Wednesday, September 21, 2016

Worries and Hope

As most of you know, in the last few months Avelyn has battled complication after complication, including 2 bouts of sepsis, more than a week of anaphylaxis symptoms, NEC, extreme hypertriglyceridemia, hyperkalemia and others. While much of these have now resolved, each took its toll on our little baby. She is only just regaining her strength, and continues to battle renal failure, and now- hypertriglyceridemia, on top of her cardiac issues. 

This week Avelyn’s triglycerides are nearly as high as they ever have been. We continue to believe the cause is “multifactorial” and centers around her absorbing high levels of carbohydrates from her dialysis, being in a constant state of stress (acute illness and constant withdrawal from sedatives), over fortified feeds, and insulin insensitivity. However, she is also being tested for potential autoimmune disorders and hereditary diseases that cause similarly high triglyceride levels (though, we do not think this these are likely). Her records have been sent to lipidologists all over the country to try and figure out the best plan of action for treatment. At current levels she is at risk for pancreatitis, and I maintain that I don’t know if she could survive pancreatitis. At the very least, it would be yet another complication that would wreak its own havoc upon poor little Avelyn’s systems. 

To combat the risks of pancreatitis, and eventually atherosclerosis, her feeds have been changed to skimmed breastmilk and a feed fortifier containing medium chain triglycerides (which are utilized more readily by the body).  She was also started on flax seed oil the other day, due to her likely having anaphylaxis to the fish oil a few weeks back. We’ve been told that the omega 3’s may lower her triglyceride level 15-20%, although there’s no guarantee in a child so young and complicated. With time and improvement of her overall condition, we hope to see a gradual decrease. This will likely be a problem that takes years to resolve. As long as she is on dialysis, lipid specialists believe she’ll likely battle some degree of hypertriglyceridemia, and if she needs a kidney transplant the immunosuppressants will also place her at risk. 
Otherwise, Avelyn has been dealing with the effects of methadone weans and continued recovery/treatment from sepsis. She is still on IV vancomycin and will be for another week or so, it makes her stomach upset  and has been contributing to continuous loose stools. The methadone weans (and new feeds) aren’t helping on that front either. 
The methadone weans often make her feel cruddy in general. She is being weaned very slowly, at half the usual rate, due to her overall fragility.  While we feel this is necessary for her safety, it prolongs the process which is frustrating for us all. We hate to see our baby uncomfortable and struggling, as the weans cause frequent gagging, diarrhea, and likely cramps, headache, and/or body aches (because she seems to respond well to Tylenol). She is currently being weaned twice a week- Mondays and Thursdays- and it takes a couple days after each wean to see her feeling like herself but then it’s time for the next wean. Unfortunately it’ll be like this for a few months. She is on a very high dose of methadone due to her lengthy intubation and multiple surgeries. Although, this has been very difficult for our sweet baby to tolerate and we hate seeing her struggle, each wean is also a blessing. 
Avelyn has lived her whole life, with the exception of a few weeks, on sedatives. Not only do we not truly know our baby, as we haven’t seen her personality not effected by substances in so long, but Avelyn does not know life without mind altering substances. She so deserves to experience the world and life without feeling the pain and discomfort of withdrawals or the effects of opiates, benzos, precedex, or clonidine. Although we are still months out, I cannot wait to have my baby free of these drugs and their effects. 
But anyway, back to current happenings.
 Like I mentioned above, Avelyn is currently doing better than she has in a long time. Though still on dialysis, oxygen, and other support, she is stable. Therefore the doctors believe it is time for a heart catheterization to optimize her cardiac function. This heart cath has been needed since April but we have avoided it due to her poor renal function. We are blessed in that her cardiac function has not declined. Amazingly, her pulmonary arteries have actually showed independent growth in the last few months, which is a small miracle. However, despite the proximal growth of her PAs, distally she still has narrowings that are causing elevated pressures in her right ventricle. Over time, these narrowings are likely to get worse and eventually overwork the right side of her heart leading to congestive heart failure. It is believed that if the PAs can be ballooned (or less preferably stented) now during babyhood, when bodily growth is most rapid, that fewer interventions will be needed. 
Expanding her PAs will not only protect her heart, it’ll also protect her lungs and help Avelyn in the gas exchange process. Right now her left sided pulmonary artery is small and receives little blood flow. Her right lung gets much more and handles most of her gas exchange needs. While this is not currently causing respiratory distress, overtime the over circulation to the right lung will damage it. 
However, opening up her left PA is not as simple as it sounds. When that left lung starts to get blood flow it’s not accustomed to, it’ll swell (which is called a reperfusion injury) and cause that lung to be quite sick in the short term (days/weeks) because of this Avelyn may need to stay intubated for a time. We don’t know how her lungs will react to PA expanding, especially given her lengthy intubation history. We hope she handles it as well as possible, and are praying she doesn’t need to be intubated long. 
In the long run, we’re hoping that the cath lab interventions will allow her to come off of oxygen completely, but will not push it if that’s not the case yet. Taking her home on a whiff of oxygen is the least of our worries, but one less tether attached to our sweet girl would surely be amazing. 
Another major worry concerning the cath is how the dye will affect her already sick kidneys. She has recently been peeing more than she has in months, although it’s still only about an eighth of what she needs to sustain herself without dialysis. Still, this is a victory in our book and we’re not at all looking forward to another step back in the kidney department. Please join us in praying for the dye to not further damage her kidneys in the long run. 
Lastly, there’s all the usual risks of a hearth cath. Vessel perforation, irritation of her heart’s conduction system, bleeding, infection and other things. All of which are serious risks, that in and of themselves are terrifying, let alone with all of Avelyn’s specific elevated risks. 
Please keep her in your thoughts Friday. Her procedure is expected to take 5-6 hours. I promise to update (likely via my Instagram account) as soon as I can. 
Thank you all for checking in and supporting our baby girl. She continues to fight with all of her might and amaze all who come in contact with her. We are so blessed to be her parents and to have your all’s love, support and prayers.














