Monday, April 24, 2017

From the Hospital to VA in 24 Hours

Last week was not the week we had expected...

Saturday Nick and I did some fun house hunting with my parents who came to Ohio for Easter weekend. Sunday morning I woke up with major pain in my stomach close to my J tube. I didn't actually think the pain was related to my tube since running my feeds was fine and didn't cause any additional discomfort, but we later found out that was not the case. I was determined to make it to church for Easter, though...It had been almost 2 months since I had made it to church thanks to my nasty masties and I REALLY, REALLY wanted to be there on Easter. 

Well, we made it to church...but I spent almost the entire service attempting to dislocate Nick's hand as I was clenching it as hard as I could. I couldn't sit up, couldn't take deep breaths, could barely speak, and sat listening to the sermon with tears streaming down my face because the pain was intensifying. Nick brought the car around and we left church to go straight to the ER.

Up until the ER, I wasn't really focused on how bad the pain was. I knew I was hurting, but I also knew that we had always been able to get my bad pain under control with some IV meds and we'd be heading home in a few hours. After a few hours in the ER, I had been given 4 rounds of my normal pain medication (which is a 1/4 dose of a standard adult dose) and had almost no relief. I think that is when it hit me that something might actually be wrong. They did a CT scan of my abdomen and found pretty significant swelling in my intestines around my J tube. I still wasn't convinced the pain was related to my tube, but they sent the scans to the GI team at the hospital who felt that the balloon holding my tube in place may have gotten dislodged. I was still in severe pain, so we tried a new medication (at an 1/8 of a normal adult dose) that thankfully took away the pain, but also came with the side effect of making me mostly unresponsive.

Apparently my tremors and unresponsiveness (both side effects of the pain med) made the EMTs who transported me from the ER to the hospital a bit uncomfortable so when we arrived, the admitting doctor immediately ordered an EEG and some anti-convulsive meds thinking I was having a seizure. Thankfully Nick was not far behind the ambulance and they were willing to hold off and listen to him tell them that as long as my vitals were stable, they didn't need to worry. That EEG would come back a few days later, but at the time, things were relatively controlled.

That all happened Sunday afternoon/evening. The next 2 days were filled with severe pain, tremors, high doses (for me) of pain meds, spending hours in somewhat of a drugged sleep to keep the pain at bay, and waiting for doctors to round to figure out what to do. The GI team and GI surgeon said that the CT showed that the balloon holding my tube in place had deflated and was stuck against my intestinal wall. Plan A was for them to try to reposition it in Interventional Radiology (IR). If that didn't work, then Plan B would be surgery to try to fix the problem. Unfortunately, this got held up an extra day as they were waiting on records from the Cleveland Clinic about my J tube procedure so if surgery was needed, they could be prepared with all my medication protocols. Glad they were making sure they were ready in case surgery was needed, but in the meantime I spent another day in some of the worst pain I've ever felt.

Wednesday morning was the day of the procedure, and it was a mess from the start. As a rare disease patient, I know it is my responsibility to be on top of my care even in the hospital and my family is very capable of managing that when I'm unable to. However, even the best laid plans and preparation can go awry when there are so many pieces out of our control.

The IR team called and said they would be coming to get me about 11:30 am. We had purposefully timed my morning pain meds and mast cell meds so that they would be in full force for the procedure to hopefully minimize any potential reaction. Except even though they brought me down about when they said, I waited over 3 hrs before they got to my procedure. That meant that my pain meds and mast cell meds had time to wear off before I even got to the procedure room...

And that's where the "fun" started...I was starting to shake from pain again, so the nurses in IR called my nurse on the floor to ask what pain meds I had been on. She told them what I had been taking for the past few days, but instead of them giving me one of the meds, they gave me both at once...I am EXTREMELY sensitive to pain medications (even when in severe pain), and both at once made me completely unresponsive. The nurses in IR were not prepared for that and kind of freaked out. They decided to give me another medication to reverse the effects of the pain meds, which woke me up, but also started causing a mast cell reaction...more benadryl on board and thankfully that was controlled. Then the real fun began...

