan says he's ready for the challenge. They also do some fun stuff, like bake cookies or go shopping...where do I sign up?! Right now, the plan is 7 days in rehab, so he might get to come home after next week.
Today, the endocrinologist came by to teach us about insulin and how to do blood sugar maintenance. Some of this I already knew since my Mom is diabetic, and she uses insulin pens rather than syringes, Dan will get to use these also. Alot of info to absorb, but Dr. Childs explained everything so well - if you watch the tv show Frasier, Dr. Childs reminds us of Niles only with dark hair. I'm glad they give us just a little info each day, I think we'll be ready come time to leave the hospital.
And today's word from everyday things around us: we watched Mayo's educational video on taking care of a new liver (did you know your liver performs over 5,000 functions?). One very important thing for Dan now will be to stay infection-free. He can't be around sick people, he needs to avoid big crowds for that same reason (Hawaii ohana, don't be offended if Dan isn't able to hug you all). He will need to practice good hand-washing hygiene and even be very careful not to get cuts or skin abrasions, believe it or not, a little cut infected can harm his new liver which will harm the entire body. God spoke loud and clear to me about the need for purity in my life and in the Body of Christ. Just like a little cut can ultimately harm Dan's entire body now, sin (even a "little sin" only I know), could ultimately harm the Body. And just like Dan needs to avoid folks that are sick, we need to avoid unhealthy relationships, media, anything that might cause a "sin" infection in the Body. 1 John 1:5-10 comes to mind.
Aloha from the desert,
Debbie and Dan
He did only 2 laps with the OT today, his lower back is sore from that fall a few days ago, the doctors have ordered an xray just to be sure nothing is broken. Dan really enjoys visits from the OTs (occupational therapists). They get him up and to the sink for grooming activities, walking his laps, then arm exercises with a towel. The hard stuff comes next week when they move him to rehab - 3 hour workouts with short breaks, but Dan says he's ready for the challenge. They also do some fun stuff, like bake cookies or go shopping...where do I sign up?! Right now, the plan is 7 days in rehab, so he might get to come home after next week.
Today, the endocrinologist came by to teach us about insulin and how to do blood sugar maintenance. Some of this I already knew since my Mom is diabetic, and she uses insulin pens rather than syringes, Dan will get to use these also. Alot of info to absorb, but Dr. Childs explained everything so well - if you watch the tv show Frasier, Dr. Childs reminds us of Niles only with dark hair. I'm glad they give us just a little info each day, I think we'll be ready come time to leave the hospital.
And today's word from everyday things around us: we watched Mayo's educational video on taking care of a new liver (did you know your liver performs over 5,000 functions?). One very important thing for Dan now will be to stay infection-free. He can't be around sick people, he needs to avoid big crowds for that same reason (Hawaii ohana, don't be offended if Dan isn't able to hug you all). He will need to practice good hand-washing hygiene and even be very careful not to get cuts or skin abrasions, believe it or not, a little cut infected can harm his new liver which will harm the entire body. God spoke loud and clear to me about the need for purity in my life and in the Body of Christ. Just like a little cut can ultimately harm Dan's entire body now, sin (even a "little sin" only I know), could ultimately harm the Body. And just like Dan needs to avoid folks that are sick, we need to avoid unhealthy relationships, media, anything that might cause a "sin" infection in the Body. 1 John 1:5-10 comes to mind.
Aloha from the desert,
Debbie and Dan
Thursday, September 4, 2008
Thursday, Sept. 4th updates
Dan walked 5 laps around the floor this morning and is very proud of that! All the IVs are out today, the pic line is still in his left arm for taking blood tests and giving some meds. He still had his feeding tube, we hope it comes out soon. He ate several meals today, lunch with me was vanilla pudding, vanilla yogurt, and V8 juice with thickener. He's not a fan of yogurt or V8 but with steely determination ate it all. We still await the urologist visit. The kidney doctor is concerned about his creatinine level which measures his kidney function, so they continue to give him lasix and albumin. The endocrinologist came by with more instructions on how to manage the diabetes which hopefully is temporary. Mayo has several videos for us to watch on how to manage life after transplant, info on meds which must be given at exact times each day. It's all a little daunting to me, thankfully Mayo is giving us lots of reading materials and a little education each day. I think we have to take a quiz before we leave the hospital! Dan is also anxious to start writing again, we'll post his writings as soon as he's ready.
As for me, I am feeling much better, Amy picked me up around 10pm last night so I could sleep at home, then she brought me back this morning after Swen was up from his nap. I'll probably continue this for the rest of the week. Dan is well taken care of at night, and God impressed upon me the importance of taking good care of myself, as when Dan gets home I need to be in good shape to help him.