Saturday, September 17, 2016

Primary Love

I know I have spoken about our love for Avelyn’s PCICU team quite a bit, but I have never spoken about Avelyn’s primary nurses or care providers specifically.

 I guess I should first explain what a primary is. A primary nurse, nurse practitioner, or doctor chooses to assume care of a patient each time they work, therefore providing consistency of care to the patient. As a nurse myself, I feel I likely understand the gravity of this choice more than most, and I hope to convey the enormity of our love and respect for our amazing primaries with this post.
I see the choice of primarying a sick baby as a sacrifice of sorts. Mainly because only the sickest babies need primaries, but it’s so much more than that. There are so many emotional and professional elements involved. They work with the same patient day in and day out. They don’t see as much variety as they would otherwise, which is often the way you evolve and maintain skills as a healthcare worker. Emotionally, they choose to ride the roller coaster right alongside the patient and family, for better or worse. Working with the same patient so closely, it’s obvious that they can’t help but get attached and give their all in hopes of setting the child along the path of wellness. In the cases where little loves on the unit have passed, I’ve seen their primaries grieve for those they couldn’t save. It’s not a choice easily made, and we do not take our primaries for granted.
It is obvious to anyone who cares to look, that our primaries love our baby girl. They celebrate each accomplishment no matter how small, often reminding me to do the same. They feel the pain of each setback and pour themselves into saving Avelyn’s life in each time of crisis. On our hardest days, having our primaries around is a comfort in and of its self. I cannot describe how much it means to know someone who loves, knows and cares for your baby is fighting tirelessly for her when you’re too broken to think. I don’t know how they function through the pain, they so obviously feel in these harrowing times, but they do. I’ll never be able to thank them enough for what they have done for our family, but at least I can share my love and admiration on this blog for all of Avelyn’s supporters to read and someday even Avie herself.
This may sound funny, but Sean and I have actually had conversations about how we could never choose which primary we like best. Each is so different and so wonderful in their own way, we could just never choose. So I’ll list them in the order they signed onto Avie’s case.

The first is Curry, an NP. Curry is hilarious and is a self-proclaimed people pleaser. She always tries to make those around her feel comfortable with the treatment plan before implementing it. In the course of the last 9 months, she has gone great lengths to pacify me which inevitably makes me laugh-even in the most stressful situations. This isn’t to say Curry is a push over, she far from it actually. She once disagreed with us in a care conference and then, through a few tears, made sure to stress that is wasn’t personal (not that we would have ever felt that way). Because that’s Curry. She wears her heart on her sleeve and truly loves the babies and families she cares for. Another quintessential Curry moment came on Avelyn’s extubation day.  At that time, Avelyn was a DNR. The weeks prior had been hard and Avelyn being ready for extubation was a miracle. We had been so wrapped up in all that was happening that we had not processed how far Avelyn had come in such a short period of time. Curry came to us and reminded us that anything could happen during the extubation process, and while she didn’t say it aloud, it was obvious that she was pleading with us to change Avie’s code status. When we agreed that it was time and we all cried and hugged. (Because if anyone can be described as a “hugger”, it’s Curry.)