Because they had reversed the effects of the pain meds, when the surgeon started the procedure the severe pain I had been dealing with the past few days just intensified. It was pain like I have never experienced...even compared to pain after my abdominal surgeries. They did start to give me more pain medications during the procedure, but nothing really kicked in until the surgeon was finished. Unfortunately, it also took a bit longer than expected because the displacement was worse than they had thought. Initially they thought the balloon holding my J tube in place had started to get imbedded in my intestinal wall. When the surgeon started the procedure, he discovered that the balloon had actually deflated enough to slip out of my intestines and was being to adhere itself to my abdominal wall while a small part of the balloon was still in my intestines. Thankfully he was still able to fix it in IR with no surgery needed, but it was an incredibly painful 30 minutes.

The CT scan after the procedure confirmed my tube was back in place, and thankfully the second round of pain meds finally started to kick in. Once the IR team felt comfortable that I was not going unresponsive again or still in severe pain, they sent me back to my room. Despite still being in pain from the procedure itself, I could tell very soon after that the problem had been resolved. The sharp, shooting pain that came with every deep breath, any amount of light touch, and any movement was gone and replaced with intense soreness like a badly pulled muscle. I cannot put into words the relief that my entire body felt when that pain was finally gone.

Wednesday after the procedure. First time since being admitted
I was actually able to sit up without severe pain.
Despite having been taken down to IR about 11:30 for a 30 minute procedure, it was almost 4 pm by the time I got back to my room. We had discussed leaving Wednesday night assuming the procedure went well, but decided to stay an additional night for pain management. Even though the pain for the most part was gone, I was terrified of it coming back in the middle of the night and not being able to do anything about it. It ended up being a non-issue because the doctor came in not much later to tell us the EEG had revealed some abnormal activity and that I would need a brain MRI so I'd have to stay one more night anyway.

I did need one more round of pain medications Wednesday night before bed, but thankfully was able to make it through the night without needing any more. Thursday we got the all clear from the GI team and neurology gave the okay for me to be discharged as long as I followed up with my neurologist. Escape the Room: Hospital Version = Complete April 2017!

To be honest, this hospital stay was very different from many of my previous admissions. Usually I end up being admitted for uncontrolled mast cell reactions. It's a matter of using IV meds to get things back under control, then sending me home to see how long I can make it until it happens again. Nothing really gets resolved, we just get me a bit more stable for a time. This time, we left actually having resolved the reason I had been admitted! Not always the case for rare disease patients or anyone with chronic illness, but we are thankful that this was something that could be fixed, and I could actually leave the hospital feeling "better."

Friday was spent resting and PACKING. Yes, I did just say packing. Less than a day after being discharged from the hospital, Nick and I road tripped down to VA for my college alumni soccer game and visit some close friends. No, I did not play in the game =P Herman, Sherman, and Mort kinda keep me from any contact sports for now...and my mast cells are doing there part to keep me from being able to run at all, so Nick and I just watched. But it was great to catch up with some people and have time to spend with our friends who graciously allowed us (and both dogs?!?!) to stay with them this weekend.

Sometimes I think our dogs are broken...
Initially I thought it would be tough to watch everyone I used to play with and be unable to play myself. Well, the 50 degree weather with pouring rain and wind kinda helped me not miss it *too* much! But it is hard sometimes when I'm reminded of how far I am from where I used to be and what I used to be able to do. I don't struggle a lot with comparing myself to other people and feeling discouraged about not measuring up, but I do struggle a lot with comparing me now to who I used to be and feeling discouraged about all the things I can no longer do. I miss being able to play soccer and swim and run. I miss being able to get up for 6 am lifting or swim practice, have a full day of classes, more practice in the afternoon, meals, go to FCA, do homework, then go to bed just to wake up to do it all over again. I miss life before my mast cells were in control.

But I am thankful for the memories. Even though some days they are more painful, I am thankful for the time I did have to do those things. In high school and college we always joked I was busy enough for 3 people. I was always a go-go-go type of person who liked to be rushing around and did well with little to no "free" time. Maybe those years of craziness were God's gift to me knowing that in a few years I'd be unable to do many of those things. Maybe He gave me the strength and energy to be able to even the crazy amount of activity I did for those years so that I'd have all those memories to sustain me when things would get tough.