A menehune (playful unseen elf according to Hawaiian folklore) came to Dan's room while I was at lunch today and left a delightful fruit basket (thanks, Nancy). Other menehunes sent gifts in the mail this past week, for which we are humbled and grateful. God has sure taught us a lesson to be joyful receivers of gifts, it's a lot easier for us to be joyful givers, isn't it? Hopefully, as we joyfully receive, we will then in turn joyfully give, and "God's creditline" continues to revolve and supply needs.
Hau'oli ë! (happiness and joy),
Debbie and Dan
As for me, I am feeling much better, Amy picked me up around 10pm last night so I could sleep at home, then she brought me back this morning after Swen was up from his nap. I'll probably continue this for the rest of the week. Dan is well taken care of at night, and God impressed upon me the importance of taking good care of myself, as when Dan gets home I need to be in good shape to help him.
A menehune (playful unseen elf according to Hawaiian folklore) came to Dan's room while I was at lunch today and left a delightful fruit basket (thanks, Nancy). Other menehunes sent gifts in the mail this past week, for which we are humbled and grateful. God has sure taught us a lesson to be joyful receivers of gifts, it's a lot easier for us to be joyful givers, isn't it? Hopefully, as we joyfully receive, we will then in turn joyfully give, and "God's creditline" continues to revolve and supply needs.
Hau'oli ë! (happiness and joy),
Debbie and Dan
Wednesday, September 3, 2008
Wednesday, September 3rd updates
God's ways sure are confusing sometimes. Labor Day, Sept. 1st, I felt a cold or something coming on so I had Amy take me home to rest and get away from Dan, since his immunity is suppressed he could catch anything easily. By the afternoon, I had a 101 temp and everything hurt. I stayed in bed the rest of Monday, all day Tuesday, and half day Wednesday (today). I am thankful for my family: Dan's folks spent long days with Dan in the hospital, Amy juggled taking care of Swen/visiting Dan/bringing me medicine and water. By this afternoon, my fever was gone and I felt among the living again. After enjoying watching Amy and Swen in the pool, Amy brought me back to the hospital for a short visit with Dan; I'll sleep at home tonight to be sure I'm completely well before I start spending the night at the hospital again. Not sure why God would allow me to get sick in the hospital, maybe He thought I needed more rest, who knows. Enough about me.
Dan is still progressing well. Here are the updates I received today:
* Heart: Cardiologists decided not to do the 2nd echocardiogram, deciding that any issues with his heart are from the liver transplant. He continues to receive the blood pressure medicine.
* Liver: They did an ultrasound and biopsy on his new liver and confirmed his liver is working perfectly.
* Infections: Dan is still getting the antibiotics, I need to find out more about this.
* Swallowing: Dan passed the swallow test today, so he got his first "meal" - a liquid diet enhanced with thickener - he didn't mind the taste of everything except the thickened iced tea, which sounds pretty gross to me also. They might take his feeding tube out tomorrow if his swallowing continues to go well.
* Walking: He walked with the PT around the floor 3 times today.
* Concerns: His blood sugar has been all over the place, from low at 64 to way high at 275. The doctors have been contacted, it may just be from his pancreas trying to heal and Dan starting to "eat" again. Also, Dan had a fall today, I don't know all the details since I was still home sick, but he went down hard on his rump. Praise God no broken hip or broken anything else, but I'm sure he will be sore tomorrow. Rules for Dan now state he needs 2 nurses to help him up.
I'll update more tomorrow, time to get home to take more medicine and rest up for tomorrow.
Debbie and Dan
Dan is still progressing well. Here are the updates I received today:
* Heart: Cardiologists decided not to do the 2nd echocardiogram, deciding that any issues with his heart are from the liver transplant. He continues to receive the blood pressure medicine.
* Liver: They did an ultrasound and biopsy on his new liver and confirmed his liver is working perfectly.
* Infections: Dan is still getting the antibiotics, I need to find out more about this.
* Swallowing: Dan passed the swallow test today, so he got his first "meal" - a liquid diet enhanced with thickener - he didn't mind the taste of everything except the thickened iced tea, which sounds pretty gross to me also. They might take his feeding tube out tomorrow if his swallowing continues to go well.
* Walking: He walked with the PT around the floor 3 times today.
* Concerns: His blood sugar has been all over the place, from low at 64 to way high at 275. The doctors have been contacted, it may just be from his pancreas trying to heal and Dan starting to "eat" again. Also, Dan had a fall today, I don't know all the details since I was still home sick, but he went down hard on his rump. Praise God no broken hip or broken anything else, but I'm sure he will be sore tomorrow. Rules for Dan now state he needs 2 nurses to help him up.
I'll update more tomorrow, time to get home to take more medicine and rest up for tomorrow.
Debbie and Dan
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