Dr. Stephanie Conrad signed up not long after Curry to be our go to intensivist. I cannot stress this woman’s brilliance enough. Not only is she incredibly intelligent, but also is one of the most genuine and caring individuals I have ever come across. Her very presence emits calm and understanding. Even while giving us news most parents could never imagine hearing, she made us feel as though we were doing all we could for our baby. Throughout this entire experience, she has gone out of her way to reassure us as parents and people. She has spear headed getting second opinions from other facilities, and has sacrificed sleep and time with her young son to come and meet with us on her days off. Though all of the attendings on the unit are amazing, Sean and I always look forward to the weeks and nights Dr. Conrad is on.

As for our nursing primaries, we’ve gotten to know them on a more personal level after spending so much time together.

Marcie was the first nurse to sign up. It was back in March, just after Avelyn’s unifocalization surgery. Though Sean and I had no way of knowing how complicated things would become, we both understood that Avelyn was a complex case and how much she needed consistency of care. When Marcie signed on I felt we had hit the jack pot. Not only is she an amazing experienced nurse but I had grown to truly adore her as a person. Marcie has seen us through some of our absolutely most terrible times. She cried with us and reassured us of our love and bravery when we chose to make Avelyn a DNR. She was also there the day Avelyn nearly coded due to sepsis. The pain of those moments will forever remain etched too sharply into my brain, but so too will Marcie’s love and her fight for our baby. Although Marcie was obviously in pain too, she handled crisis with calm efficiency, preparing for the worst, while doing all she could to stabilize our precious girl.
On a personal level, Marcie isn’t your average individual and I feel she gets our weirdness more than most. She has a dry wit and loves to pick at us, Sean in particularly, which I find hilarious. She adores her animals, two cats (who are hurricane Katrina refugees) and her dogs-Daisy and Harper, and often reminds me of my need to visit the Pickel pups. As a fellow introvert, she knows when Sean or I need space and when we are being quiet just because we don’t have anything to say. She knows when to push us and Avelyn and is responsible for much of Avleyn’s muscular strength. Marcie is also notorious for reminding me to celebrate Avelyn’s accomplishments (it’s not that I don’t realize how far she’s come, it’s just that sometimes I need help seeing past her current issues). Recently Marcie has started clinical work for her master’s degree and is mostly working weekends, which is so great in that I worry less while at work because Marcie is there. On the other hand I really miss my friend.
Molly signed up to primary Avie not long after Marcie. When she told me, I was shocked. Molly had just been the primary of a patient who had spent months on the unit. I figured she would want a break for the emotional roller coaster that comes with being a primary, but that’s not Molly. Molly is the type of person who always puts the wellbeing of her patients’ above her own. She often needs to be forced into taking a lunch break or going home on the more busy days. While on the unit, she’s always on the go and going above and beyond to help everyone out. One of the greatest things about Molly is her attention to detail. This manifests in amazingly well organized notes, coordinating outfits for the baby and also in noticing the slightest deviation from Avelyn’s baseline and acting upon it.  All of which, I appreciate.
Besides being a great nurse, Molly is a hilarious story teller and often makes me envious with the accounts of her travels. She is also honest to a fault and cracks me up with self-deprecating depictions of her adventures/misadventures. She has a recue dog, Roisin, who loves to hike and play fetch in the house. Molly obviously loves her boyfriend Dan, who supposedly puts up with her bad “show-infidelity”. For those of you who don’t know what show-infidelity is, it’s where you start watching a show with your significant other with the understanding of watching the episodes together, but then you cheat and finish the season by yourself. Maybe this isn’t a thing for most people, but I find comfort in knowing I am not the only one how has tortured the man I love so ;)
 