Despite doing very little all weekend, by Sunday night, I was exhausted. I am glad we decided to go ahead with our trip to VA that we had been planning for a few months now, but especially after the week we had in the hospital last week, I was wiped. I know some people probably think we're crazy for taking a road trip less than 24 hrs after getting out of the hospital, but the reality is that if we waited for the perfect conditions and ideal health, we might be waiting forever and watching life pass us by. Living with a chronic illness means that I often choose to push myself knowing I may pay for it later so that we can have some moments of victory over my mast cells. Sometimes I may miscalculate and end up suffering major repercussions for those choices. But sometimes we're able to walk the fine line that lies between pushing things too far and not allowing my mast cells to completely dictate how I live. Nick and I managed to find that fine line this weekend and have a good weekend with each other and friends. And we won't even really know if I really do crash from this trip because I'm getting Xolair today so that will mask any crashing symptoms! Small blessings... =)

This past week was NOT the week we expected. We are thankful it is over and that my J tube was able to be fixed without surgery. We are so very thankful that we were able to make the trip down to VA this weekend and see one of my best friends and her husband. We might not have expected last week, but let's be honest, our whole life is nothing we could have anticipated. We're still finding reasons to smile every day and praying that our lives reflect God's goodness even in the tough moments. Ain't no mast cells gonna stop us!

Wednesday, April 12, 2017

Third Time's a Charm, Right???

Tomorrow will be Take 3 on attempting to complete some GI testing...Both of the first two attempts had to be rescheduled due to an inability to keep any liquids in my body which is necessary for this test. Round 2 even came with blood sugars in the 40s...just cause, you know, puking bile and stomach acid at 8 am wasn't enough fun to begin the day with...

So, Breath Test vs. Kylene's Nasty Masties Round 3 will go down (hopefully) tomorrow afternoon. And I really, really need my body to cooperate tomorrow. This breath test cannot be done within 6 weeks of having had a colonoscopy. After tomorrow, the next availability for this breath test is not until May and, you guessed it, AFTER the colonoscopy that was also scheduled after my GI appointment last week. So I'm going in prepared with a double dose of zofran and some benadryl (cause you know, nausea probably isn't enough excitement for my mast cells to throw at me, there's always the potential for some allergic reaction to what I have to drink, too...) and ready for tomorrow afternoon to be the best. day. ever. (If you haven't caught on to the amount of sarcasm usually used in these posts, please insert sarcasm and re-read that last sentence =P)

Anyway, puking episodes delaying this breath test is not the only fun that's been happening since my GI appointment last week. I am cautiously optimistic that the appointment went well and this doctor may actually be able to help us figure some stuff out. Unfortunately I have learned that only time will tell when it comes to determining whether a doctor will truly be helpful, but I am encouraged and we are hoping that he will be able to at least get us moving in the right direction.

The best part of the appointment for me was the very end when we were getting up to leave. Leni had been tucked under his desk the entire appointment, but had been so quiet that he hadn't realized she was there. He spent 45 minutes with her head less than 6 inches from his feet...I'm just glad she didn't try to rest her head on his foot! He actually asked me, "Has she been here this whole time?" I wasn't sure how to reply to that other than to smile and nod. I wish my quick, witty comebacks that come so easily when I'm writing here would come to mind in the moment... =P No...she vaporized into the room silently right about when we started talking about my Creon dosage...

Anyway, moving past the case of the silent service dog, the appointment did go well. At least as well a first appointment can go. Like I said, we'll really know how well it went in the follow-up from the testing, but for now we're cautiously hopeful. I was referred to this doctor by my GI surgeon and motility specialist (also both at the Clinic) because both of them thought I might have some form of pancreatic insufficiency going on and this doctor's main specialty is in pancreatic issues.

He spent about 45 minutes with me going over all my recent history in depth and listening to my progression of symptoms and how my mast cell disease was impacted by these GI issues. He felt that my symptoms and lab work are not consistent with chronic pancreatitis (which I've been diagnosed with about 6 times) which my mast cell doctors agree. He said that the scarring found on my pancreas during an endoscopic ultrasound is also not consistent with chronic pancreatitis, although it could be an atypical presentation. He also felt that it was not actual scarring but clusters of tissue which he said could be indicative of mast cell infiltration of my pancreas. This was what my specialist had guessed when we mentioned these pancreas issues to him, so it was interesting to get another point of view on this. Unfortunately, there's no easy way to look into this further...the only option would be a biopsy which is not something we feel is needed right now.

We also discussed some of my other issues with absorption and blood sugar fluctuations. The reality is that these symptoms could be entirely mast cell driven with no GI mechanism behind them. If that is the case, it makes figuring out the next steps a bit more challenging as we may have to look into treatment options that bypass my intestines and hope we can get things under control then pray I can transition back onto oral/liquid meds and stay stable. But before we go that route, we still have some more GI testing to do to make sure we aren't missing anything.

Ironically, one benefit of having nonstop absorption issues is that I am able to give a stool sample at the drop of a hat! Small blessings, right?? =P He ordered a few stool tests to check for parasites, malabsorption, and a few other potential causes that we don't want to miss simply because we thought it was too simple to test for. Those results have all come back and I am parasite, h pylori, and c diff free, so that is good news. (See Liz, 8 years later and still no real Herman =P) The stool samples did confirm that my body is not absorbing electrolytes properly and is dumping them out of my body at fairly high levels. Obviously that is not good, but didn't really give us any additional information that we didn't already know, just confirmed what we already knew. We're adding in some extra blood work to see what my overall electrolyte levels are to determine if we need to adjust what I am getting in the fluids I run at home twice a week.

This breath test that I'm going to do tomorrow (hear that mast cells?!?!) was supposed to be last Thursday. It will indicate whether I have a bacterial overgrowth in my small intestines. The complication with it is that I have to drink (and keep down) a mixture of disgusting tasting stuff that will activate any possible bacteria that may have accumulated in my small intestines. I can avoid having to taste it by putting it directly into my stomach through Herman (G tube), but since it has to go in my stomach, there is still the possibility that I can throw it up. And that would be why I will be going in to Round 3 armed with a double dose of zofran and some benadryl.

We also scheduled a colonoscopy for the beginning of May. It's been almost 10 years since my last colonoscopy and he felt that it was time to re-do it based on the symptoms I'm currently having. He will be checking for specific inflammation patterns that could potentially indicate a bowel disease that could be treated independent of my mast cell disease and taking biopsies for anything that may be happening on a microscopic level. Can't say I'm looking forward to having to deal with anesthesia again...I was hoping that my J tube surgery was going to have been the last time for a while.

BUT the good news is that things will hopefully go as smoothly as they did for my J tube. When I had that surgery, the head of the anesthesiology department had overseen my case and stayed in the room with me the entire procedure. He had researched mast cell diseases was able to keep things under control and prevent any severe reactions; it was about the best I had ever tolerated having to be put under. He had given me his card and said he would either personally oversee any future procedures or make sure whoever was on my case was up to speed on how to handle things. When I emailed him he said he would be happy to make sure things go smoothly again and that if he was not able to personally be on my case (since it's not in an OR) he would talk with whoever was assigned to me. So we are hoping that things will go well on that front!

Other than that, we're back to any chronic illness patient's favorite thing to do...hurry up and wait...We already have the results of the stool samples, and I'll have the results of the breath test tomorrow when it's finished. I go back to see my allergist in 2 weeks for an actual appointment (not to be confused with my twice monthly quick appointments when I get my Xolair), so I'm hoping we'll have at least something to discuss from the testing.

In other news, I am now officially 32 DAYS epi free!!! Despite still feeling incredibly sick most days and not having much resolution of symptoms as a whole, this is HUGE! Anaphylaxis is incredibly taxing on the body. It is literally the body going into shut down mode from shock. The only way to reverse that is to give an equally shocking injection (epi) to jump start the body and follow that with IV medications to stabilize things. It feels about as jarring as it while I do hope that my epipen usage soon matches my actual symptoms, in the meantime, I am so very thankful to be a month free from anaphylaxis.

So that's the update from my GI appointment last week and what we're hoping to sort out in the next few weeks. Lots of testing, lots of waiting, and of course, lots of nasty masties...nothing to do but keep moving forward, finding reasons to smile, and continuing to work on Leni's ninja skills to keep surprising unsuspecting doctors!

Thursday, April 6, 2017

Remembering it ALL

This past week, Nick and I went to a class our church was offering based on Tim Keller's book, Walking with God Through Pain and Suffering. The class is a multi-week course, but the church opened up couple of sessions to anyone who wanted to hear some personal testimonies from the lead pastor and another member of the church who is pretty much a modern day Paul.