Lastly is Brianna. The first time I met Bri, she was on orientation after coming to Vanderbilt from Phoenix. It was 2 or 3 in the morning and Bri was looking over Avelyn while the nurse assigned to her was at lunch. She came in and spoke of being surprised to see me in the room and how great that was. Honestly I remember being a bit rude to her, I figured she was being sarcastic. Because who could really be that nice? Well Bri, that’s who. She is one of the kindest most caring individuals I have ever met. She too loves the babies she cares for and has such a patient gentle spirit. She’s also a total team player and hard worker. She graduated with her bachelors in nursing when she was only 19 and has never looked back. (When I was 19 all I cared about was besting Sean in rugby, becoming a nurse had yet to cross my mind-let alone caring for critically ill children.)
Bri is quite vocal about her love for Avelyn. So much so that Sean and I have joked, that if Avie is ever abducted, Bri would be the prime suspect- and at least we wouldn’t have to worry about her wellbeing, because Bri very well may care for better than we could.  Back when Avelyn was intubated, I would wake in the middle of the night to see Bri sitting at Avie’s bedside stroking her hair and talking to her. I cannot explain how much I appreciated someone just being there and reassuring our girl that she isn’t alone in her fight. These days Avelyn’s cries are no longer silent and I hear her when she wakes, but often Bri still manages to get to her first and will encourage me to lie back down. I can’t describe how Bri’s love and patience for Avelyn touches our hearts. On the nights Bri is there, Sean and I actually sleep. Knowing, even when we aren’t there that Avelyn’s cries won’t go unanswered means so much to us.
 

We love and hold each of these women close to our hearts. Each is in part responsible for Avelyn still being here and for her knowing that she is loved. I seriously could never thank them enough nor adequately convey the reverence we feel towards them. But rest assured, they are wonderful and we’ll always love them.

Also, this post has showed me that I need to take more photos with those who are actively saving our baby girl's life. We love them so and need to be able to show Avelyn the photos some day!

I promise to post an Avelyn update soon. In the meantime you can find mini updates on my Instagram account https://www.instagram.com/somerpickel/.

Thursday, September 8, 2016

Dangerous Times

Living in the hospital is dangerous and that goes for any hospital, not just our beloved Vanderbilt. Hospitals are dirty nasty places that harbor the most deadly bacteria unseen right under your nose, and all around your fragile loved ones. The longer one is in the hospital the greater the risk of acquiring infection-that's just how it works-not just here, everywhere.
Avelyn has now been septic more than her fair share, from endocarditis in January (that nearly killed her and has set her down this hellacious path of complications including four months of intubation and kidney failure), to sepsis in late July (that severely damaged her left ventricle and nearly sent her into cardiac arrest), to sepsis (MRSA) and NEC last week that has again forced her to fight for her life. 
So the story goes....
Last weekend, while I was away working, Avelyn was really fussy. She was teething, had terrible diarrhea and a bleeding diaper rash. Her fussiness was chalked up to all of that, but again, maybe we should have been more weary. While driving to Nashville Monday, I got a call from one of her primary nurses saying that she wasn't acting like herself. Her work of breathing was increased and her color was worse usual. Some interventions were made, she pinked up and seemed to do better but was still really fussy. But again, her diaper rash was hideous and she was actively cutting a new tooth. 
By that evening Avelyn was in such pain that I knew something else was wrong and was scared. I requested to see the doc who had seen her through the week prior's anaphylactic episodes, and therefore knows her well. When she came in I told the doc I didn't know what was wrong, but that something was amiss and was I was concerned, very concerned. She was in pain, her color looked awful and she was crying like she does before a big crash. The doc looked her over, and at that given moment she looked ok. She said she would check in on her frequently, God bless this doctor for taking my vague concerns seriously. She saved Avelyn's life that night. Seriously. 
Not long afterward Avelyn had a bloody diaper that spilled onto her bedding. I changed her and asked the nurse for help changing her bed. I put her diaper on the scale (all of her in's and out's are calculated), we got her settled and then I crashed, believing the nurse would follow up appropriately. (I had been up nearly 36 hours at this point, with only a 1.5 hour nap before driving to Nashville after work, and despite my worry-I am human.)
An hour or two later, the doc came in to check on her and Avelyn woke writhing in pain again. I told her I was super concerned about the bloody diaper. I assumed the nurse had called and that's why the doc was there.
Nope. 
The doc didn't know about the diaper and was just there to check in because of me expressing my concerns earlier in the night (seriously, this doc is amazing). I don't know why the nurse hadn't told her, because a bloody diaper is a big deal in this sick kid world as it is often a precursor to sinister happenings (maybe she was just incredibly busy with the kiddo next door, maybe she wasn't, I don't know but I have tried not to dwell upon it). 
Anyway, hearing this the doc literally fished through the trash to find the diaper. After seeing it, she ordered a slew of labs and tests. These came back showing Avelyn had a terrible active infectious process and so she was immediately started on antibiotics. This was prior to the NEC or pneumatosis ever being found on her X-ray. 
I fully believe the quickness in which the doc ordered the antibiotics is what saved Avie's life. 
The rest of the week passed slowly given Avelyn was so critical and we were all so worried. Her blood cultures came back showing she had a MRSA infection in her blood stream on top of the NEC. Infectious disease doctors were in and out multiple times a day, monitoring her progress and asking us how we felt she was doing. Surgeons were in and out multiple times a day too, because in all reality her bowel could have perferated at any time. 
Sean and I again were forced to have talks no parents should. We questioned whether we could put Avelyn through a major abdominal surgery, even if it was considered life saving. Such a surgery for Avelyn would be devastating. Not only would removing part of her intestines be a major ordeal with likely life long consequences, but also it would mean disruption in her paratoneal dialysis. This would force her onto hemodialysis. None of this was discussed with us by the team, maybe because the NEC was caught so early but as usual my brain was miles ahead. After eight months of this hell, it's hard not to live that way.
But, by the grace of God and quick actions of our Amazing PCICU team, it didn't come to that. Our Avie fought through yet again with unbridled tenacity that continues to floor me. (I don't know where she gets it, but the kid is amazing.)

After a really tough touch and go week, Avelyn seems to have stabilized. The infectious disease team came to the conclusion that her MRSA bacteremia was likely a central line associated infection. They encouraged the team to remove the affected PICC line and insert a new one. Once bacteria is set up in plastic, there's way to treat it. 
So yesterday she had a new PICC line placed. The hospital has a special team of nurses that come into the room and place PICCs. The team's only job is to place, monitor, and trouble shoot PICCs- they do it all day every day. 
I was woken by a member of the PICC team early yesterday morning to sign a consent form. While signing it, I specifically stated that Avelyn has been really sick with sepsis and that she is extremely fragile. I requested only an experienced nurse place the PICC and for no trainees to work on her. The nurse assured me that she would pass the message to her preceptor and they would take good care of her. The preceptor came in, literally five minutes later, and rushed me out. I figured she was rude because she had a busy schedule or maybe that's just her personality, now I question it. 
Did they take my concerns and requests the wrong way and treat my baby differently because of me? I hope not, but in these circumstances I can't help but question EVERYTHING.
A couple hours later I got the call that the PICC was placed, Avelyn did well, and I could come back. When I got to her room, Avelyn's nurse asked if I knew about the skin tear under her arm. I said no, and asked which arm. Of course l, and not coincidentally, it was the the same arm the new PICC was placed in. 
I asked to see the tear, because Avelyn's night time primary and I had just given her a thorough bath the night before. We checked all of her folds and powdered them because sometimes she'll get skin breakdown between them. We checked her diligently, her skin was fine. We then dressed her in a sleeveless shirt. There's no way I wouldn't have noticed a inch long >1.5 centimeter deep wound in her arm pit that was bleeding everywhere. Because that's what we found when the dressing was removed. 
The nurse seemed very surprised at how bad the wound was too, the PICC team had discribed as a "skin tear". 
At first I was in shock. 

How could this happen? 

Seriously, how in the hell could this happen!? 

How rough did they have to be with my baby to cause her skin to rip like this?! 