This week, the lead pastor shared his story about losing his brother in a motorcycle accident and how that impacted him, his family, and his relationship with God. Even though our experiences are so vastly different, I was reminded that it is through our seasons of struggle and pain that our understanding of God's character and purpose grows, and through that, our relationship with God (eventually...sometimes we don't see that right away...).

But what I really took away from his talk was a comment he made at the very beginning of his testimony. He made the comment that there is "something about pain that wire memories so we don't forget" anything about those moments in our lives. For him, it was his last day with his brother and the hours/days after hearing the news of his brother's death. I'm sure many other people have similar stories of recalling specific details from some of the darkest moments of their lives.

My initial thought was how weird it must be to remember so vividly certain moments in life when most of us can barely remember what we did a week ago! But as he kept speaking, I realized that even though my pain is not the same that he experienced, I do have some of those moments of vivid memories. I can remember specific details about certain days, weeks, and seasons with incredible clarity (while still barely remembering the previous week...). And in realizing that, I also realized that I have been given a gift.

My pain is not that unexpected, acute shock that he spoke about. It is a chronic, building pain that grows over time and continually pushes the boundaries of how much worse can things get. It is on going with no end in sight. Living with a chronic illness means that I have learned to live with the echo of pain always in the background, but also facing the reality that there are moments where that pain explodes from the background back to center stage. It is in many of those moments of pain that increase beyond my normal baseline where I experience moments like our pastor spoke about that cement memories into my mind with incredible clarity.

And here's the gift...those moments of increased pain may have been what triggered my brain to retain those snapshots in time, but in doing so, also meant that I retained other details about those same moments...things I might not have remembered otherwise...

I remember the day I had to use my first epipen and how terrifying it was to feel my throat closing and being unable to swallow...but I also remember friends from church stepping up to help, nurses helping to keep me calm and actually stabbing me with the first epipen, others calling Nick and an ambulance and making sure the EMTs had my medical info, and the many texts I received that night and the next day from people asking how I was doing and letting me know they were praying for me.

I remember heading in to my first endoscopy and tube change at a new hospital and being terrified of going in anaphylaxis from the anesthesia...but I also remember doing MadLibs with Nick in the pre-op area that made me laugh so much I was sore the next day (and not from the procedure =P).

I remember being admitted 2 days before Christmas and spending all of Christmas Eve in the hospital dealing with doctors who didn't understand mast cell disease, my body not responding properly, and a clogged feeding tube...but I also remember somehow fitting me, Nick, and Leni in my hospital bed to watch the Christmas Eve service online and just spending time together in the midst of the crazy holiday season.

I remember endless days of being unable to eat, throwing up, pain, and more...but I also remember Nick willingly bringing me (also seemingly endless) slurpees each night when I couldn't tolerate anything else.

I remember a day where I had not left the house in over a week, had been throwing up multiple times, passed out twice, and was physically, mentally, and spiritually exhausted...but I also remember Nick coming home with a Venus Fly Trap that we started feeding flies and spiders to. (It lived 2 weeks, I think =P)

I remember when I was struggling to walk because of balance issues, loss of coordination, and muscle weakness and felt scared because we had no answers and so limited in my independence and ability to do things...but I also remember Nick pushing me around the Toledo Zoo in a double stroller (they were out of wheelchairs =P) so we could enjoy one of my favorite things (zoos!) and spend time with friends.

There are so many other moments that have been cemented into my memory because of the pain of that day/week/season. It goes beyond just vague recollections and hazy mental images...these are clear moments of specific details that echo in my mind as reminders of some of my toughest moments. Yet these memories are so much more than sad and painful...they are also full of joy, encouragement, laughter, and smiles.

Without the pain, these memories of joy would not be as clear. The toughest moments that have left their mark on my life like scars that never fully disappear, have also allowed me to remember things that otherwise would have faded into the background and been forgotten. It is BECAUSE of my pain that I have the GIFT of these other memories. For me, my pain and hope, sadness and joy, tears and laughter are so closely woven together that I can't have one without the other. And I wouldn't change that for anything.

Monday, April 3, 2017

Big Appointment This Week

I've been home from VA a full week, and I think it has rained every least that's a decent representation of how my body's been feeling, too...

Other than my Xolair last Monday, I have not left the house. It's been a rough week... I knew it would be. I pushed myself to be able to do things with family and friends when I was in VA. Sometimes I'll make a decision to do that extra activity or eat some food knowing I'll pay for it later. I made a few more of those choices that week than maybe I "should" have... I'm not sorry I made any of those decisions, but that doesn't make the symptoms I have been dealing with now any less severe...

Leni working hard at a Trippin' with Jamie conference in VA
Anyway, for the past few months (pretty much all 2017), we've been waiting for an appointment that is now this week! Since this recent flare started, I've been having major issues with absorption. Meaning my medications are not being absorbed, any food I do eat is coming out undigested, and my tube feeds have been running through me. That is the main reason I now have IV meds to use when my intestines are just not playing nice. At least those IV meds have gotten the constant anaphylaxis under control, but it hasn't solved the problem, just slapped on a temporary band-aid.

And that's what we are hoping and praying this appointment will be able to help with. I'm seeing a pancreas specialist in the GI department at the Cleveland Clinic on Tuesday. I currently have a GI and GI surgeon at the Clinic and both have referred me to this new GI to hopefully get some insight on all these absorption issues. My allergist and neurologist are also both waiting to hear what this doctor has to say too, because we can't try any new medications until we get my absorption sorted out.

Lazy day snuggles on my parent's couch
So you could say there's a lot riding on this appointment...I hope this doctor is ready! But seriously, there is A LOT riding on this appointment...and I'm nervous. I've had more than my share of doctors who can't or won't do anything to help. And I don't know what we'll do if that happens with this one, too... All my current doctors have deferred to this appointment. We can't try any new oral meds until we get the absorption figured out, so we've been waiting months for this appointment to get here. When I saw my allergist and neurologist earlier this year, they both were just asking what I needed from them to GET to this appointment because there's nothing more for us to do until we get some answers about my pancreas.

It's great to have doctors so willing to help, but also frustrating (and the unfortunate reality of rare disease patients) when there's nothing they can do. As my allergist said, until we can get my body absorbing my meds, we can't even try any new meds for my mast cell disease because we won't know if they just don't work for me or if they're not working because I'm not absorbing them. Even though I do have IV access, we really don't want me getting dependent on IV meds long term. If we were to start any IV treatments, then I'd be stuck relying on those, so we're holding off on that unless absolutely necessary and we have no other options. So that means these past few weeks/months have been a matter of just getting through the days as best as possible and keeping me as stable as possible so I can get to this appointment...

And now that the appointment is here, we have to pray and hope that he's willing to listen and can do something to at least get us moving in the right direction...NO PRESSURE, right??

Let's do this!
So that's what's up this week! Big appointment that will either give us a new direction to go in and potentially new angle for treatment options OR will be a complete waste of time and I'll leave wondering "now what?"...Please be praying that second possibility is NOT the case.

In other news, I am now 26 WHOLE DAYS EPI FREE!!!! That, my friends, is big news on it's own! Since October, I've been going into anaphylaxis every 4-5 days and needing at least one (often more) dose of epi multiple times a week. When we finally got the IV medication situation sorted out, I made it 15 days before the unfortunate run-in with the essential oils fair. After we reset the counter yet again, I am now SO CLOSE to a full month without epi!! That's a reason to celebrate! Although we'll be keeping it super low-key because we know strong emotions can be a mast cell trigger and we don't want to rock the boat when I'm so close to A MONTH!!!

I know my posts have been less frequent lately, and that's mostly because there hasn't been a lot going on (at least that is worth sharing online =P). Like I mentioned above, the past few months have been a holding period waiting for this appointment this week. Now that it's here, hopefully (prayerfully) we will be able to start moving in the right direction to get things under better control and get me back to where I was last summer.

As always, THANK YOU for your prayers. In my absence from this blog, please know that I am very much aware of many of you who have been faithfully lifting up me and my family in your prayers. We are so very grateful and thankful for that! Please be praying that this appointment with the pancreas specialist is productive and that he will have the insight that we need to move in a good direction. Please be praying for strength and encouragement for me as I am struggling with some increasing symptoms and feeling more isolated and unable to manage simple daily tasks some days. Please pray for strength and joy for Nick as he is working full-time, serving me so selflessly, and acting as the main point person for our house hunt. Please pray that even in the midst of this season of life, our lives would be a light to the doctors and others that we meet and that our struggle is being used in a way to bring encouragement and Christ to others who are also hurting.