I was soon so angry and heart broken for poor Avelyn I could barely speak and was just crying for sometime. It took me a little while to compose myself and ask to see the nurse manager.  
To her credit, Avelyn's nurse handled the situation well. She wasn't in the room when it happened but told me exactly what she knew and was very upfront in answering my questions. From what I was able to gather, the nurse who placed the PICC was not the same one who prepped Avie's arm. From the look of the injury, her arm was ripped by being hyperextended and pulled too hard away from her body. The PICC team passed off the wound to Avie's nurse like it was already there, I figure they truly thought this. 
(I can't stomach the thought of someone knowingly causing such harm to a baby and then lying about it- I really don't believe Vanderbilt would employ someone like that.) 
Human error and/or negligence has significantly harmed my child, and I understand that happens sometimes. But that doesn't mean I am not pissed and heart broken for her. She is in such pain from this wound, every time she's awake and moves that arm she cries a high pitch cry of pain. 
I want whoever was too rough with her to know the pain she has caused and the risk she has placed Avelyn in. I want her to know that these babies are insanely fragile and you cannot treat them as you would a normal child. I want her to think how she would feel if someone had caused a gaping wound on her baby. 
I thank god for momma instincts I often don't understand but follow anyway. I was adamant about Avelyn recieving dilaudid, rather than the intended morphine, prior to leaving Avelyn's room for them to place the line. I pray she didn't feel the injury fully but I know it must've caused her serious pain either way. 
Despite this happening, it has reaffirmed my love for Vanderbilt. I know things like this can and do happen at every hospital. I work in a hospital and they are filled with imperfect people, most of whom do their very best but all of whom are fallible. 
I feel my anger and concerns are being heard and documented. The PCICU's manager is sending the manager of the PICC team to speak with me and, while at first I was indifferent about it, I am now looking forward to it. Avelyn cried much of the night and has been needing regular doses of morphine to treat the pain associated with the wound. 
I want the manager to know this and ensure no other baby experiences such an unnecessary and painful experience again. I want it documented that this happened and who was in the room when it happened. I want a paper trail. That way, in the case of another child sustains an injury maybe a pattern can be seen in behavior. 
In hospitals, if it's not documented it didn't happen- so my focus right now is ensuring I take every step in the proper channels I can. 
I truly feel the staff and management are supporting me in this effort.The mark of a good hospital is acknowledging and apologizing for mistakes and wrong doing and then taking steps to ensure such does not happen again. 
Vanderbilt Children's is rising to that challenge and I am not at all surprised. This place has been such a blessing to us. I feel blessed to be here and on a unit, that for the most part, loves and cares for my girl as she deserves. There will always be bad apples and mistakes but overall our Avelyn is so very loved and well cared for. 
This unit's staff have saved her life time and time again, for that I am eternally greatful. In times like these I must keep this in the forefront of my mind, not just because it allows me to get through the day without losing my temper (that would be of no help to anyone), but because it is true and the hospital's PCICU team's greatness deserves to be acknowledged.
On another note, Avelyn's wound has already showed incredible healing overnight. It's not nearly as deep and I am so greatful to see its progress. I didn't take a photo yesterday, but it was much deeper-at least a centimeter. I am shocked that Avelyn is healing so well given she was off of feeds for a week. 
Besides that she is doing ok, not great but ok. She still has moments where her color is terrible and it's obvious that an infectious process continues to brew but those moments seem to be less frequent and intense. This week's attending thinks she is also suffering effects from going a week without nutrition and it'll just take time to see her feeling like herself again. She's still breathing heavy and the cause to that is difficult to pin point, hopefully it'll subside with as her over all condition improves. 
Of major note, after nearly three months of weans, she is finally off of precedex, which is the sedative she has been on since she was a month old. We don't know how this drug has effected her development or overall clinical picture and I am so glad she's off of it. Today's wean was twice the normal size (because the IV pump was already at the lowest setting), so she'll likely struggle with the wean more than usual. I hope not, but knowing Avelyn it'll be a rough day. With the precedex coming off, she is for the first time in 7 months completely off of IV drips. This is bigger news than Ican describe and I wish she were in a place I felt comfortable celebrating. Maybe next week she'll be feeling better and not in as much pain, that way we can find a way to celebrate this huge accomplishment!  
As usual thank you for checking in and following our sweet precious baby. She continues to give her all and fight through challenges no one should have to. We are beyond proud to be her parents and able to witness her remarkable journey. Sean and I are often overwhelmed by the love and support given by all of those who Avelyn's story has touched. You all are amazing and thank you for all your prayers and love.
Until next time, take care!

The photos below are in chronological order. As I have said before, I don't often take photos of her at her worst, it's just too sad. The photo of her in her diaper was the night before she sustained the wound under her arm. You would be able to see it bleeding if it were there. The photo of the wound was taken more than 24 hours afterwards, it's already started to heal amazingly (it was about a centimeter deeper, not that you can tell the depth well anyway due to the bleeding or poor photo in general), please pray it continues to do so. 
   P